Emergency department use for injuries by adolescents in foster care

Highlights

• We examined the ED utilization patterns of adolescents in foster care.

• Group home youth have higher frequency of self-inflicted and conflict injuries.

• Findings highlight opportunity for targeted interventions for youth in foster care.

Abstract

Youth in foster care are overrepresented with respect to their utilization of emergency department (ED) services. This study examines the ED utilization patterns of adolescents in foster care and evaluates the characteristics of injury related versus non-injury related visits. We found that adolescents in foster care have high rates of ED use (1.84 visits per year (95% CI 1.59, 2.12)), with 31.2% of ED visits being injury-related. Male gender was found to be the only independent predictor of having an injury related vs. non-injury related ED visit (odds ratio 2.22 (95% CI 1.27–3.87)). Regarding the mechanisms of injury, adolescent youth in group homes were significantly more likely to present with injuries inflicted by themselves or by others in their residence (p < 0.05 for both) but less likely to present with accidental injuries or injuries sustained during recreation (p < 0.05 for both). Resources and interventions targeted at both youth and group home staff related to behavioral health assessment, post-traumatic coping skills and conflict management may have beneficial effects.

Introduction

As of 2012, nearly 400,000 children were in foster care in the United States, according to data from the federal Adoption and Foster Care Analysis and Reporting System (AFCARS) (U.S. Department of Health and Human Services, A.f.C.a.F., & Y.a.F. Administration on Children, Children's Bureau, 2013). As compared to the general population, children in foster care have significantly higher frequencies of medical conditions. This population, in fact, has been recognized by the American Academy of Pediatrics as a uniquely disadvantaged group with special health care needs (AAP District II, N.Y.S., 2005). Analyses of large cohorts of children entering the foster care system have identified that approximately half of children have at least one medical condition, including obesity, dental conditions, sexually transmitted infections, lead poisoning and anemia (Steele and Buchi, 2008, Simms et al., 2000, Landers et al., 2013, Stein et al., 2013, Takayama et al., 1998).

It is not surprising then that children in foster care are overrepresented with respect to utilization of emergency department (ED) services. Chronic health conditions such as those seen in children in foster care account for a significant proportion of emergency department (ED) visits for children (Reynolds, Desguin, Uyeda, & Davis, 1996). Shatlin et al. demonstrated that low income children with chronic conditions have higher ED utilization than children with private insurance (Shatlin, Levin, Ireys, & Haller, 1998). Furthermore, the transient nature of children in foster care with disruptions in primary care; lack of electronic records to convey existing medical conditions, current medications and plans of care; and issues related to Medicaid reimbursement are each counter to the need for continuous and comprehensive medical services. Almgren et al. found that a child's foster care history was an independent predictor of high ED utilization (Almgren & Marcenko, 2001). A cross-sectional analysis of the National Survey of Child and Adolescent Well-Being (Jee et al., 2005) found that nearly 1 out of 3 children in foster care had visited the ED or urgent care within the past 12 months with subgroups of children with chronic conditions, children of younger age and children with younger foster caregivers having particularly high rates of use. Rubin et al. (2004) analyzed Medicaid claims data linked to foster care administrative data and found that older foster children had increasingly greater ED use than did their Medicaid-eligible peers, with nearly double the rate of ED visits in the adolescent age group.

Although adolescents in foster care have increased rates of medical conditions and lack of prior medical history that may account for increased ED utilization, they may also be at risk of increased ED visits due to injury. Several factors might contribute to higher rates of injury visits including a lack of supervision in foster settings, behavioral disorders that predispose to injury, group home placements with other high risk adolescents, and increased rates of substance use.

We are not aware of any study that looks at the ED utilization patterns of adolescents in foster care with respect to the frequency of injury. We hypothesize that ED utilization for adolescents will include a high frequency of presentation for evaluation of injury in both family-based foster care and group homes. The objectives of this study are to describe the ED utilization patterns of adolescents in foster care and to compare the characteristics of adolescents who visit the ED for injury related versus medical events while in foster care.