Andrea K. Morrison

Low caregiver health literacy is associated with higher pediatric emergency department use and nonurgent visits.

OBJECTIVE We sought to determine the association between low caregiver health literacy and child emergency department (ED) use, both the number and urgency of ED visits. METHODS This year long cross-sectional study utilized the Newest Vital Sign questionnaire to measure the health literacy of caregivers accompanying children to a pediatric ED. Prior ED visits were extracted from a regional database. ED visit urgency was classified by resources utilized during the index ED visit. Regression analyses were used to model 2 outcomes-prior ED visits and ED visit urgency-stratified by chronic illness. Analyses were weighted by triage level. RESULTS Overall, 503 caregivers completed the study; 55% demonstrated low health literacy. Children of caregivers with low health literacy had more prior ED visits (adjusted incidence rate ratio 1.5; 95% confidence interval 1.2, 1.8) and increased odds of a nonurgent index ED visit (adjusted odds ratio 2.4; 95% confidence interval 1.3, 4.4). Among children without chronic illness, low caregiver health literacy was associated with an increased proportion of nonurgent index ED visits (48% vs. 22%; adjusted odds ratio 3.2; 1.8, 5.7). CONCLUSIONS Over half of caregivers presenting with their children to the ED have low health literacy. Low caregiver health literacy is an independent predictor of higher ED use and use of the ED for nonurgent conditions. In children without a chronic illness, low health literate caregivers had more than 3 times greater odds of presenting for a nonurgent condition than those with adequate health literacy.

Dexamethasone for Acute Asthma Exacerbations in Children: A Meta-analysis

BACKGROUND AND OBJECTIVE: Dexamethasone has been proposed as an equivalent therapy to prednisone/prednisolone for acute asthma exacerbations in pediatric patients. Although multiple small trials exist, clear consensus data are lacking. This systematic review and meta-analysis aimed to determine whether intramuscular or oral dexamethasone is equivalent or superior to a 5-day course of oral prednisone or prednisolone. The primary outcome of interest was return visits or hospital readmissions. METHODS: A search of PubMed (Medline) through October 19, 2013, by using the keywords dexamethasone or decadron and asthma or status asthmaticus identified potential studies. Six randomized controlled trials in the emergency department of children ≤18 years of age comparing dexamethasone with prednisone/prednisolone for the treatment of acute asthma exacerbations were included. Data were abstracted by 4 authors and verified by a second author. Two reviewers evaluated study quality independently and interrater agreement was assessed. RESULTS: There was no difference in relative risk (RR) of relapse between the 2 groups at any time point (5 days RR 0.90, 95% confidence interval [CI] 0.46–1.78, Q = 1.86, df = 3, I2 = 0.0%, 10–14 days RR 1.14, 95% CI 0.77–1.67, Q = 0.84, df = 2, I2 = 0.0%, or 30 days RR 1.20, 95% CI 0.03–56.93). Patients who received dexamethasone were less likely to experience vomiting in either the emergency department (RR 0.29, 95% CI 0.12–0.69, Q = 3.78, df = 3, I2 = 20.7%) or at home (RR 0.32, 95% CI 0.14–0.74, Q = 2.09, df = 2, I2 = 4.2%). CONCLUSIONS: Practitioners should consider single or 2-dose regimens of dexamethasone as a viable alternative to a 5-day course of prednisone/prednisolone.

Caregiver low health literacy and nonurgent use of the pediatric emergency department for febrile illness.

OBJECTIVE To examine the association between caregiver health literacy and the likelihood of a nonurgent emergency department (ED) visit in children presenting for fever. METHODS This cross-sectional study used the Newest Vital Sign to assess the health literacy of caregivers accompanying children with fever to the ED. Visit urgency was determined by resources utilized during the ED visit. Findings were stratified by race and child age. Chi-square and logistic regression analysis controlling for race were conducted to determine the association between low health literacy and ED visit urgency. RESULTS A total of 299 caregivers completed study materials. Thirty-nine percent of ED visits for fever were nonurgent, and 63% of caregivers had low health literacy. Low health literacy was associated with a higher proportion of nonurgent ED visits for fever (44% vs 31%, odds ratio 1.8, 95% confidence interval [CI] 1.1, 2.9). Low health literacy was associated with higher odds of a nonurgent visit in white and Hispanic caregivers but not in black caregivers. In regression analysis, children ≥ 2 years old had higher odds of a nonurgent visit if caregivers had low health literacy (adjusted odds ratio 2.0; 95% CI 1.1, 4.1); this relationship did not hold for children <2 years old (adjusted odds ratio 0.8; 95% CI 0.4, 1.8). CONCLUSIONS Nearly two-thirds of caregivers with their child in the ED for fever have low health literacy. Caregiver low health literacy is associated with nonurgent ED utilization for fever in children over 2 years of age. Future interventions could target health literacy skills regarding fever in caregivers of children ≥ 2 years.

Measuring Health Literacy in Caregivers of Children A Comparison of the Newest Vital Sign and S-TOFHLA

Objective. We examined the performance of the Newest Vital Sign (NVS) and the Short Test of Functional Health Literacy in Adults (S-TOFHLA) in caregivers of children. Method. Caregivers of children ≤12 years old seeking care for their child in a pediatric emergency department (ED) were tested using the NVS and the S-TOFHLA to measure health literacy. The results were compared with ED use outcomes. Result. The S-TOFHLA was found to have a ceiling effect as compared to the NVS; few caregivers scored in low literacy categories (P < .0001). This finding was demonstrated in both lower (P = .01) and higher (P < .001) educational attainment groups. The NVS was predictive of ED use outcomes (P = .02 and P < .01) whereas the S-TOFHLA was not (P = .21 and P = .11). Conclusions. The measures do not seem to function similarly nor predict health outcomes equally. The NVS demonstrates sensitivity in identifying limited health literacy in younger adult populations.

Health Literacy Affects Likelihood of Radiology Testing in the Pediatric Emergency Department

OBJECTIVE To test the hypothesis that the effect of race/ethnicity on decreased radiologic testing in the pediatric emergency department (ED) varies by caregiver health literacy. STUDY DESIGN This was a secondary analysis of a cross-sectional study of caregivers accompanying children ≤ 12 years to a pediatric ED. Caregiver health literacy was measured using the Newest Vital Sign. A blinded chart review determined whether radiologic testing was utilized. Bivariate and multivariate analyses, adjusting for ED triage level, child insurance, and chronic illness were used to determine the relationship between race/ethnicity, health literacy, and radiologic testing. Stratified analyses by caregiver health literacy were conducted. RESULTS Five hundred four caregivers participated; the median age was 31 years, 47% were white, 37% black, 10% Hispanic, and 49% had low health literacy. Black race and low health literacy were associated with less radiologic testing (P < .01). In stratified analysis, minority race was associated with less radiologic testing only if a caregiver had low health literacy (aOR 0.5; 95% CI 0.3-0.9), and no difference existed in those with adequate health literacy (aOR 0.7; 95% CI 0.4-1.3). CONCLUSIONS Caregiver low health literacy modifies whether minority race/ethnicity is associated with decreased radiologic testing, with only children of minority caregivers with low health literacy receiving fewer radiologic studies. Future interventions to eliminate disparities in healthcare resource utilization should consider health literacy as a mutable factor.

On Target: A Case of Acute Hemorrhagic Edema of Infancy

Case: A 16-month-old female presented to a referring emergency department with a 2-day history of a progressive rash and swelling that started on her right lower extremity and spread to her upper extremities, trunk, and face (Fig 1). The patient had recently been hospitalized at the referring hospital for bronchiolitis caused by respiratory syncytial virus and was being treated with amoxicillin for otitis media. Her mother had stopped the antibiotic 1 day before presentation after development of a rash and had given the patient diphenhydramine, with no improvement. The patient had a fever with the preceding illness but on admission to the emergency department was afebrile. She had received hepatitis B and diphtheria-tetanus-acellular pertussis vaccines at her 15-month well-child examination 3 weeks before the onset of the rash. The patient had 1 day of decreased oral intake and decreased urine output and a 2-day history of loose stools. Family history is significant for multiple maternal family members with reaction to penicillin causing hives and edema. At the referring hospital, intraosseous (IO) access was obtained after multiple attempts to place intravascular access were unsuccessful, secondary to diffuse body edema. In our emergency department, the medical team attempted to obtain intravascular access with ultrasound guidance; however, they were also unsuccessful because of the patient’s persistent edema. The patient received normal saline via the IO line in addition to oral acetaminophen and diphenhydramine. FIGURE 1 A 16-month-old female with rash and swelling. Physical examination revealed a fussy but consolable, well-nourished toddler with diffuse body edema, scratching at her arms and thighs. She was afebrile, tachycardic to 134 beats per minute, and hypertensive to 126/97 mm Hg. Erythematous annular lesions surrounded the patients …

Parents’ pain medication underdosing is associated with more emergency department visits in sickle cell disease

To determine the association between health literacy, medication knowledge, and pain treatment skills with emergency department (ED) use of parents of children with sickle cell disease (SCD).

Health Information Preferences of Parents in a Pediatric Emergency Department

Parents of children seeking nonurgent care in the emergency department completed surveys concerning media use and preferences for health education material. Results were compiled using descriptive statistics, compared by health literacy level with logistic regression, adjusting for race/ethnicity and income. Semistructured qualitative interviews to elicit reasons for preferences, content preference, and impact of health information were conducted and analyzed using content analysis. Surveys (n = 71) showed that despite equal access to online health information, parents with low health literacy were more likely to use the internet less frequently than daily (P < .01). Surveys and interviews (n = 30) revealed that health information will be most effective when distributed by a health care professional and must be made available in multiple modalities. Parents requested general information about childhood illness, including diagnosis, treatment, and signs and symptoms. Many parents believed that appropriate health information would change their decision-making regarding seeking care during their child’s next illness.