Primary Care Quality and Subsequent Emergency
Department Utilization for Children
in Wisconsin Medicaid
David C. Brousseau, MD, MS; Marc H. Gorelick, MD, MSCE;
Raymond G. Hoffmann, PhD; Glenn Flores, MD; Ann B. Nattinger, MD, MPH
Objective.—Children enrolled in Medicaid have disproportion-
ately high emergency department (ED) visit rates. Despite the
growing importance of patient reported quality-of-care assess-
ments, little is known about the association between parent-
reported quality of primary care and ED utilization for these
high-risk children. Our goal was to determine the association be-
tween parent-reported primary care quality and subsequent ED
utilization for children in Medicaid.
Methods.—We studied a retrospective cohort of children en-
rolled inWisconsin Medicaid. Parentsof children sampled during
fall 2002 and fall 2004 completed Consumer Assessment of
Healthcare Providers and Systems surveys assessing their child’s
primary care quality in 3 domains: family centeredness, timeli-
sequent nonurgent and urgent ED visits, extracted from claims
data for the year after survey completion. Negative binomial re-
gression was used to determine the association between the do-
mains of care and ED utilization.
Results.—A total of 5468 children were included. High-quality
family centeredness was associated with a 27% (95% confidence
interval [95% CI] 11%–40%) lower nonurgent ED visit rate, but
no lowering of the urgent visit rate. High-quality timeliness was
associated with 18% (95% CI, 3%–31%) lower nonurgent and
18% (95%CI, 1%–33%) lower urgentvisit rates. High-quality re-
alized access was associated with a 27% (95% CI, 8%–43%)
lower nonurgent visit rate and a 33% (95% CI, 14%–48%) lower
urgent visit rate.
Conclusions.—Parent-reported high-quality timeliness, family
centeredness, and realized access for a publicly insured child
are associated with lower nonurgent ED, with high-quality time-
liness and realized access associated with lower urgent ED utili-
KEY WORDS: Medicaid; pediatrics; quality of care; utilization
Academic Pediatrics 2009;9:33–9
the percentage of these ED visits that are nonurgent range
from 37% to 60%,2–6with children enrolled in Medicaid
making a disproportionately high percentage of ED visits
in general, and nonurgent ED visits specifically.6,7These
nonurgent ED visits are associated with ED overcrowd-
ing,8–10cost more than a primary care provider visit,11–13
and fragment the care of children, leading to worse health
Previous studies focusing on process-of-care measures
of quality, such as the receipt ofimmunizations and asthma
here are approximately 30 million emergency de-
partment (ED) visits by children under 18 years
old in the United States each year.1Estimates for
process measures is associated with decreased ED utiliza-
tion.16–20More recently, patient or parentreports ofquality
of care have gained importance; however, little is known
about their association with ED utilization. Only one pre-
care is also associated with ED utilization.6High-quality
family centeredness and effectiveness, 2 of the 6 quality-
of-care domains highlighted for improvement in the Insti-
tute of Medicine’s ‘‘Crossing the Quality Chasm’’report,21
were associated with decreased nonurgent ED visits for
The previous study was limited by its reliance on parent
reports for the numberofED visits thatoccurred duringthe
follow-up period and by the relatively small number of
publicly insured children. We therefore sought to deter-
mine whether high-quality parent-reported quality of
care, assessed by the Consumer Assessment of Healthcare
Providers and Systems (CAHPS),22for children in Medic-
aid is associated with lower subsequent nonurgent ED visit
rates when ED use is based on administrative claims data.
Study Population and Source of Data
This is a retrospective cohort analysis linking the results
of cross-sectional CAHPS surveys evaluating quality of
From the Department of Pediatrics, Children’s Research Institute,
Medical College of Wisconsin (Dr Brousseau and Dr Gorelick);
Department of Pediatrics, Medical College of Wisconsin, Milwaukee,
Wis (Dr Hoffmann); Division of General Pediatrics, Department of
Pediatrics, UT Southern Medical Center, and Children’s Medical
Center, Dallas, Tex (Dr Flores); and Department of Medicine, Patient
Care and Outcomes Research Center Medical College of Wisconsin,
Milwaukee, Wis (Dr Nattinger).
Address correspondence to David C. Brousseau, MD, MS, Department
of Pediatrics, Medical College of Wisconsin, CCC 550, 999 N 92nd St,
Milwaukee, Wisconsin 53226 (e-mail: firstname.lastname@example.org).
Copyright ? 2009 by Academic Pediatric Association
Volume 9, Number 1
January–February 2009 33
analysis of administrative Medicaid data.
The study population combines 2 cohorts of children,
one cohort from 2002 and the other from 2004. In the
partment of Health and Family Services sent CAHPS sur-
veys to randomly selected enrollees in the Wisconsin
Managed Care Medicaid program. The response rate was
39.2% in 2002 and 42.1% in 2004, a response rate similar
to a previously published statewide sample that used the
same instrument.23Although a higher response rate would
have been preferable, the similarities between respondents
and the overall Wisconsin Medicaid population and the be-
lief that a low response rate was unlikely to alter the rela-
tionship between quality of care and subsequent ED
utilization allowed us to be confident in our analysis.
conclusion of the survey year. For our analysis, we included
only those surveys that assessed the quality of care for chil-
dren, as reported by the parent. All children with a care-
giver-completed CAHPS survey were eligible for inclusion.
Data on quality of primary care were linked to all ED
visits for the complete calendar year after completion of
the survey through administrative claims data from the
Wisconsin Department of Health and Family Services.
To ensure complete utilization data, and consistent with
previous publications, children were subsequently ex-
cluded if they had a period of 2 consecutive months
when they were not enrolled in the Medicaid program dur-
ing the follow-up year; over 90% of the final sample was
enrolled in Medicaid for the entire 12 month follow-up
period. The final cohort thus allowed for an evaluation of
the association between parent-reported quality of primary
a statewide Medicaid program.
The study was approved by the Medical College of Wis-
consin Institutional Review Board.
The primary outcomes were the rates of nonurgent and
urgent ED visits per child per year that occurred during
the follow-up period. ED visits were identified by UB92
revenue codes in the range 0450–0459 (ED charges), and
ED visits with an admission were identified by UB92 rev-
enue codes in the range 0100–0169 (inpatient room
charges) on the same date of service as the ED visit.
Urgency was based on the resources utilized during the
visit. This method of assigning urgency has previously
been used in large database studies, and it is the method
most preferred for database research by the Acadamic
Pediatric Association’s Pediatric Emergency Medicine Spe-
visit that resulted in laboratory work, a radiograph, an elec-
trocardiogram, an electroencephalogram, or admission to
as nonurgent.6,25Laboratory work was determined by a cur-
rent procedural terminology (CPT) procedure code starting
with 8 (8xxxx) or a healthcare common procedure coding
system (HCPCS) code starting with P (Pxxx); a radiograph
was determined by a CPT procedure code starting with 7
(7xxxx) orHCPCS codestartingwithR (Rxxx). Anelectro-
or 932xx), and an electroencephalogram by any of the fol-
lowing CPT procedure codes: 95812, 95813, 95816,
95819, 95822, 95824, 95827, 95829, or 95830.
ED visit rates for the final cohort of children were calcu-
lated by using all ED visits during the calendar year after
ter the quality of primary care assessments were completed
by the parents.
Assessment of Health Care Quality Domains
Parents assessed the quality of primary care received by
the child over the preceding year from a personal doctor or
partment of Health and Family Services. If the parent did
not report having a personal doctor or nurse for the child,
the questions were answered about the usual source of
care. As per the recommendations of the Agency for
Healthcare Research and Quality’s guidelines for analyz-
ing the CAHPS survey, the 9 quality-of-care questions
are grouped into composite scores for 3 quality domains:
(1) family centeredness, (2) timeliness, and (3) ‘‘realized
access’’ to care.27‘‘Realized access’’ is one aspect of the
health care domain effectiveness that addresses whether
families perceive problems obtaining necessary care or re-
ferrals. The individual questions comprising each compos-
ite and their Likert scales are listed in Table 1.
The composite scores for each child were obtained by
averaging the individual answered questions that comprise
the quality-of-care composites, with higher scores corre-
sponding with higher quality. Consistent with previous re-
search, the timeliness and family centeredness composites,
both scored on a 4-point Likert scale, were dichotomized,
with scores of >3.5 indicating the highest quality care and
scores of #3.5 indicating lower-quality care. For realized
access, which was scored on a 3-point Likert scale, scores
were dichotomized as 3 vs <3.6,28
Other patient/family characteristics included the follow-
ing: age (categorized as 0–2 years, 3–11 years, and 12–17
years), gender, race/ethnicity (non-Latino white, Latino,
non-Latino black, and other [Asian/Pacific Islander, Native
American and Alaskan native]), having a primary nurse or
doctor (yes or no), interview language (English, Spanish,
or both), parent-reported child health status (excellent or
very good vs good, fair, or poor), and the highest level of
parental educational attainment (dichotomized as high
school graduate or less vs beyond high school graduate).
binomial regression to determine the association between
quality of primary care and subsequent ED utilization rates
from the statewide sample of children in Medicaid.
Second, we compared the results from this first aim to
the results from publicly insured children from the nation-
ally representative Medical Expenditure Panel Survey
(MEPS) to assess potential differences in associations
34 Brousseau et alACADEMIC PEDIATRICS
when ED visits were extracted from administrative data
(Wisconsin Medicaid) or prospectively collected by parent
report (MEPS). The c2test was used to compare the demo-
A negative binomial regression analysis, to account for
sociation between each composite score and the rates of
subsequent nonurgent and urgent ED visits per child. Re-
sults from the regressions are presented as the incidence
rate ratios (IRR) for the rates of urgent or nonurgent ED
visits per child for the year of follow-up. An IRR of <1 in-
dicates that higher-quality care is associated with a lower
rate of ED visits per child.
Each quality-of-care domain was analyzed in a negative
binomial regression with each measure of ED utilization.
All covariates were entered into the model and grouped
as previously described. They are listed in Table 2.
A total of 5582 children had completed CAHPS surveys,
of which 114 were excluded for incomplete subsequent en-
rollment. The final cohort of children was very similar in
age and gender to the population of all children enrolled
in the Managed Care Medicaid program as determined
by comparison to enrollment data from the Department
of Health and Family Services. Of the 5468 children in
the final cohort, 1540 children (28.2%) made a total of
2792 ED visits during the follow-up year, yielding an over-
all ED visit rate of 51.1 visits/100 person-years; 59% of
those ED visits were classified as nonurgent.
Assessment of parent-reported quality-of-care domains
showed that 79% of parents rated family centeredness,
84% rated realized access, and 69% rated timeliness as
children with $1 urgent ED visit and $1 nonurgent ED
visit by characteristic are shown in Table 2. Children 0–2
years old were the only age group in which the proportion
of children with nonurgent ED visits was significantly
greater than the proportional representation in the overall
population (comprising 30% of those making a nonurgent
visit, but only 20% of the population). In addition, those
children whose parents had a high school education or
less were more likely to make urgent and nonurgent visits.
The association between parent-reported quality of care
and rates of subsequent ED visits, adjusting for potential
confounders, was determined through multivariate model-
ing(Table 3). High-quality carewas associated with signif-
icantly lower rates of nonurgent ED utilization in each of
the 3 domains: a 27% lower nonurgent ED visit rate with
high-quality family centeredness, an 18% lower rate with
high-quality timeliness, and a 27% lower rate with high-
quality realized access. When both high-quality family
centeredness and realized access were added to the nonur-
was a 44% lower nonurgent ED visit rate. For urgent ED
visits, high-quality realized access was associated with
a 33% lower visit rate, and high-quality timeliness was as-
sociated with an 18% lower urgent visit rate, both being
significantly different from children receiving lower qual-
ity care in those domains. There was no significant associ-
ation between high-quality family centeredness and the
rate of urgent ED visits per child. When both high-quality
timeliness and realized access were added to the urgent
model together, the combined IRR was a 40% lower non-
urgent ED visit rate.
The addition of the quality-of-care composites to the
multivariate model had essentially no impact on the IRRs
for the other covariates. Of the covariates, 3 factors (high-
est educational attainment, parent reported health status,
and age) were consistently associated with ED utilization
in each model (Table 3). Both a higher level of educational
attainment and better parent-reported child health status
were associated with significantly lower urgent and nonur-
gent visit rates. Children $12 years showed consistently
higher urgent ED utilization, while children #2 years
showed consistently higher nonurgent ED utilization.
Child race/ethnicity showed no association with either ur-
gent or nonurgent ED utilization when other covariates
were included in the model. In addition to these factors,
not having an identified primary care provider was associ-
ated with increased nonurgent ED utilization.
One aim of this study was to determine whether the as-
sociation among 3 of the domains of high-quality care and
ED utilization was similar in parent-reported and adminis-
trative data on ED utilization. Therefore, we compared the
IRRs from this study to previously published findings from
the Medical Expenditure Panel Survey (MEPS; Table 4).
The values were similar between the Medicaid and
Table 1. Individual Consumer Assessment of Healthcare Providers and
Systems (CAHPS) Questions Comprising Quality-of-Care Composites*
1. Family centeredness (1 ¼ never, 2 ¼ sometimes,
3 ¼ often, 4 ¼ always)
1. How often providers explained things so you un-
2. How often providers showed respect for what you
had to say
3. How often providers spent enough time with you
4. How often providers listened carefully to you
2. Timeliness (1 ¼ never, 2 ¼ sometimes, 3 ¼ often,
4 ¼ always)
1. Howoftengotan appointment for aninjury orillness
as soon as wanted
2. How often got a routine appointment as soon as
3. How often able to get help by phone
3. Realized access (1 ¼ a big problem, 2 ¼ somewhat of
a problem, 3 ¼ not a problem)
1. How big a problem to get care you or a doctor
2. How big a problem to get a referral to a specialist
*Highest quality indicated by a composite score of >3.5 on a 4-point
scale for timeliness and family centeredness, and score of 3 on a 3-point
scale for realized access. Composites were obtained by averaging
answered questions within a domain.
ACADEMIC PEDIATRICS Emergency Department Utilization in Wisconsin Children35
noting. With the larger sample size of the current study,
high-quality primary care for all 3 domains is now associ-
ated with lower subsequent rates of nonurgent ED visits
in the Medicaid data set. For urgent ED visit rates, high-
quality realized access is associated with lower rates,
with the IRR for realized access potentially having an im-
portant difference from the IRR from the MEPS sample.
The study findings indicate that specific domains that
comprise high parent-reported quality of primary care for
children are associated with lower subsequent nonurgent
and urgent visit rates to the ED. High-quality family cen-
teredness, timeliness, and realized access were all associ-
ated with lower subsequent nonurgent utilization of the
ED for children, while high-quality timeliness and realized
All Children in Sample, %
(n ¼ 5468)
All Children With $1 Urgent ED
Visit, % (n ¼ 808)
All Children with $1 Nonurgent ED
Visit, % (n ¼ 1063)
Reported health status
Primary doctor or nurse
Highest family education
High school graduate or less
More than high school
*Data on utilization were obtained from Wisconsin Medicaid administrative claims data.
†Significantly different from percentage of population, P <.01 (c2test).
Table 3. Multivariate Analysis Showing the Association Between High-Quality Primary Care in Each Quality Domain and the Rates of Urgent and Non-
urgent Emergency Department (ED) Visits During the Year After Quality-of-Care Assessments†
Quality of Care CompositeUrgent ED Visits IRR (95% CI)Nonurgent ED Visits IRR (95% CI)
Gender: female (ref: male)
Primary doctor/nurse: no (ref: yes)
Health status: good/fair/poor (ref: excellent/very good)
Education: more than high school graduate (ref: high school or less)
Language: Spanish (ref: English)
†Negative binomial regression. Regression coefficients for the covariates are from model without quality-of-care composites. Adding composites re-
sulted in minimal changes, so baseline model was used to ease comparison. Results are presented as incidence rate ratios (IRR) with 95% confidence
intervals (95% CI). Data on utilization were obtained from Wisconsin Medicaid administrative claims data.
*Significant at P <.05.
36Brousseau et alACADEMIC PEDIATRICS
access were also associated with a lower subsequent urgent
visit rate to the ED.
The findings from this study that high-quality parent-
reported family centeredness and realized access are asso-
ciated with lower subsequent nonurgent ED utilization are
similar to our previous study, which relied on parent-
reported ED utilization.6In our previous study, the associ-
ation between high-quality timeliness and nonurgent ED
utilization did not reach statistical significance, despite
a decrease of 26% in visits during the follow-up period.
In the current study, with its larger sample size of publicly
insured children, the association was statistically signifi-
cant, with a lowering of 18% in the nonurgent ED visit
rate per child with high-quality timeliness.
The association between parent-reported quality of care
and subsequent urgent ED utilization in this study does
show significantly lower urgent ED utilization with parent-
reported high-quality care realized access that the previous
study did not. High-quality realized access was associated
with a 33% lower urgent ED visit rate. Additionally, high-
quality timeliness was associated with a lower urgent ED
visit rate per child in this study of children in Medicaid.
The finding that high-quality timeliness is associated
with a lower subsequent rate of nonurgent ED visits per
child may not be surprising, but the fact that the point esti-
mate for a decrease in urgent utilization was similar to that
for nonurgent utilization is interesting. This relationship
may suggest that in the setting of an acute illness, timely
access to a primary care provider may actually decrease
ED visits for urgent conditions as well. This could be sec-
ondary to primary care practices providing resources that
would classify a visit as urgent, or alternatively, a visit to
a primary care provider for some complaints may be able
to be managed without the use of resources that an ED
would expend because of better knowledge of the child.
In this case, what would have been an urgent ED visit
most likely becomes a nonurgent clinic visit, but could
become an urgent clinic visit if the resources are available.
The finding that high-quality realized access is associ-
ated with lower subsequent urgent ED utilization is
plausible if a referral to a specialist decreases the overall
need for urgent care. Previous studies have shown that
specialty care decreases the levelof disease severity, which
may serve to decrease the number of illnesses requiring
urgent ED care.29,30In this case, it may be that the overall
level of urgency for the illness is less, thus eliminating
urgent ED visits.
When evaluating the strengths of the associations, the
quality-of-care composites show a similar strength of asso-
ciation with the ED outcome measures as parent-reported
health status and education level for both urgent and non-
urgent utilization. Age has a stronger strength of associa-
tion than any single quality-of-care composite; however,
the combination of high-quality family centeredness and
realized access results in a similar lowering of nonurgent
ED utilization as that seen with increased age.
A sustaining goal of the American Academy of Pediat-
develop a strong relationship with a primary care provider.
childwith aprimaryproviderwith whom the child receives
the bulk of his/her care, and a place where the family feels
that responsibility for coordinating the child’s care and
medical home delivers care that is ‘‘accessible, family-
centered, continuous, comprehensive, coordinated, com-
passionate and culturally effective.’’32Many investigators
have attempted to study the effect of a medical home by
simply indicating the existence of an identified primary
care provider33–36; this study utilizes the parent report of
the quality of primary care received, thereby providing
a more in-depth assessment of the primary care provider’s
when and where to seek care for a child, and it is therefore
only by understanding the parent perspective on the rela-
tionship between family and primary care provider that
one can understand the decisions that families make when
deciding where and when to seek care.
The other novel aspect of this study is its focus on chil-
dren in Medicaid to evaluate the relationship between par-
ent reported quality of primary care and subsequent use of
the ED. Low-income children are less likely to receive
timely and patient-centered medical care,37and they use
the ED at twice the rate of children from higher-income
families.38The findings from this study highlight the im-
portance of reducing the disparity in quality of care and
could explain why the ED utilization rate is so high among
thesehigh-riskchildren. From apolicystandpoint,improv-
ing the quality of care for all children in Medicaid is an im-
portant objective, but the realization that increased ED
utilization may be the result of low-quality care will, we
hope, encourage the implementation of policies aimed at
improving the quality of care.
was only 40%. The resulting cohort, however, was demo-
enrolled in the Medicaid managed care program. Although
a low response rate introduces the potential for selection
bias, it is unclear how a low response to the survey would
Table 4. Association Between High-Quality Care and Emergency De-
partment (ED) Utilization Between Wisconsin Medicaid ED Utilization
Data and National Parent-Reported ED Utilization Data*
IRR (95% CI)†
National Sample of
Children, IRR (95% CI)‡
Nonurgent ED visits
Urgent ED visits
*IRR indicates incidence rate ratio; 95% CI indicates 95% confidence
†Data on utilization were obtained from Wisconsin Medicaid adminis-
trative claims data.
‡Data on utilization were parent reported and were obtained from the
Medical Expenditure Panel Survey.6
ACADEMIC PEDIATRICS Emergency Department Utilization in Wisconsin Children37
alter the relationship under investigation. All surveys were
period, and there was no knowledge of this study’s hypoth-
esis among those who completed the survey. In addition, it
is difficult to predict why the relationship between quality
of care and subsequent utilization would differ between re-
spondents and nonrespondents. Another limitation is the
classification of urgency, which was based on the resources
used. Although this method has been widely used in the
medical literature, it is still possible that some visits may
have been misclassified. However, misclassification would
most likely have led urgent visits to be misclassified as
nonurgent, thus biasing towards the null, leading us to un-
derestimate the magnitude of the association. In addition,
children with asthma or children who require intravenous
fluids for dehydration may also be classified as nonurgent
in this study. Although some of those visits may have
been urgent, these 2 conditions are both pediatric quality
of primary care indicator conditions and may themselves
represent decreased quality of primary care.39
Parent-reported high-quality timeliness, family cen-
teredness, and realized access of primary care for a child
are associated with significantly lower rates of subsequent
nonurgent ED visits while high-quality realized access and
visits. Whether the ED visits are parent reported or are
based on administrative data, the relationship between
these domains of care and subsequent utilization is similar,
thus strengthening the argument that parent-reported qual-
ity of primary care provides important information about
the care childrenreceiveand the conclusionthat high-qual-
ity primary care in specific domains is associated with
lower rates of ED utilization.
This work was supported by a grant (K08 HS015482-01A1) to Dr
Brousseau from the Agency for Healthcare Research and Quality. The
authors report no conflicts of interest or corporate sponsors.
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