Explainable AI decision support improves accuracy during telehealth strep throat screening.

BACKGROUND: Artificial intelligence-based (AI) clinical decision support systems (CDSS) using unconventional data, like smartphone-acquired images, promise transformational opportunities for telehealth; including remote diagnosis. Although such solutions' potential remains largely untapped, providers' trust and understanding are vital for effective adoption. This study examines how different human-AI interaction paradigms affect clinicians' responses to an emerging AI CDSS for streptococcal pharyngitis (strep throat) detection from smartphone throat images. METHODS: In a randomized experiment, we tested explainable AI strategies using three AI-based CDSS prototypes for strep throat prediction. Participants received clinical vignettes via an online survey to predict the disease state and offer clinical recommendations. The first set included a validated CDSS prediction (Modified Centor Score) and the second introduced an explainable AI prototype randomly. We used linear models to assess explainable AI's effect on clinicians' accuracy, confirmatory testing rates, and perceived trust and understanding of the CDSS. RESULTS: The study, involving 121 telehealth providers, shows that compared to using the Centor Score, AI-based CDSS can improve clinicians' predictions. Despite higher agreement with AI, participants report lower trust in its advice than in the Centor Score, leading to more requests for in-person confirmatory testing. CONCLUSIONS: Effectively integrating AI is crucial in the telehealth-based diagnosis of infectious diseases, given the implications of antibiotic over-prescriptions. We demonstrate that AI-based CDSS can improve the accuracy of remote strep throat screening yet underscores the necessity to enhance human-machine collaboration, particularly in trust and intelligibility. This ensures providers and patients can capitalize on AI interventions and smartphones for virtual healthcare.

Strep pharyngitis, or strep throat, is a bacterial infection that can cause a sore throat. Artificial intelligence (AI) can use photos taken on a person's phone to help diagnose strep throat, offering an additional way for doctors to screen patients during virtual appointments. However, it is currently unclear whether doctors will trust AI recommendations or how they might use them in decision-making. We surveyed clinicians about their use of an AI system for strep throat screening with smartphone images. We compared different ways of providing AI recommendations to standard medical guidelines. We found that all tested AI methods helped clinicians to identify strep throat cases. However, clinicians trusted AI less than their usual clinical guidelines, leading to more requests for follow-up in-person testing. Our results show how AI may improve the accuracy of pharyngitis assessment. Still, further research is needed to ensure doctors trust and collaborate with AI to improve remote healthcare.

Pediatric Chest Compression Improvement Via Augmented Reality Cardiopulmonary Resuscitation Feedback in Community General Emergency Departments: A Mixed-Methods Simulation-Based Pilot Study.

BACKGROUND: Yearly, more than 20,000 children experience a cardiac arrest. High-quality pediatric cardiopulmonary resuscitation (CPR) is generally challenging for community hospital teams, where pediatric cardiac arrest is infrequent. Current feedback systems are insufficient. Therefore, we developed an augmented reality (AR) CPR feedback system for use in many settings. OBJECTIVE: We aimed to evaluate whether AR-CPR improves chest compression (CC) performance in non-pediatric-specialized community emergency departments (EDs). METHODS: We performed an unblinded, randomized, crossover simulation-based study. A convenience sample of community ED nonpediatric nurses and technicians were included. Each participant performed three 2-min cycles of CC during a simulated pediatric cardiac arrest. Participants were randomized to use AR-CPR in one of three CC cycles. Afterward, participants participated in a qualitative interview to inquire about their experience with AR-CPR. RESULTS: Of 36 participants, 18 were randomized to AR-CPR in cycle 2 (group A) and 18 were randomized to AR-CPR in cycle 3 (group B). When using AR-CPR, 87-90% (SD 12-13%) of all CCs were in goal range, analyzed as 1-min intervals, compared with 18-21% (SD 30-33%) without feedback (p < 0.001). Analysis of qualitative themes revealed that AR-CPR may be usable without a device orientation, be effective at cognitive offloading, and reduce anxiety around and enhance confidence in the CC delivered. CONCLUSIONS: The novel CPR feedback system, AR-CPR, significantly changed the CC performance in community hospital non-pediatric-specialized general EDs from 18-21% to 87-90% of CC epochs at goal. This study offers preliminary evidence suggesting AR-CPR improves CC quality in community hospital settings.

Paediatric chest compression performance improves via novel augmented-reality cardiopulmonary resuscitation feedback system: A mixed-methods pilot study in a simulation-based setting.

Aim: More than 20,000 children experience a cardiac arrest event each year in the United States. Most children do not survive. High-quality cardiopulmonary resuscitation (CPR) has been associated with improved outcomes yet adherence to guidelines is poor. We developed and tested an augmented reality head mounted display chest compression (CC) feedback system (AR-CPR) designed to provide real-time CC feedback and guidance. Methods: We conducted an unblinded randomized crossover simulation-based study to determine whether AR-CPR changes a user's CC performance. A convenience sample of healthcare providers who perform CC on children were included. Subjects performed three two-minute cycles of CC during a simulated 18-minute paediatric cardiac arrest. Subjects were randomized to utilize AR-CPR in the second or third CC cycle. After, subjects participated in a qualitative portion to inquire about their experience with AR-CPR and offer criticisms and suggestions for future development. Results: There were 34 subjects recruited. Sixteen subjects were randomly assigned to have AR-CPR in cycle two (Group A) and 18 subjects were randomized to have AR-CPR in cycle three (Group B). There were no differences between groups CC performance in cycle one (baseline). In cycle two, subjects in Group A had 73% (SD 18%) perfect CC epochs compared to 17% (SD 26%) in Group B (p < 0.001). Overall, subjects enjoyed using AR-CPR and felt it improved their CC performance. Conclusion: This novel AR-CPR feedback system showed significant CC performance change closer to CC guidelines. Numerous hardware, software, and user interface improvements were made during this pilot study.

Artificial intelligence to diagnose ear disease using otoscopic image analysis: a review.

AI relates broadly to the science of developing computer systems to imitate human intelligence, thus allowing for the automation of tasks that would otherwise necessitate human cognition. Such technology has increasingly demonstrated capacity to outperform humans for functions relating to image recognition. Given the current lack of cost-effective confirmatory testing, accurate diagnosis and subsequent management depend on visual detection of characteristic findings during otoscope examination. The aim of this manuscript is to perform a comprehensive literature review and evaluate the potential application of artificial intelligence for the diagnosis of ear disease from otoscopic image analysis.

Interhospital Transport of Children With Peripheral Venous Catheters by Private Vehicle: A Mixed Methods Assessment.

BACKGROUND: Many children seeking emergency care at community hospitals require transport to tertiary centers for definitive management. Interhospital transport via ambulance versus patient's own vehicle (POV) are 2 possible modes of transport; however, presence of a peripheral venous catheter (PIV) can determine transport by ambulance. Caregiver satisfaction, patient comfort, and PIV complications related to POV transport have not been described. OBJECTIVE: The aims of the study were to examine caregivers' satisfaction and perceptions of POV transport in children with/without PIVs and to assess PIV-related complications during transport. METHODS: We performed a mixed-methods, prospective cohort study of children who presented with low-acuity conditions to a community hospital and subsequently required transfer to a pediatric tertiary center. Caregivers of patients with/without PIVs were given the choice of transport by POV or ambulance. Surveys completed after transport used dichotomous, 5-point Likert scale, and open-ended responses to assess satisfaction, perceptions, and PIV-related complications. Responses were quantitatively and qualitatively analyzed accordingly. The receiving hospital assessed PIV integrity. RESULTS: Sixty-nine of 78 eligible patients were enrolled; of those, 67 (97%) elected transport by POV and 55 (82%) completed surveys. Most caregivers had positive responses related to satisfaction, comfort, and safety. Results did not differ significantly between those with/without PIVs. The majority (96%) would choose POV transport again. There were no reported PIV complications; all PIVs were functional upon arrival. Qualitative analysis identified themes of comfort, convenience, and efficiency. CONCLUSIONS: In select scenarios, interfacility transport by POV is preferred by families and doing so with a saline-locked PIV does not result in complications.

Pediatric Coping During Venipuncture With Virtual Reality: Pilot Randomized Controlled Trial.

BACKGROUND: Virtual reality (VR) has shown promise in reducing children's pain and anxiety during venipuncture, but studies on VR lack objective observations of pediatric coping. Notably, the process of capturing objective behavioral coping data can be labor- and personnel-intensive. OBJECTIVE: The primary aims of this pilot trial were to assess the feasibility of conducting a trial of VR in a pediatric emergency department and the feasibility of documenting observed coping behaviors during pediatric procedures. Secondarily, this study examined whether VR affects child and caregiver coping and distress during venipuncture in the pediatric emergency department. METHODS: This stratified, randomized, controlled pilot trial compared coping and distress between child life-supported VR engagement and child life specialist support without VR during painful procedures in children aged 7-22 years in the pediatric emergency department. An external control (reference group) received no standardized support. Primary feasibility outcomes included rates of recruitment, rates of withdrawal from VR, and rates of completed Child Adult Medical Procedure Interaction Scale-Short Form (CAMPIS-SF) observations. Secondary clinical outcomes were applied to venipuncture procedures and included CAMPIS-SF coping and distress (range 0-1.0), pain and anxiety on a visual analog scale (range 0-10), and cybersickness symptoms. RESULTS: Overall recruitment was 93% (66/71), VR withdrawal rate was 27% (4/15), and of the completed procedures, 100% (63/63) CAMPIS-SF observations were completed. A total of 55 patients undergoing venipuncture in the pediatric emergency department were included in the analyses of clinical outcomes: 15 patients (15 caregivers) randomized to VR, 20 patients (15 caregivers) randomized to child life specialist support, and 20 patients (17 caregivers) in the reference group. Patient coping differed across groups with higher coping in the VR group and child life specialist group than in the reference group (P=.046). There were no significant differences in the distress and pain ratings for patients and caregivers between the groups. Caregivers rated the lowest perceived anxiety in the child life specialist group (P=.03). There was no apparent change in cybersickness symptoms before and after VR use (P=.37). CONCLUSIONS: Real-time documentation of observed behaviors in patients and caregivers was feasible during medical procedures in which VR was utilized, particularly with the availability of research staff. VR and child life specialists improved coping in children during venipuncture procedures. Given the high participation rate, future studies to evaluate the efficacy of VR are recommended to determine whether an off-the-shelf VR headset can be a low-cost and low-risk tool to improve children's coping during venipuncture or other related procedures. TRIAL REGISTRATION: ClinicalTrials.gov NCT03686176; https://clinicaltrials.gov/ct2/show/NCT03686176.

Resource Use During Pediatric Venipuncture With Virtual Reality: Secondary Analysis of a Randomized Controlled Pilot Trial.

OBJECTIVES: Virtual reality (VR) therapy is growing in use and popularity during pediatric medical procedures. Currently, data that describe the hospital resources used during pediatric procedures with off-the-shelf VR games that are not tailored to medical procedures are lacking. In this study, we aimed to characterize procedural resources associated with VR use during venipuncture in a pediatric emergency department. METHODS: This was a secondary analysis of a 2-arm randomized, controlled pilot trial with an external group. Resource use was evaluated in 3 groups: child life (CL)-supported VR engagement, CL support without VR, and a reference group that received no intervention (ie, no CL and no VR). RESULTS: The study sample (N = 55) included the following: 15 patients randomly assigned to VR, 20 patients randomly assigned to CL, and 20 patients in the reference group. There was a significant difference in procedure duration, with the VR group exhibiting the longest duration compared with the CL and reference groups (P = .01). CONCLUSIONS: Longer procedure times associated with VR use during venipunctures (4-6 minutes on average) may be attributed to pauses to troubleshoot VR games not tailored for medical procedures. Although they are inexpensive and accessible, nontailored VR games may warrant the need for dedicated staff to provide restraint and/or assistance to navigate the VR application. In this study, we offer a protocol on the application of nontailored VR games for pediatric procedures. For those considering a VR program in an inpatient setting, the benefits of pain/anxiety reduction must be weighed against the resources needed, including device costs, staff availability, and increased procedure duration.

Evaluation of digital otoscopy in pediatric patients: A prospective randomized controlled clinical trial.

BACKGROUND: Acute otitis media is often misdiagnosed. Pediatric trainees learn otoscopy from supervisors who cannot concurrently view the eardrum. Digital, smartphone otoscopes show promise to improve the visibility and learning due to a concurrent view by trainees and supervisors. We aimed to determine whether use of digital otoscopes improved accuracy of the ear exams between medical trainees and their supervisors, compared to using traditional otoscopes. Secondarily, we evaluated whether the use of digital otoscopes reduced the number of repeat ear examinations by supervisors, changed the trainee's confidence in their exam findings, and led to differences in the rate of antibiotics prescribed. METHODS: This study was a randomized controlled trial comparing use of a digital otoscope to a traditional otoscope, in a pediatric emergency department and primary care clinic in an academic tertiary care children's center. We used a modified validated image-based grading scale to compare accuracy of the ear exam between trainees and supervisors. Surveys documented modified OMgrade scores, frequency of supervisor exams, trainee confidence on a 5-point Likert scale, and antibiotic prescriptions. Inter-rater agreement of trainees and supervisors, the number of supervisor confirmatory examinations performed, trainee confidence, and antibiotic prescription rates were evaluated. RESULTS: Amongst 188 children, 375 ears were examined by 85 trainees and 22 supervisors. The digital otoscope was utilized in 92 (48.9%) exams and 96 (51.1%) used the traditional otoscope. Accuracy of ear exam findings between trainees and supervisors improved by 11.2% (95% CI: 1.5, 21.8%, p = 0.033) using the Cellscope Oto (74.8%, 95% CI: 67.3, 82.1%) compared to the traditional otoscope (63.5%, 95% CI: 56.7, 70.4%). Fewer repeat supervisor exams were performed in the digital otoscope group (27.2%) vs. the traditional otoscope group (97.9%) (p < 0.001). There was no difference in mean trainee confidence in their examination (p = 0.955) or antibiotic prescription rates when using digital versus traditional otoscopes (p = 0.071). CONCLUSIONS: Utilization of a digital otoscope resulted in increased accuracy of the ear exam between trainees and supervisors, and fewer total number of examinations performed on a given child. Compared to a traditional otoscope, a digital otoscope may be a more efficient and effective diagnostic tool.

Pediatric Otoscopy Video Screening With Shift Contrastive Anomaly Detection.

Ear related concerns and symptoms represent the leading indication for seeking pediatric healthcare attention. Despite the high incidence of such encounters, the diagnostic process of commonly encountered diseases of the middle and external presents a significant challenge. Much of this challenge stems from the lack of cost effective diagnostic testing, which necessitates the presence or absence of ear pathology to be determined clinically. Research has, however, demonstrated considerable variation among clinicians in their ability to accurately diagnose and consequently manage ear pathology. With recent advances in computer vision and machine learning, there is an increasing interest in helping clinicians to accurately diagnose middle and external ear pathology with computer-aided systems. It has been shown that AI has the capacity to analyze a single clinical image captured during the examination of the ear canal and eardrum from which it can determine the likelihood of a pathognomonic pattern for a specific diagnosis being present. The capture of such an image can, however, be challenging especially to inexperienced clinicians. To help mitigate this technical challenge, we have developed and tested a method using video sequences. The videos were collected using a commercially available otoscope smartphone attachment in an urban, tertiary-care pediatric emergency department. We present a two stage method that first, identifies valid frames by detecting and extracting ear drum patches from the video sequence, and second, performs the proposed shift contrastive anomaly detection (SCAD) to flag the otoscopy video sequences as normal or abnormal. Our method achieves an AUROC of 88.0% on the patient level and also outperforms the average of a group of 25 clinicians in a comparative study, which is the largest of such published to date. We conclude that the presented method achieves a promising first step toward the automated analysis of otoscopy video.

Pediatric outpatient utilization by differing Medicaid payment models in the United States.

BACKGROUND: In the United States (US), Medicaid capitated managed care costs are controlled by optimizing patients' healthcare utilization. Adults in capitated plans utilize primary care providers (PCP) more than emergency departments (ED), compared to fee-for-service (FFS). Pediatric data are lacking. We aim to determine the association between US capitated and FFS Medicaid payment models and children's outpatient utilization. METHODS: This retrospective cohort compared outpatient utilization between two payment models of US Medicaid enrollees aged 1-18 years using Truven's 2014 Marketscan Medicaid database. Children enrolled > 11 months were included, and were excluded for eligibility due to disability/complex chronic condition, lack of outpatient utilization, or provider capitation penetration rate < 5% or > 95%. Negative binomial and logistic regression assessed relationships between payment model and number of visits or odds of utilization, respectively. RESULTS: Of 711,008 children, 66,980(9.4%) had FFS and 644,028(90.6%) had capitated plans. Children in capitated plans had greater odds of visits to urgent care, PCP-acute, and PCP-well-child care (aOR 1.21[95%CI 1.15-1.26]; aOR 2.07[95%CI 2.03-2.13]; aOR 1.86 [95%CI 1.82-1.91], respectively), and had lower odds of visits to EDs and specialty care (aOR 0.82 [95%CI 0.8-0.83]; aOR 0.61 [95%CI 0.59-0.62], respectively), compared to FFS. CONCLUSIONS: The majority of children in this US Medicaid population had capitated plans associated with higher utilization of acute care, but increased proportion of lower-cost sites, such as PCP-acute visits and UC. Health insurance programs that encourage capitated payment models and care through the PCP may improve access to timely acute care in lower-cost settings for children with non-complex chronic conditions.

Factors Associated With Urgent Care Reliance and Outpatient Health Care Use Among Children Enrolled in Medicaid.

Importance: Urgent care (UC) centers are a growing option to address children's acute care needs, which may cause unanticipated changes in health care use. Objectives: To identify factors associated with high UC reliance among children enrolled in Medicaid and examine the association between UC reliance and outpatient health care use. Design, Setting, and Participants: A retrospective cohort study used deidentified data on 4 133 238 children from the Marketscan Medicaid multistate claims database to calculate UC reliance and outpatient health care use. Children were younger than 19 years, with 11 months or more of continuous Medicaid enrollment and 1 or more UC, emergency department (ED), primary care provider (PCP; physician, advanced practice nurse, or physician assistant; well-child care [WCC] or non-WCC), or specialist outpatient visit during the 2017 calendar year. Statistical analysis was conducted from November 11 to 26, 2019. Exposures: Urgent care, ED, PCP (WCC and non-WCC), and specialist visits based on coded location of services. Main Outcomes and Measures: Urgent care reliance, calculated by the number of UC visits divided by the sum of total outpatient (UC, ED, PCP, and specialist) visits. High UC reliance was defined as UC visits totaling more than 33% of all outpatient visits. Results: Of 4 133 238 children in the study, 2 090 278 (50.6%) were male, with a median age of 9 years (interquartile range, 4-13 years). A total of 223 239 children (5.4%) had high UC reliance. Children 6 to 12 years of age were more likely to have high UC reliance compared with children 13 to 18 years of age (adjusted odds ratio, 1.07; 95% CI, 1.06-1.09). Compared with white children, black children (adjusted odds ratio, 0.81; 95% CI, 0.81-0.82) and Hispanic children (adjusted odds ratio, 0.61; 95% CI, 0.60-0.61) were less likely to have high UC reliance. Adjusted for age, sex, race/ethnicity, and presence of chronic or complex conditions, children with high UC reliance had significantly fewer PCP encounters (WCC: adjusted rate ratio, 0.60; 95% CI, 0.60-0.61; and non-WCC: adjusted rate ratio, 0.41; 95% CI, 0.41-0.41), specialist encounters (adjusted rate ratio, 0.31; 95% CI, 0.31-0.31), and ED encounters (adjusted rate ratio, 0.68; 95% CI, 0.67-0.68) than children with low UC reliance. Conclusions and Relevance: High UC reliance occurred more often in healthy, nonminority, school-aged children and was associated with lower health care use across other outpatient settings. There may be an opportunity in certain populations to ensure that UC reliance does not disrupt the medical home model.

A Resident-Led QI Initiative to Improve Pediatric Emergency Department Boarding Times.

BACKGROUND: Pediatric emergency department (PED) overcrowding and prolonged boarding times (admission order to PED departure) decrease quality of care. Timely transfer of patients from the PED to inpatient units is a key driver that relieves overcrowding. In 2015, PED boarding time at our hospital was 10% longer than the national benchmark. We described a resident-led quality-improvement initiative to decrease PED mean boarding times by 10% (from 173 to 156 minutes) within 6 months among general pediatric admissions. METHODS: We applied Plan-Do-Study-Act (PDSA) methodology. PDSA 1 (October 2016) interventions were bundled to include streamlined mobile communications, biweekly educational presentations, and reminder signs. PDSA 2 (August 2017) provided alternative workflows for senior residents. Outcomes were mean PED boarding times for general pediatrics admissions. The proportion of PICU transfers within 12 hours of admission served as a balancing measure. Statistical process control charts were used to analyze boarding times and PICU transfer rates. RESULTS: Leading up to PDSA 1, monthly mean boarding times decreased from 173 to 145 minutes and were sustained throughout the study period and up to 1 year after study completion. The X-bar chart demonstrated a shift with 57 consecutive months of mean boarding times below the preintervention mean. There were no changes in PICU transfer rates within 12 hours of admission. CONCULSIONS: Resident-led quality improvement efforts, including education and streamlined workflow, significantly improved PED boarding time without causing harm to patients.

Urgent Care Utilization in a Pediatric Population With Private Health Insurance.

INTRODUCTION: Pediatric urgent care (UC) utilization patterns have been studied in Medicaid enrollees, but not in those with private insurance. METHODS: Utilization patterns of UC at a suburban pediatric primary care practice with patients with private health insurance were reviewed. Descriptive data were obtained. RESULTS: Three hundred twenty-five charts were reviewed. Most UC visits were for children under 6 years of age (59.7%), a diagnosis of fever (12.2%), and with low severity illness (57.8%). Seventy percent occurred during weekdays and during times when the primary care practice was open. Most children (67.4%) had a diagnostic test performed at UC and 42.2% received a prescription for antibiotics. DISCUSSION: Primary care providers should target caregiver education on low acuity conditions and consider process improvements to accommodate urgent visits. While pediatric UC benchmarks are needed, data suggests that general UCs are at risk for overprescribing antibiotics compared to national ambulatory averages.

Acceptance of Preventive Dental Services for Children at a Retail-Based Clinic: A Pilot Study.

Purpose: Low-income children with high caries risk are disproportionately affected by poor access to dental care. Retail-based clinics (RBCs) can provide accessible ancillary oral health care. The purposes of this study were: (1) to measure caregivers' acceptance rate of an oral health screening, fluoride varnish (FV) application, and caries risk assessment offered to children on a walk-in basis in an RBC; and (2) to categorize the caries risk and demographics among the participants.
Methods: Screenings and FV applications were provided to children younger than 18 years at a Walgreens Health Care Clinic in Baltimore, Md., USA, from October 2016 to October 2017. The acceptance rate and caries risk using the American Dental Association caries risk assessment form were documented. Descriptive statistics and Fisher's exact test were used to analyze the data.
Results: Eighty-five children and their caretakers were approached and 32 (38 percent) agreed to participate. Most children had high caries risk (84.3 percent) and a dental home (81.2 percent), but only 50 percent reported visiting their dentist in the last year.
Conclusion: Our results demonstrate modest acceptance of FV application for children on a convenience basis. This population had predominantly high caries risk, with poor adherence to follow-up with their dental home. Retail-based dental care should not replace the dental home but could support it by increasing access to preventive dental care in children. (J Dent Child 2019;86(1):40-6)
Received July 2, 2018; Last Revision August 13, 2018; Accepted August 13, 2018.

Urgent Care Utilization in the Pediatric Medicaid Population.

OBJECTIVE: To assess healthcare utilization patterns associated with high (≥3 visits/year) urgent care utilization. STUDY DESIGN: Retrospective analysis of 2 723 792 children who were less than 19 years of age in the 2013 Marketscan Medicaid database. Healthcare utilization categorized as inpatient, emergency department, urgent care, well-child primary care provider (PCP), acute PCP, and specialist visits was documented for 4 groups. We hypothesized that children with high urgent care utilization would have decreased utilization at other sites of care. Multivariable logistic models compared the odds of high urgent care utilization. RESULTS: Of children in the study population, 92.0% had no urgent care visits; 4.7% had 1; 1.5% had 2; and 1.0% had ≥3. Patient attributes of high urgent care utilization were: ages 1-2 years (aOR = 2.32, 95% CI: 2.18-2.36, reference group: 13-18 years), presence of a complex chronic condition (CCC) (aOR = 1.98, 95% CI: 1.88-2.07, reference group: no CCC) and no CCC but ≥3 chronic conditions (aOR = 2.85, 95% CI: 2.73-2.97, reference group: no CCC, no chronic conditions). High urgent care utilization was associated with ≥5 PCP visits for acute care (aOR = 1.16, 95% CI: 1.11-1.20, reference group: 0 visits), and ≥3 emergency department visits (aOR = 2.15, 95% CI: 2.10-2.23, reference group: 0 visits). CONCLUSIONS: Increased urgent care utilization was associated with an increase in overall healthcare utilization. Even though those with higher urgent care utilization had more visits for acute care, patients continued to see their PCP for both well-child and acute care visits.