Understanding frequent emergency room use by Medicaid-insured children with asthma: a combined quantitative and qualitative study.

BACKGROUND: Medicaid-insured asthmatic children frequently use emergency rooms (ERs). The reasons are unclear and have predominantly been studied in inner-city populations. METHODS: We used billing data and focus groups to clarify reasons for frequent ER use by Medicaid-insured children with asthma living in rural areas and 23 towns in Kansas. RESULTS: High ER utilization was concentrated in a small percentage of provider practices and children with asthma. Parents expressed strong preference for primary care treatment, and identified real or perceived difficulties in using primary care as the principal reasons for ER use. Difficulties included trouble contacting primary care physicians or obtaining urgent appointments, limited continuity of care, practice systems poorly adapted to patient needs, a perception that physicians preferred patients to use emergency services, and difficulties in obtaining medications. Parents were not aware of preventive measures or case management but reported high interest in these. Parents did not recall provider discussion of asthma risk factors/preventive strategies during primary care visits, although all children with high ER utilization had multiple risk factors, including exposure to high levels of household smoking. CONCLUSIONS: Reducing ER utilization by Medicaid-insured asthmatic children depends on overcoming barriers to effective treatment in primary care and in greater attention to preventive services.