Risk and Protective Factors for Hospital Admissions and Emergency Department Visits among Children with Complex Chronic Conditions

The purpose of this dissertation is to explore the factors associated with hospital admissions and emergency department (ED) visits among children with complex chronic conditions (CCC), a population that typically has high rates of utilization. An integrative literature review was conducted to identify how previous studies examined hospital admissions and ED visits and to expose gaps in the published literature. This convergent parallel mixed methods exploratory study addressed the gaps identified during literature review. A descriptive, retrospective cohort investigation using medical record review was performed concurrently with parent/caregiver interviews and health care provider focus groups. Findings from quantitative linear regression modeling and qualitative directed content analysis were merged to create a comprehensive risk profile. Finally, a sub-study was conducted to explore whether factors associated with rural versus urban residence placed children at increased risk. Key risk factors identified were: conditions with greater complexity, younger age, a greater number of siblings, lacking resources such as transportation, telephone access, and income, having public insurance or self-pay status, ineffective parent-provider communication, and lacking community resources. Key protective factors identified included: parents' ever-growing knowledge and experience, parents' vigilance over the child, family member support, open parent-provider communication, strong parent-provider relationships, and community support. Rural residence was also identified as a risk factor since findings suggested rural disparities in access to primary and outpatient care. Prospective studies are needed to confirm the hypothesized risk and protective factors, and studies with larger samples and wider age ranges are needed to improve the generalizability of the findings. Future studies should also incorporate a wider perspective of health care utilization including other hospitals/EDs, primary care, and outpatient services. Finally, interventions should be designed or refined to minimize the effect of risk factors and strengthen the impact of protective factors on hospital/ED utilization among children with CCC. Findings from this dissertation are significant for nurses and other health care providers because they allow for a more complete understanding of the issues faced by children with CCC and their families necessary to tailor steps to decrease rates of hospital/ED utilization.