Disparities in Pediatric Outpatient Office Visits After First-time Migraine-related Emergency Visit
Danielle Kellier1, Marissa Anto2, Mary Regina Boland5, Craig Press2, Naomi Hughes3, Svetlana Ostapenko4, John Farrar1, Christina Szperka2
1Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, 2Department of Neurology, 3Department of Emergency Medicine, 4Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, 5Saint Vincent College
Objective:
To identify socioeconomic factors associated with rates of outpatient evaluation after a pediatric emergency department (ED) visit for migraine applying natural language processing to identify migraine through clinical notes.
Background:
Children of color are seen disproportionately in the ED for headache compared to those evaluated by outpatient neurology providers and are less likely to be assigned a migraine diagnosis, potentially impacting access to outpatient management.
Design/Methods:
We developed a language-learning model to identify migraine-related visits at one pediatric ED (sensitivity of model: 0.85; specificity: 0.69) trained on clinical notes from first-time visits with a chief complaint of headache and verified by chart review for patients ages 5-17 between January 2016 to February 2020. Analysis was restricted to patients with a primary pediatrician within our network. We calculated risk ratios for demographic and clinical traits for the likelihood of visiting an outpatient neurology or primary pediatric clinic within 6 months following their initial ED visit for migraine.
Results:
Across 3,622 headache visits, our model selected 1,595 children with migraine (43.2% male). We found a decreased likelihood of neurology evaluation for patients who were: male (RR 0.73 [95% CI 0.62-0.85]), Non-Hispanic Black (NHB; 0.65 [0.51-0.82]), or lacked private insurance (0.73 [0.59-0.90]). Follow-up with a primary pediatrician was more likely for NHB patients (1.23 [1.05-1.47]) and less likely for boys (0.78 [0.67-0.89]).
Conclusions:
NHB children, boys, and children without private insurance were less likely to see an outpatient neurologist within 6 months of an ED visit for migraine. However, NHB patients were more likely to see their primary pediatrician. Previous research found lower rates of specialized outpatient care for patients from marginalized backgrounds; however, our novel model identified patients by documented clinical presentation rather than billing diagnosis, potentially reducing selection bias. This study serves as proof-of-concept for using automated diagnostic tools in health outcomes research.