Addressing inequalities in childhood febrile illness associated with paediatric Emergency Department attendance in England

Background: Paediatric Emergency Department (ED) consultation for fever is common in England. Whilst few febrile illness presentations lead to serious health consequences, they can still have a considerable impact on childhood health, causing a diagnostic challenge for clinicians and parental anxiety. There is a social gradient in the likelihood of infections and paediatric emergency service use. This thesis explores inequalities in patient pathways to ED attendance and admission for paediatric fever on the basis of socioeconomic conditions (SECs) in England. Methods: I used a mixed methods - qualitative (empirical data from semi-structured interviews with 15 parents and 5 doctors, and emotional journey maps with 11 parents and secondary analysis of existing focus group data) and quantitative (datasets) approach informed by health inequalities theory. First, emotional journey mapping and thematic analysis of semi-structured interviews with parents and doctors (N=20) explored reasons for attending ED for fever. Second, a longitudinal regression analysis of routinely collected data evaluated inequalities in paediatric admissions for ambulatory care sensitive conditions (ACSCs) in England and explored any mediating effects by access to care measures. Third, a similar analysis further evaluated inequalities in admissions and admission duration for fever associated with infectious disease, across all ages. Fourth, using logistic regression, I investigated the effect of SECs on paediatric admission from the ED, conditional on attendance, in a tertiary care setting, and explored the association of SECs on outcomes such as out of hours attendance and diagnosis. Results: Study 1 generated one overarching theme – ‘factors influencing unscheduled care’ and four main themes ‘parental proficiency, and experience’, ‘social networks and access to services’, ‘fever phobia, uncertainty and anxiety’, and ‘reassurance’. Journey mapping illustrated the influence of parents’ emotions on parental decision making. Study 2 found a positive association between SECs and emergency admissions for acute ACSCs in younger children (0-9 years) and older children (10-19 years) and for chronic ACSCs in younger children. No significant association was observed for chronic ACSCs in older children. Study 3 found that SECs was associated with increased emergency admissions for febrile illness for children (0-14 years), adults (15-64 years), and older adults (65+ years). Increasing SECs was associated with decreasing admission duration for younger adults. No association was observed for other age groups. Adjustment for primary and secondary care access did not meaningfully impact the magnitude of the associations in Studies 2 and 3. Study 4 found that, upon adjustment for case mix and disease severity measures, deprivation was positively associated with risk of paediatric hospital admission conditional on attendance to the ED. Conclusion: My findings show increasing emergency healthcare use by children presenting with fever, despite no observed evidence of increased disease severity. Inequalities in paediatric hospital admissions relevant to febrile illness remain significant, suggesting the observed rise is not necessarily inexorable and is amenable to intervention. Qualitative insight further highlights key areas where interventions could best address inequalities.