Driving Factors in Pediatric Emergency Department Use: an Ecological Retrospective Study

Background Pediatric emergency departments (PEDs) often face high volumes of low-acuity visits, reflecting gaps in primary care access and socio-economic disparities. We investigated how neighborhood socio-economic vulnerability, pediatrician availability, and proximity to the PED jointly influence PED utilization in Geneva, Switzerland.

In this retrospective ecological study (Jan 2023-Dec 2024), we aggregated all PED visits for children aged 0-16 years by neighborhood and Canadian Triage Acuity Scale (CTAS) level. Neighborhood visit incidence (unique patients per child population) was modeled using mixed-effects regression against a composite socio-economic vulnerability index (NSVI), pediatrician density within a 2 km radius, and distance to the PED, incorporating an exponential decay function for distance and postal code as a random intercept.

There were 68,482 PED visits by 35,994 children (35.1% of Geneva under-16 population). Low-acuity visits (CTAS 4-5) comprised ∼50% of encounters. Both distance and socio-economic vulnerability showed clear dose-response relationships, with stronger effects observed for lower-acuity visits, and no interaction effect between them. Overall, proximity accounted for up to 20.8% of non-urgent PED use, while neighborhood socio-economic vulnerability explained up to 19.7% of low acuity visits across Geneva. Pediatrician density showed a modest inverse association for low-acuity visits only.

Both proximity and socio-economic vulnerability are independent determinants of non-urgent PED use. Policies focusing only on primary care access risk missing key drivers of PED use, highlighting the need for locally tailored strategies such as community outreach near hospitals or programs to strengthen health literacy among families. Summary Proximity and socio-economic vulnerability each explain up to 20% of non-urgent pediatric emergency visits, highlighting major contextual drivers of avoidable care use. What’s Known on This Subject Pediatric emergency department crowding, often driven by low-acuity visits, has been linked to socio-economic disadvantage, poor primary care access, and proximity. Yet, few studies have jointly examined these factors or compared their impact within a universal healthcare setting. What This Study Adds This study disentangles the effects of distance, socio-economic vulnerability, and pediatrician density on PED use. Proximity and disadvantage each explain ∼20% of low-acuity visits, while pediatrician density has limited impact, highlighting the need for targeted, locally adapted interventions. Competing Interest Statement The authors have declared no competing interest. Funding Statement No funding was associated with this study Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study was exempt from formal ethical review under the Swiss Human Research Act, as confirmed by the Geneva Research Ethics Commission (req-2025-00269), and was approved by HUG institutional board for non-HRA research. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes 6 DATA SHARING This study was authorized as quality-of-care study the Geneva Research Ethics Commission (req-2025-00269) and HUG’s institutional board for non-HRA research, but no authorization to share patients’ data was granted. Data will be made available upon request, conditioned to the approval of a proposal with a signed data access agreement and to the approval of the ethical commission concerned. Abbreviation - PED - Pediatric emergency departments - CTAS - Canadian Triage Acuity Scale