Evaluation of Insurance Type as a Proxy for Socioeconomic Status in the Pediatric Emergency Department: A Pilot Study

Abstract

ObjectiveTo determine whether insurance status can function as a sufficient proxy for socioeconomic status (SES) in emergency medicine (EM) research by examining the concordance between insurance status and direct SES measures in a sample of pediatric patients. MethodsWe conducted a cross-sectional pilot study of patients aged 5 to 17 years in the emergency department of a quaternary care children’s hospital. SES was measured using highest level of caregiver education (low: less than Bachelor’s degree; high: Bachelor’s or greater) and previous year household income (low: <$75k; high: ≥$75k). We calculated the misclassification rate of insurance status (low: public; high: private) using education and income as reference standards. Results were expressed as percents with 95% confidence intervals. Results300 patients were enrolled (median age 11, years, 44% female). Insurance status misclassified 23% (18%, 28%) and 14% (10%, 19%) of patients when using caregiver education and income, respectively, as reference standards. ConclusionsInsurance status misclassified SES in up to 23% of pediatric patients, as measured by caregivers’ education and income. EM studies of pediatric patients using insurance as a covariate to adjust for SES may need to consider this misclassification and the resulting potential for bias. These findings require confirmation in larger, more diverse samples, including adult patients.