This is the first comprehensive analysis of hospital visits comparing pediatric asylum-seeking with non-asylum-seeking patients in Europe. Overall, the number of visits by asylum-seeking patients was small but the comparison to visits of non-asylum-seeking patients showed important differences.
Asylum-seeking patients originated from a considerable number of countries with Afghanistan, Eritrea and Syria being the most frequent countries of origin in the period studied. Compared to our previous analysis of asylum-seeking patients in 2015 the main difference is that Syrian patients have become more frequent . This shift is a result of current migration patterns in which Syrians represented 54% of the total number of recorded arrivals in Europe in 2015 and 2016 . In 2018, 2.7 million Syrian refugee children were living outside of Syria . Due to the severity and complexity of the armed conflict, Syria has shifted from a temporary to a permanent country of origin of refugees. This results in a continuously decreasing health status of Syrian citizens as also demonstrated that by a recent study in which only 64% had access to general pediatric care, 28% had up-to-date vaccination status and 16% access to healthy nutrition . The Syrian context is contrasted by Afghanistan, which has been one of the top 20 countries of origin of refugees since the 1980s . These changing trends in nationalities, contexts and demographics of the asylum-seeking population influence the health needs of asylum-seekers and highlight the need for host countries to continuously monitor their practice of health provision.
A substantial number of visits by asylum-seeking patients were by male adolescents. This is an important patient group reflecting the current age and sex distribution among refugees in Europe. In 2017, 82% of the first-time asylum seekers were less than 35 years old and 75% of the 14 to17 years old asylum-seekers were male, many being unaccompanied minor refugees . The frequency of this age group in hospital visits may be a surrogate for poor health or limited access to health care in this group of refugees. The Unaccompanied Refugee Minors Program of the United States showed that and that long-term health care remained challenging in this group . The results of our study show that most visits in this age group were in somatic departments and relatively few admissions to the psychiatric department were noted. This is somewhat surprising in the light of literature describing the importance of mental health problems in asylum-seeking adolescents [25-30]. One explanation may be cultural differences in expressing mental health needs. Symptoms may appear somatic to health care providers in high-resource countries and underlying mental health problems may have passed undetected .
A further important age group in the asylum-seeking patients was children below three years of age; however, this was also the case in the non-asylum-seeking patients. In both groups a considerable number of emergency department visits were noted. A similar age distribution in pediatric emergency department visits was seen in other parts of the world. A Californian and a Korean study both showed frequent visits to emergency departments were more common in children aged 1 to 4 years [31, 32]. However, these studies did not detail if asylum-seeking children were included. Interestingly, in our study the asylum-seeking children had a lower proportion of emergency department visits compared to non-asylum-seeking children. This finding contrasts to a recently published study, showing that asylum-seeking children were 5 times more likely to use emergency services . One explanation for the lower proportion in our setting may be that the nurse-led health care system present at Swiss asylum-seeking reception centers which may help to prevent visits to the emergency department, as diseases are detected early. Alternatively, it is possible that asylum-seeking children did not have sufficient access to the emergency department.
The generally low proportion of 1% of visits by asylum-seeking patients and the lower proportion of emergency department visits are in line with results from a recent report by the University College London Lancet Commission on Migration . The results underline that public statements in current debates about asylum-seekers disproportionately burdening the health care system are not true for all settings . A study done at an emergency department at the inner city of London also echoed these results, showing that asylum-seekers were only a minority group . Improved access to community-based physicians was described as an option to improve health care and lower the impact of migrants on emergency departments in general . Current health care delivery models to asylum-seekers vary substantially between regions and countries. In our research context, asylum-seeking children are fully covered for all health care visits by the national health insurance. As mentioned in a German study, presentations with ambulatory care sensitive conditions at tertiary health care facilities could be used as an indicator to compare primary care delivery models for asylum-seekers in different regions .
One further important finding of our study is that a small proportion of asylum-seeking patients had an outsized number of visits accounting for almost half of the visits. An emerging area of pediatric research focuses on “children with medical complexity”, which typically need frequent health care visits and high financial resources . One likely explication is that asylum-seeking patients presented with serious and inadequately treated medical problems, as their health needs had not sufficiently been addressed in their country of origin and while being on the escape. Once arrived in the host country, they required more intense and prolonged treatment compared to their local peers with the same conditions. Alternatively, the spectrum of disease in asylum-seeking and non-asylum-seeking patients with frequent visits may be different and asylum-seeking patients may suffer from particularly complex or rare diseases . A study analyzing adults with multiple chronic diseases showed that their average annual health care expenditures were three times higher compared to patients without chronic diseases . Despite costs, investment in pediatric patients is generally considered to be cost effective, as it is preventing expensive chronic conditions in adulthood . A third explication for more frequent visits could be that they the asylum-seeking patients had less access to primary care pediatricians, resulting in more frequent presentations at the tertiary health care facility.
This study has several limitations. First, it is a single-center study. The generalizability of the results is therefore limited.
The systematic registration of patients as “asylum-seeking” allowed identifying the health information of this study population. This is considered as strength of the study and described as urgently needed in more settings . However, some asylum-seeking patients might have been missed by administration staff and the number of asylum-seeking patients was potentially underestimated.
This study focused on recent asylum-seekers and therefore excluded visits by asylum-seeking children who visited the hospital before 2015. This helped to prevent the dilution of differences between recent asylum-seekers and non-asylum-seekers. The exclusion of these visits might however limit the results and excludes data from long-term asylum-seeking children. Of note, the proportion of children with non-Swiss nationality in the comparison group with 36% is considerable. Potential differences between Swiss nationals and non-asylum-seekers without Swiss nationality were missed. In addition, migrant children without official documents are not represented in this study.
Another limitation was that the retrospective nature of the study resulted in missing data. Important questions, such as transition countries of asylum-seeking patients before they reached Switzerland could not be included in the analysis as the percentage of missing data was too high. Contacting patients to gather additional information was not deemed feasible due to the size of the dataset. This limited an in-depth analysis of many aspects like analyzing the main diagnosis leading to the visits, the family structure or describing the socio-economic background of the study population, but allowed to include all visits, providing a comprehensive overview of health visits by asylum-seeking patients. To address some of the research questions mentioned in the limitations, further studies are analyzing smaller subgroups of the study population. This allows the comparison of main diagnosis in asylum-seeking and non-asylum-seeking inpatients , an in-depth analysis of the subgroup of frequently visiting patients  as the investigation of potentially preventable hospital admissions and emergency department visits . Further to this an earlier qualitative study from our institution was done to understand the perspective of the asylum-seeking families on including on aspects for the escape and the quality of care provided at the hospital. .
Finally, patients which required a change of wards were counted as separate hospital admission. This allowed us to correctly identify all wards where patients were admitted, however, this may have resulted in overestimation of hospital admissions in both groups.