High Diagnostic Uncertainty and Inaccuracy in Adult Emergency Department Patients With Dyspnea: A National Database Analysis.

Analysis of Emergency Department Visits for Palpitations (from the National Hospital Ambulatory Medical Care Survey)

213 High Diagnostic Uncertainty and Inaccuracy in Older Adult Emergency Department Patients With Dyspnea

Dyspnea is the second leading cause of US emergency department (ED) visits and an independent predictor of morbidity and mortality1 in older adult patients aged ≥65 years. Unfortunately, the diagnosis of the cause of dyspnea presents diagnostic challenges to emergency physicians2-4 that disproportionately affects older adults.5 One in 5 dyspneic older adults experience missed diagnosis in the ED2 and 21% are treated for ≥1 pneumonia, acute exacerbation of chronic obstructive pulmonary disease [COPD], and acute exacerbation of heart failure [HF].5 Importantly, some may have multiple causes of their dyspnea but accurate diagnosis remains critical.

Introduction: Stroke incidence is reportedly increasing in younger adults. While increasing vascular risk factor prevalence has been suggested as a cause, the reasons for rising stroke incidence in the young are not clear. We explored several alternate explanations: trends in neurologically-focused emergency department (ED) visits, differential diagnostic classification of stroke and TIA over time, and changes in the use of advanced imaging in young and older adults. Methods: We performed a retrospective, serial, cross-sectional study on a nationally representative sample of all ED visits in the United States to quantify changes in patterns of neurologically-focused ED visits, stroke and TIA diagnoses, and rates of MRI utilization for young (18 – 44 years) and older (65+ years) adults over a 17-year period (1995 – 2000; 2005 – 2015) using National Hospital Ambulatory Medical Care Survey (NHAMCS) data. Results: In young adults, 0.4% (95% CI 0.3% – 0.5%) of neurologically-focused ED visits resulted in a primary diagnosis of stroke vs. 6.8% (95% CI 6.2% – 7.5%) for older adults. In both populations, the incidence of neurologically-focused ED visits has increased over time (+111/100,000 population/year, 95% CI +94 – +130 in the young vs. +70/100,000 population/year, 95% CI +34 – +108 in older adults). There was no evidence of differential classification of TIA to stroke over time (OR 1.001 per year, 95% CI 0.926 – 1.083 in the young; OR 1.003 per year, 95% CI 0.982 – 1.026 in older adults) and no evidence of disproportionate rise in MRI utilization for neurologically-focused ED visits in the young (OR 1.057 per year, 95% CI 1.028 – 1.086 in the young; OR 1.095 per year, 95% CI 1.066 – 1.125 in older adults). Conclusions: If the specificity of stroke diagnosis amongst ED visits is similar amongst young and older populations, then the combination of data observed here, including (1) a lower prior probability of stroke diagnoses in the young and (2) an increasing trend in neurologically-focused ED visits in both age groups, suggests that false positive diagnoses will increase over time, with a faster rise in the young compared to older adults. These data suggest a potential explanation that may contribute to higher stroke incidence in the young and merits further scrutiny.

COPD Surveillance—United States, 1999-2011

While recent studies have demonstrated an overall increase in psychiatric visits in the emergency department (ED), none have focused on a nationally representative pediatric population. Understanding trends in pediatric psychiatric ED visits is important because of limited outpatient availability of pediatric specialists, as well as long wait times for psychiatric appointments. The study aim was to evaluate the trends in ED psychiatric visits for children between 2001 and 2010 with comparison by sociodemographic characteristics. This was a retrospective, cross-sectional analysis of ED psychiatric visits for children<18years of age using the National Hospital Ambulatory Medical Care Survey (NHAMCS). Visits were identified by International Classification of Diseases, Ninth Revision (ICD-9), codes. Outcome measures included frequency of visits for children with psychiatric diagnosis codes and odds and adjusted odds of psychiatric visits controlling for temporal, demographic, and geographic factors. From 2001 to 2010, an average of 28.3 million pediatric visits to EDs occurred annually. Among those, an approximately 560,000 (2% of ED visits) were psychiatric visits each year. Pediatric psychiatric ED visits increased from an estimated 491,000 in 2001 to 619,000 in 2010 (p=0.01). Teenagers (adjusted odds ratio [AOR]= 3.92, 95% confidence interval [CI]=3.37 to 4.57) and publicly insured patient visits (AOR= 1.47, 95% CI=1.25 to 1.74) had increased odds of psychiatric ED visits. Pediatric ED psychiatric visits are increasing. Teenagers and children with public insurance appear to be at increased risk. Further investigation is needed to determine what the causative factors are.

2 Evaluation of Mid-Regional Pro-Adrenomedullin, Mid-Regional Pro-atrial Natriuretic Peptide, and Procalcitonin for the Diagnosis and Risk Stratification of Emergency Department Patients With Dyspnea

BackgroundAtypical symptom presentations of Acute Coronary Syndrome (ACS) are common in older adults and may contribute to diagnostic delays or missed recognition in emergency departments (EDs). National-level data examining this relationship remains limited.ObjectiveTo evaluate whether atypical chest pain presentations are associated with reduced likelihood of ACS diagnosis among U.S. adults aged 65 years and older during ED visits.MethodsWe conducted a retrospective cross-sectional study using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2014 to 2020. ED visits by adults aged ≥65 years were analyzed. Atypical presentations were defined using Reason for Visit (RFV) codes for symptoms such as weakness, dyspnea, dizziness, nausea, syncope, and abdominal pain. The primary outcome was an ED diagnosis of ACS based on ICD-9-CM codes. Multivariable logistic regression was used to assess associations.ResultsAmong 2,470 eligible ED visits, only 15 (0.6%) were diagnosed with ACS. Of those, 7 (46.7%) presented with atypical symptoms. Atypical presentation was not significantly associated with ACS diagnosis (OR: 0.90; 95% CI: 0.32-2.49; p = 0.83). No significant associations were found with age, sex, race/ethnicity, or ED disposition. The variable "admitted to hospital from ED" was excluded due to collinearity.ConclusionNearly half of older adults diagnosed with ACS presented atypically, yet atypical presentation was not significantly associated with missed ACS diagnosis in the ED. Given the limitations of administrative data and low ACS event rates, future research using richer clinical datasets and follow-up outcomes is needed to better understand diagnostic gaps in this high-risk population.

Motor vehicle collisions (MVCs) are the second most common cause of nonfatal injury among U.S. adults age 65 years and older. However, the frequency of emergency department (ED) visits, disposition, pain locations, and pain severity for older adults experiencing MVCs have not previously been described. The authors sought to determine these characteristics using information from two nationally representative data sets. Data from the 2008 Healthcare Cost and Utilization Project Nationwide Emergency Department Sample (NEDS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) were used to estimate MVC-related ED visits and ED disposition for patients 65 years and older. NHAMCS data from 2004 through 2008 were used to further characterize MVC-related ED visits. In 2008, the NEDS contained 28,445,564 patient visits, of which 760,356 (2.7%) were due to MVCs. The NHAMCS contained 34,134 patient visits, of which 1,038 (3.0%) were due to MVCs. National estimates of MVC-related ED visits by patients 65 years and older in 2008 are 226,000 (95% confidence interval [CI]=210,000 to 240,000) for NEDS and 270,000 (95% CI=185,000 to 355,000) for NHAMCS. Most older adults with MVC-related ED visits were sent home from the ED (proportion discharged NEDS 78%, 95% CI=78% to 79%; NHAMCS 77%, 95% CI=66% to 86%). During the years 2004 through 2008, of MVC-related ED visits by older adults not resulting in hospital admission, moderate or severe pain was reported in 61% (95% CI=52% to 70%) of those with recorded pain scores. Older patients sent home after MVC-related ED visits were less likely than younger patients to receive analgesics (35%, 95% CI=26% to 43% vs. 47%, 95% CI=44% to 50%) during their ED evaluations or as discharge prescriptions (52%, 95% CI=41% to 62% vs. 65%, 95% CI=61% to 68%). In 2008, adults age 65 years or older made more than 200,000 MVC-related ED visits. Approximately 80% of these visits were discharged home from the ED, but the majority of discharged patients reported moderate or severe pain. Further studies of pain and functional outcomes in this population are needed.

A number of medications have pharmacogenetic recommendations indicating more or less effectiveness of a drug depending on the patient’s genotype. Up to 35% of patients may have a relevant genotype. We sought to determine via a cross sectional analysis the proportion and associated characteristics of emergency department (ED) visits that would be impacted by medications with pharmacogenetic recommendations. We used data from the 2010-2015 National Hospital Ambulatory Medical Care Survey (NHAMCS), to estimate the number of ED visits in which there was an order for at least one medication with Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines with evidence of Level A or B, indicating potentially altered dosing or drug recommendations. We examined demographic and clinical information, reasons for visit, and ED and hospital diagnoses, and calculated national-level estimates (95% confidence intervals [CI]) of these characteristics. From a total of 165,155 entries representing 805,726,000 United States (US) ED visits in the 2010-2015 National Hospital Ambulatory Medical Care Survey (NHAMCS), there were 148,243,000 ED visits (18.4%) in which medications with CPIC guidelines recommendations were ordered. The most common CPIC medication was tramadol (6.3%) (Table 1). Visits involving CPIC medications had significantly higher proportions of patients who were female, had private insurance and self-pay, and were discharged from the ED. They also involved significantly lower proportions of patients with Medicare and Medicaid. Almost 1 in 5 US ED visits involve a medication with a pharmacogenetic recommendation. Acute care systems should consider means to provide decision support to optimize such pharmacological therapy.Tabled 1Top 10 Most Common ED Medications with CPIC GuidelinesMedicationCPIC Guideline LevelEstimate (95% CI)Weighted Patient # (in 1000s)Any CPIC Medications18.4% (17.6%, 19.2%)148243TRAMADOLA6.3% (5.9%, 6.6%)50575ONDANSETRONA4.0% (3.6%, 4.4%)32223OXYCODONEA3.5% (3.0%, 3.9%)27847LIDOCAINEB3.0% (2.8%, 3.2%)24336CODEINEA1.0% (0.9%, 1.1%)8381OMEPRAZOLEB0.6% (0.5%, 0.6%)4526PANTOPRAZOLEB0.5% (0.4%, 0.6%)4241CIPROFLOXACINB0.5% (0.4%, 0.6%)4147SULFAMETHOXAZOLE/TRIMETHOPRIMB0.3% (0.3%, 0.4%)2650CPIC assigns CPIC levels to gene/drug pairs (A, B, C, and D) representing the strength of evidence. Open table in a new tab

Current outpatient diagnostic algorithms for urinary tract infection (UTI) in older adults require the presence of classic signs and symptoms of UTI, such as fever and genitourinary symptoms. However, older adults with UTI may present with atypical signs and symptoms. The objective was to identify the associations of age and nursing home status with the clinical presentation of emergency department (ED) patients diagnosed with UTI. This was a retrospective, cross-sectional analysis of the 2001-2008 National Hospital Ambulatory Medical Care Survey (NHAMCS), ED component. Participants were adult ED patients diagnosed with UTI. Outcome variables were presence of fever, altered mental status, and urinary tract symptoms. Multivariable logistic regression models were constructed for each outcome. Age and nursing home status were the independent variables of interest. Age was divided into adults 18 to 64 years, older adults 65 to 84 years, and oldest adults 85 years of age and older. There were 25.4 million ED visits in which UTI was diagnosed from 2001 through 2008, including 5.0 million in older adults and 2.2 million in the oldest adults. Fever was present in 13% of adults, 21% of older adults, and 19% of the oldest adults. Altered mental status was present in 1% of adults, 7% of older adults, and 13% of the oldest adults. Urinary tract symptoms were identified in 32% of adults, 24% of older adults, and 17% of the oldest adults. In multivariable analysis, altered mental status was more common in older adults (odds ratio [OR] = 1.94) and in the oldest adults (OR = 2.49). Urinary tract symptoms were less common in older adults (OR = 0.60) and the oldest adults (OR = 0.48). Nursing home residence was associated with increased fever (OR = 1.63) and altered mental status (OR = 4.79) and with decreased urinary tract symptoms (OR = 0.35). Fever and urinary tract symptoms are absent in a large proportion of adults over 65 years of age diagnosed with UTI in the ED. Age over 65 years and nursing home residence are associated with increased presence of altered mental status and with lack of urinary tract symptoms. Nursing home residence is also associated with increased presence of fever. Emergency physicians (EPs) continue to diagnose UTI in patients without classic symptoms. Diagnostic criteria for UTI among adults 65 years and over specifically designed for use in the acute care setting should be developed and validated to prevent both inappropriate overdiagnosis and underdiagnosis of UTI.

Spectrum of Dizziness Visits to US Emergency Departments: Cross-Sectional Analysis From a Nationally Representative Sample

IntroductionMillions of people present to the emergency department (ED) with chest pain annually. Accurate and timely risk stratification is important to identify potentially life-threatening conditions such as acute coronary syndrome (ACS). An ED-based observation unit can be used to rapidly evaluate patients and reduce ED crowding, but the practice is not universal. We estimated the number of current hospital admissions in the United States (US) eligible for ED-based observation services for patients with symptoms of ACS.MethodsIn this cross-sectional analysis we used data from the 2011–2015 National Hospital Ambulatory Medical Care Survey (NHAMCS). Visits were included if patients presented with symptoms of ACS (eg, chest pain, dyspnea), had an electrocardiogram (ECG) and cardiac markers, and were admitted to the hospital. We excluded patients with any of the following: discharge diagnosis of myocardial infarction; cardiac arrest; congestive heart failure, or unstable angina; admission to an intensive care unit; hospital length of stay > 2 days; alteplase administration, central venous catheter insertion, cardiopulmonary resuscitation or endotracheal intubation; or admission after an initial ED observation stay. We extracted data on sociodemographics, hospital characteristics, triage level, disposition from the ED, and year of ED extracted from the NHAMCS. Descriptive statistics were performed using sampling weights to produce national estimates of ED visits. We provide medians with interquartile ranges for continuous variables and percentages with 95% confidence intervals for categorical variables.ResultsDuring 2011–2015 there were an estimated 675,883,000 ED visits in the US. Of these, 14,353,000 patients with symptoms of ACS and an ED order for an ECG or cardiac markers were admitted to the hospital. We identified 1,883,000 visits that were amenable to ED observation services, where 987,000 (52.4%) were male patients, and 1,318,000 (70%) were White. Further-more, 739,000 (39.2%) and 234,000 (12.4%) were paid for by Medicare and Medicaid, respectively. The majority (45.1%) of observation-amenable hospitalizations were in the Southern US.ConclusionEmergency department-based observation unit services for suspected ACS appear to be underused. Over half of potentially observation-amenable admissions were paid for by Medicare and Medicaid. Implementation of ED-based observation units would especially benefit hospitals and patients in the American South.

Epidemiology of epistaxis in us emergency department patients, 1992-2001

ObjectiveAlthough 911 calls for acute shortness of breath are common, the role of emergency medical services (EMS) in acute asthma care is unclear. We sought to characterize the demographics, course, and outcomes of adult emergency department (ED) patients with asthma in the United States receiving initial EMS care.MethodsWe analyzed data from the 2016–2019 National Hospital Ambulatory Medical Care Survey (NHAMCS). We included patients aged ≥18 years with an ED visit diagnosis of asthma, stratifying the cases according to initial EMS care. Accounting for the survey design of NHAMCS, we generated nationalized estimates of the number of EMS and non‐EMS asthma visits. Using logistic regression, we determined the associations between initial EMS care and patient demographics (age, sex, race, and insurance type), ED course (initial vital signs, triage category, testing, medications), and outcomes (hospital admission, ED length of stay).ResultsOf 435 million adult ED visits during 2016–2019, there were ≈5.3 million related to asthma (1.3 million annually, 1.2%; 95% confidence interval [CI], 1.1%–1.4%). A total of 602,569 (150,642 annually, 11.3%; 95% CI, 8.6%–14.8%) ED patients with asthma received initial EMS care. Compared with non‐EMS asthma patients, EMS asthma patients were more likely to present with an “urgent” ED triage category (odds ratio [OR], 22.2; 95% CI, 6.6–74.9) and to undergo laboratory (OR, 2.78; 95% CI, 1.41–5.46) or imaging tests (OR, 2.42; 95% CI, 1.21–4.83). ED patients with asthma receiving initial EMS care were almost 3 times more likely to be admitted to the hospital (OR, 2.81; 95% CI, 1.27–6.25). There were no differences in demographics, ED use of β‐agonists or corticosteroids, or ED length of stay between EMS and non‐EMS asthma patients.ConclusionsApproximately 1 in 10 adult ED patients with asthma receive initial care by EMS. EMS asthma patients present to the ED with higher acuity, undergo more diagnostic testing in the ED, and are more likely to be admitted. Although limited in information regarding the prehospital course, these findings highlight the more severe illness of asthma patients transported by EMS and underscore the importance of EMS in emergency asthma care.