Trends in the Management of Headache Disorders in US Emergency Departments: Analysis of 2007-2018 National Hospital Ambulatory Medical Care Survey Data.

PND51 Trends and Characteristics in Opioid Analgesic Use for Migraine in US Emergency Departments: Analysis of National Hospital Ambulatory Medical Care Survey 2007-2018 Data

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

Epidemiology of opioid-related visits to US Emergency Departments, 1999–2013: A retrospective study from the NHAMCS (National Hospital Ambulatory Medical Care Survey)

Using 2003–2018 National Ambulatory Medical Care Survey data for office-based visits and 2003–2018 National Hospital Ambulatory Medical Care Survey data for emergency department (ED) visits, we conducted cross-sectional analyses to examine cough medication (CM) use trends in the United States (US) ambulatory care settings. We included adult (≥18 years) patient visits with respiratory-infection-related or non-infection-related cough as reason-for-visit or diagnosis without malignant cancer or benign respiratory tumor diagnoses. Using multivariable logistic regressions, we examined opioid antitussive, benzonatate, dextromethorphan-containing antitussive, and gabapentinoid use trends. From 2003–2005 to 2015–2018, opioid antitussive use decreased in office-based visits (8.8% to 6.4%, Ptrend = 0.03) but remained stable in ED visits (6.3% to 5.9%, Ptrend = 0.99). In both settings, hydrocodone-containing antitussive use declined over 50%. Benzonatate use more than tripled (office-based:1.6% to 4.8%; ED:1.5% to 8.0%; both Ptrend < 0.001). Dextromethorphan-containing antitussive use increased in ED visits (1.8% to 2.6%, Ptrend = 0.003) but stayed unchanged in office-based visits (3.8% to 2.7%; Ptrend = 0.60). Gabapentinoid use doubled in office-based visits (1.1% in 2006–2008 to 2.4% in 2015–2018, Ptrend < 0.001) but was negligible in ED visits. In US office-based and ED ambulatory care settings, hydrocodone-containing antitussive use substantially declined from 2003 to 2018, while benzonatate use more than tripled, and dextromethorphan-containing antitussive and gabapentinoid use remained low (<3%).

This article describes trends in suicide attempt visits to emergency departments in the United States (US). Data were obtained from the National Hospital Ambulatory Medical Care Survey using mental-health-related ICD-9-CM, E and V codes, and mental-health reasons for visit. From 1992 to 2001, mental-health-related visits increased 27.5% from 17.1 to 23.6 per 1000 (p < .001). Emergency Department (ED) visits for suicide attempt and self injury increased by 47%, from 0.8 to 1.5 visits per 1000 US population (p(trend) = .04). Suicide-attempt-related visits increased significantly among males over the decade and among females from 1992/1993 to 1998/1999. Suicide attempt visits increased in non-Hispanic whites, patients under 15 years or those between 50-69 years of age, and the privately insured. Hospitalization rates for suicide attempt-related ED visits declined from 49% to 32% between 1992 and 2001 (p = .04). Suicide attempt-related visits increased significantly in urban areas, but in rural areas suicide attempt visits stayed relatively constant, despite significant rural decreases in mental-health related visits overall. Ten-year regional increases in suicide attempt-related visits were significant for the West and Northeast only. US emergency departments have witnessed increasing rates of ED visits for suicide attempts during a decade of significant reciprocal decreases in postattempt hospitalization. Emergency departments are increasingly important sites for identifying, assessing and treating individuals with suicidal behavior.

Published data from 1998 revealed that most patients treated for migraine in an emergency department received opioids. Over the intervening years, a large body of evidence has emerged demonstrating the efficacy and safety of non-opioid alternatives. Expert opinion during these years has cautioned against use of opioids for migraine. Our objectives were to compare current frequency of use of various medications for acute migraine in US emergency departments with use of these same medications in 1998 and to identify factors independently associated with opioid use. We analyzed National Hospital Ambulatory Medical Care Survey data from 2010, the most current dataset available. The National Hospital Ambulatory Medical Care Survey is a public dataset collected and distributed by the Centers for Disease Control and Prevention. It is a multi-stage probability sample from randomly selected emergency departments across the country, designed to be representative of all US emergency department visits. We included in our analysis all patients with the ICD9 emergency department discharge diagnosis of migraine. We tabulated frequency of use of specific medications in 2010 and compared these results with the 1998 data. Using a logistic regression model, into which all of the following variables were entered, we explored the independent association between any opioid use in 2010 and sex, age, race/ethnicity, geographic region, type of hospital, triage pain score and history of emergency department use within the previous 12 months. In 2010, there were 1.2 (95% confidence interval 0.9, 1.4) million migraine visits to US emergency departments. Including opioid-containing oral analgesic combinations, opioids were administered in 59% of visits (95% confidence interval 51, 67). The most commonly used parenteral agent, hydromorphone, was used in 25% (95% confidence interval 19, 33) of visits in 2010 versus less than 1% (95% confidence interval 0, 3) in 1998. Conversely, use of meperidine had decreased markedly over the same timeframe. In 2010, it was used in just 7% (95% confidence interval 4, 12) of visits compared to 37% (95% confidence interval 29, 45) in 1998. Metoclopramide, the most commonly used anti-dopaminergic, was administered in 17% (95% confidence interval 12, 23) of visits in 2010 and 3% (95% confidence interval 1, 6) of visits in 1998. Use of any triptan was relatively uncommon in 2010 (7% (95% confidence interval 4, 11) of visits) and in 1998 (10% (95% confidence interval 6, 15) of visits). Of the predictor variables listed above, only emergency department use within the previous 12 months was associated with opioid administration (adjusted odds ratio: 2.87 (95% confidence interval 1.03, 7.97)). In spite of recommendations to the contrary, opioids are still used in more than half of all emergency department visits for migraine. Though use of meperidine has decreased markedly between 1998 and 2010, it has largely been replaced by hydromorphone. Opioid use in migraine visits is independently associated with prior visits to the same emergency department in the previous 12 months.

The median emergency department (ED) boarding time for admitted patients has been a nationally reportable core measure that now also affects ED accreditation and reimbursement. However, no direct national probability samples of ED boarding data have been available to guide this policy until now. The authors studied new National Hospital Ambulatory Medical Care Survey (NHAMCS) survey items to establish baseline values, to generate hypotheses for future research, and to help improve survey quality in the future. This was a cross-sectional, multistage, stratified annual analysis of EDs and ED visits from the National Hospital Ambulatory Medical Care Survey public use files from 2007 to 2010, a total of 139,502 visit records. These data represent the only national measure of ED boarding. The main outcome of interest was boarding duration for individual patient visits. Data analyses accounted for complex sampling design. The national median boarding time was 79 minutes, with an interquartile range of 36 to 145 minutes. The prevalence of boarding for more than 2 hours among admitted patients was 32% (95% confidence interval [CI] = 30% to 35%). Average ED volume, occupancy, acuity, and hospital admission rates increased abruptly from the second to the third quartile of median boarding duration. The half of hospitals with the longest median boarding times accounted for 73% of ED visits and 79% of ED hospitalizations nationally. Thirty-nine percent of EDs (95% CI = 32% to 46%) reported never holding patients for more than 2 hours, but visit-level analysis at these EDs found that 21% of admissions did in fact stay in the ED over 2 hours. Only 19% of EDs (95% CI = 16% to 22%) used a strategy of moving admitted patients to alternative sites in the hospital during crowded times. In this national survey, ED boarding of admitted patients disproportionately affects hospitals with higher ED volumes, which also see sicker patients who wait longer to be seen, but not hospitals with higher proportions of Medicaid or uninsured visits. This finding implies that, unlike other quality measures, there is a negative volume-outcome relationship for timely hospitalization from the ED.

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.

BackgroundDrug-related emergency department (ED) visits are escalating, especially for stimulant use (i.e., cocaine and psychostimulants such as methamphetamine). We sought to characterize rates, presentation, and management of ED visits related to cocaine and psychostimulant use, compared to opioid use, in the United States (US).MethodsWe used 2008–2018 National Hospital Ambulatory Medical Care Survey data to identify a nationally representative sample of ED visits related to cocaine and psychostimulant use, with opioids as the comparator. To make visits mutually exclusive for analysis, we excluded visits related to 2 or more of the three possible drug categories. We estimated annual rate trends using unadjusted Poisson regression; described demographics, presenting concerns, and management; and determined associations between drug-type and presenting concerns (categorized as psychiatric, neurologic, cardiopulmonary, and drug toxicity/withdrawal) using logistic regression, adjusting for age, sex, race/ethnicity, and homelessness.ResultsCocaine-related ED visits did not significantly increase, while psychostimulant-related ED visits increased from 2008 to 2018 (2.2 visits per 10,000 population to 12.9 visits per 10,000 population; p < 0.001). Cocaine-related ED visits had higher usage of cardiac testing, while psychostimulant-related ED visits had higher usage of chemical restraints than opioid-related ED visits. Cocaine- and psychostimulant-related ED visits had greater odds of presenting with cardiopulmonary concerns (cocaine adjusted odds ratio [aOR] 2.95, 95% CI 1.70–5.13; psychostimulant aOR 2.46, 95% CI 1.42–4.26), while psychostimulant-related visits had greater odds of presenting with psychiatric concerns (aOR 2.69, 95% CI 1.83–3.95) and lower odds of presenting with drug toxicity/withdrawal concerns (aOR 0.47, 95%CI 0.30–0.73) compared to opioid-related ED visits.ConclusionPresentations for stimulant-related ED visits differ from opioid-related ED visits: compared to opioids, ED presentations related to cocaine and psychostimulants are less often identified as related to drug toxicity/withdrawal and more often require interventions to address acute cardiopulmonary and psychiatric complications.

MP40-11 TRENDS IN OPIOID AND NONSTEROIDAL ANTI-INFLAMMATORY DRUG USE FOR PATIENTS WITH KIDNEY STONES IN UNITED STATES EMERGENCY DEPARTMENTS FROM 2015 TO 2021

Introduction: Renal colic is frequently treated with opioids; however, narcotic analgesic use can lead to dependence and abuse. We evaluated use trends of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management of kidney stones in United States emergency departments (EDs) from 2015 to 2021. Methods: Kidney stone encounters were identified using National Hospital Ambulatory Medical Care Survey data. We applied a multistage survey weighting procedure to account for selection probability, nonresponse, and population weights. Medication use trends were estimated through logistic regressions on the timing of the encounter, adjusted for selected demographic and clinical characteristics. Results: Between 2015 and 2021, there were an estimated 9,433,291 kidney stone encounters in United States EDs. Opioid use decreased significantly (annual odds ratio [OR]: 0.87, p = 0.003), and there was no significant trend in NSAID use. At discharge, male patients were more likely than females (OR: 1.93, p = 0.001) to receive opioids, and Black patients were less likely than White patients (OR: 0.34, p = 0.010) to receive opioids. Regional variation was also observed, with higher odds of discharge prescriptions in the West (OR: 3.15, p = 0.003) and Midwest (OR: 2.49, p = 0.010), compared with the Northeast. Thirty-five percent of patients received opioids that were stronger than morphine. Conclusion: These results suggest improved opioid stewardship from ED physicians in response to the national opioid epidemic. However, regional variation as well as disparities in discharge prescriptions for Black and female patients underscore opportunities for continued efforts.

BackgroundObservation care is a core component of emergency care delivery, yet, the prevalence of emergency department (ED) observation units (OUs) and use of observation care after ED visits is unknown. Our objective was to describe the 1) prevalence of OUs in United States (US) hospitals, 2) clinical conditions most frequently evaluated with observation, and 3) patient and hospital characteristics associated with use of observation.MethodsRetrospective analysis of the proportion of hospitals with dedicated OUs and patient disposition after ED visit (discharge, inpatient admission or observation evaluation) using the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2001 to 2008. NHAMCS is an annual, national probability sample of ED visits to US hospitals conducted by the Center for Disease Control and Prevention. Logistic regression was used to assess hospital-level predictors of OU presence and polytomous logistic regression was used for patient-level predictors of visit disposition, each adjusted for multi-level sampling data. OU analysis was limited to 2007–2008.ResultsIn 2007–2008, 34.1% of all EDs had a dedicated OU, of which 56.1% were under ED administrative control (EDOU). Between 2001 and 2008, ED visits resulting in a disposition to observation increased from 642,000 (0.60% of ED visits) to 2,318,000 (1.87%, p<.05). Chest pain was the most common reason for ED visit resulting in observation and the most common observation discharge diagnosis (19.1% and 17.1% of observation evaluations, respectively). In hospital-level adjusted analysis, hospital ownership status (non-profit or government), non-teaching status, and longer ED length of visit (>3.6 h) were predictive of OU presence. After patient-level adjustment, EDOU presence was associated with increased disposition to observation (OR 2.19).ConclusionsOne-third of US hospitals have dedicated OUs and observation care is increasingly used for a range of clinical conditions. Further research is warranted to understand the quality, cost and efficiency of observation care.

Objective Telemedicine has the potential to improve the delivery of emergency medical care: however, the extent of its adoption in United States (US) emergency departments is not known. Our objective was to characterise the prevalence of telemedicine use among all US emergency departments, describe clinical applications for which it is most commonly used, and identify emergency department characteristics associated with its use. Methods As part of the National Emergency Department Inventory-USA survey, we queried all 5375 US emergency departments open in 2016. Multivariable logistic regression analyses identified characteristics associated with emergency department receipt of telemedicine services. Results Overall, 4507 emergency departments (84%) responded to our survey, with 4031 responding to both telemedicine questions (75%). Although 1694 emergency departments (42%) reported no telemedicine in 2016, most did: 1923 (48%) emergency departments received telemedicine services, 149 (4%) emergency departments received telemedicine services and were in hospitals that provided telemedicine, and 265 emergency departments (7%) did not receive telemedicine but were in hospitals that provided telemedicine services. Among emergency departments receiving telemedicine, the most common applications were stroke/neurology (76%), psychiatry (38%), and paediatrics (15%). In multivariable analysis, telemedicine-receiving emergency departments had higher annual total visit volume for adults and lower annual total visit volume by children; were less likely to be academic or freestanding; and varied by region. In multivariable analysis, emergency departments in telemedicine-providing hospitals had higher annual total visit volume for adults and children, were more likely to be academic and were less likely to be freestanding. Conclusion In 2016, telemedicine was used in most US emergency departments (58%), especially for stroke/neurology and psychiatry. Future research is needed to understand the value of telemedicine for different clinical applications, and the barriers to its implementation.

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

Circulatory system diseases are leading causes of emergency department (ED) visits in the United States. Understanding trends in these visits is crucial for healthcare planning. This study aimed to identify the most frequent primary circulatory system diagnoses presenting to EDs, examine temporal trends in ED visit rates from 2016 to 2022, and assess disparities by patient age, sex, race/ethnicity, insurance status, and geographic region. A cross-sectional analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS) data (2016-2022) identified ED visits with a primary circulatory disease diagnosis using International Classification of Diseases (ICD) codes. Weighted estimates ensured national representativeness. Descriptive statistics and inferential statistics were used to assess trends. Analyses were performed in STATA 17 (StataCorp., College Station, TX, USA) (p<0.05). Overall ED visit rates for circulatory diseases rose from 15 per 1,000 in 2016 to 17 per 1,000 in 2019 (p<0.01), declined to 16 per 1,000 in 2020 (p<0.05 vs. 2019), and stabilized at 17 per 1,000 in 2021-2022 (no significant change, p=0.12). Essential hypertension (14%), hypertensive heart or kidney disease (13%), acute myocardial infarction (11%), atrial fibrillation/flutter (10%), and ischemic stroke (8%) represented the five most common primary diagnoses, accounting for over 56% of circulatory presentations. Older adults (65+) exhibited the highest visit rates (peaking at 55 per 1,000 in 2022), males had slightly higher rates than females (18 vs. 16 per 1,000 in 2022), and non-Hispanic Black individuals had persistently elevated rates (28 per 1,000 in 2022) compared to non-Hispanic White individuals (17 per 1,000) and Hispanic individuals (12 per 1,000) (all p<0.05). The Midwest and Northeast regions reported the highest rates, whereas the West had the lowest, underscoring geographic variation in circulatory disease burden. Medicare beneficiaries had the highest utilization (44 per 1,000 in 2022), highlighting insurance-related disparities. In this nationally representative analysis, primary ED presentations for circulatory diseases were dominated by hypertension-related conditions and acute ischemic events. Stabilization of rates post-2020, particularly among older and Medicare-insured patients, indicates potential targets for intervention. Strengthening primary care access and preventive programs, especially for older adults and non-Hispanic Black individuals, may reduce ED reliance and improve equity in cardiovascular care.