Ambulatory Medical Care Survey Data Research Articles

Health Care Use for Eye Pain

National estimates regarding the frequency of presentations and patterns of care for eye pain are unknown. This information could guide research and clinical efforts to optimize outcomes. To estimate eye pain visits in the US in the outpatient and emergency department (ED) settings. This retrospective cross-sectional study of National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey data (2008-2019) analyzed a population-based sample of visits to outpatient clinics and EDs. The sample consisted of patients presenting with eye pain. Data were analyzed from September 2023 to April 2024. Weighted sample data estimated outpatient and ED eye pain presentations including patient and clinician characteristics, diagnoses (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10]), and disposition. From 2008 through 2019, 4.6 million (95% CI, 3.9 million to 5.3 million) outpatient and 1.0 million (95% CI, 0.8 million to 1.1 million) ED eye pain visits occurred annually. Patients were predominantly women (63.2% [95% CI, 59.4%-67.0%]) and older than 60 years (46.6% [95% CI, 42.4%-51.0%]) in the outpatient setting. Patients presenting to the ED were more often men (51.8% [95% CI, 48.7%-55.0%]) and aged younger than 45 years (aged <15 years: 16.4% [95% CI, 13.9%-18.8%]; 15-24 years: 19.2% [95% CI, 16.6%-21.7%]; and 25-44 years: 35.6% [95% CI, 32.7%-38.5%]). In nearly half of outpatient eye pain visits, the major problem was classified as nonacute (2.0 million [95% CI, 1.6 million to 2.3 million]). Eye pain was the primary reason for the visit (RFV) in 42.0% (95% CI, 37.8%-46.2%) of outpatient visits and 66.9% (95% CI, 62.9%-70.9%) of ED eye pain visits. It was the only RFV in 18.3% (95% CI, 15.0%-21.7%) of outpatient and 32.7% (95% CI, 29.0%-36.4%) of ED eye pain encounters. Ophthalmologists evaluated the largest number of outpatient visits (45.3% [95% CI, 38.8%-51.7%). The primary diagnosis was non-vision threatening for most outpatient (78.5% [95% CI, 56.8%-100%]) and ED (69.9% [95% CI, 62.1%-77.7%]) visits when eye pain was the primary RFV. Additional follow-up was scheduled in 89.4% (95% CI, 86.2%-92.6%) of visits. More than 5 million eye pain visits occur annually; the largest percentage are outpatient with ophthalmologists. Most diagnoses were non-vision threatening in both the outpatient and ED setting and resulted in additional care. Expanding therapeutic approaches to treat the causes of eye pain may reduce the burden on the health care system and optimize outcomes.

Menopause hormone therapy prescribing in ambulatory care visits among midlife and older U.S. women from 2018 to 2019

The rates of prescription for menopause hormone therapy have been low in the U.S. since the 2002 Women's Health Initiative study, but no recent studies have assessed the prescribing of hormone therapy in the U.S. Using the National Ambulatory Medical Care Survey data from 2018 to 2019, we found that hormone therapy was prescribed in 3.8 % of U.S. visits by midlife and older women, with 60 % of these visits including estradiol-only prescriptions. Older age and Hispanic/Latina ethnicity were associated with decreased odds of prescribing, while White race and depression were associated with increased odds, indicating possible disparities in menopause care.

A real-world study of the quality of Outpatient Pain Management in patients with Cancer.

Up to 40% patients with cancer reporting pain may not receive optimal analgesia indicating inadequate treatment of pain. We examined the patterns of outpatient pain management in patients with cancer who reported pain. We used the National Ambulatory Medical Care Survey data for outpatient visits from 2006 to 2018 for patients with any cancer and reporting pain. The primary outcome was prescription of pain medications among these patients. We performed multinomial logistic regression to identify factors associated with analgesic prescriptions among patients with cancer who reported pain. We captured an estimated total of 412 million outpatient visits of which 22 million visits dealt with patients with cancer reporting pain. An estimated total of 13.8 million (61.33%) patient visits had pain reported but were not prescribed any pain medications. 5.5 million (24.44%) patient visits had non-opioid analgesic prescription while opioid analgesics were prescribed during 3.2 million (14.22%) visits. Patients who were black, aged 45-64 years, residing in rural geographical areas, visiting medical subspecialty practices, and having cancers of the respiratory and digestive systems had higher odds of receiving opioid prescription. As one of the largest pain management studies among patients with cancer in the outpatient setting, covering 412 million patient visits, our study shows that a significant proportion of patients with cancer who reported pain did not receive a prescription for analgesics suggesting a possibility of undertreatment of pain. Undertreatment of pain continues to remain a major unmet need in patients with cancer.

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.

Alcohol and Substance Use Among the Working Age Population: A Nationwide Study of Fall-Related Emergency Department Visits.

Prior studies have linked fall-related emergency department (ED) visits among older adults to alcohol use. Characteristics related to falls in the working age population (WAP; 15-64 years) may vary with alcohol and substance use. This study aimed to identify factors associated with fall-related ED visits related to alcohol and substance use in the WAP. Using nationally representative 2019-2020 National Hospital Ambulatory Medical Care Survey data, fall-related ED visits within 72 hours were stratified by indication of alcohol use, substance use, and concurrent alcohol and substance use. Descriptive statistics accounting for the survey's complex design were used along with multivariable logistic regression to identify associated factors. Between 2019 and 2020, an estimated 10,800,000 fall-related ED visits occurred among the WAP, with 51.7% related to alcohol use, substance use, or both. Multivariable logistic regression analysis revealed that the WAP with fall-injury ED visits were associated with alcohol use (adjusted odds ratio [AOR] = 2.3, 95% CI [1.0, 5.9]) or concurrent alcohol and substance use (AOR = 8.5, 95% CI [1.6, 43.0]), and individuals with alcohol and substance use with a depression diagnosis are twice as likely to visit EDs with fall injuries. Individuals with alcohol and substance use with depression were twice as likely to visit EDs for fall injuries. Higher fall-related ED visits in the WAP were attributed to alcohol and substance use. Identified factors could improve injury prevention and timely intervention among the WAP in the United States.

Association Between Facility and Clinician Characteristics and Family Planning Services Provided During U.S. Outpatient Care Visits.

Recent guidelines from the Centers for Disease Control and Prevention emphasize the importance of access to comprehensive family planning services and recommend patient-centered contraceptive counseling be incorporated into routine primary care visits for reproductive-age individuals. This study aims to describe family planning service provision in outpatient care settings and assess differences by facility and clinician characteristics. Using National Ambulatory Medical Care Survey data, a nationally representative survey of outpatient care visits, we assessed family planning service provision by facility location, facility type, physician specialty, types of clinicians seen, and whether the patient was seen by their primary care provider. We used random intercept logistic regression with robust standard errors, adjusting for patient characteristics, and state and year fixed effects. The analytic sample included 53,489 patient visits with reproductive-age (15-49years) individuals between 2011 and 2019. Family planning services were provided at 8% of total sampled visits and were more likely to be provided in urban compared with rural areas (adjusted odds ratio, 1.45; p=.02) and at community health centers compared with private physician practices (adjusted odds ratio, 1.74; p=.00). Family planning services were also more likely to be provided when the patient saw a physician assistant or nurse compared with only a physician. After controlling for observed covariates, measures of between-clinician heterogeneity indicate wide variation in which clinicians provided family planning services. Family planning services were more likely to be provided in urban areas, at community health centers, and when patients received team-based care. The wide variation between clinicians suggests a need to better incorporate family planning services into primary care and other outpatient settings to meet patient needs and preferences.

Benzodiazepines Prescribed With and Without Opioids at Discharge From the Emergency Department: A Serial Cross-Sectional Study of National Hospital Ambulatory Medical Care Survey Data for 2014-2019.

Benzodiazepines Prescribed With and Without Opioids at Discharge From the Emergency Department: A Serial Cross-Sectional Study of National Hospital Ambulatory Medical Care Survey Data for 2014-2019.

Acne accounts for an almost 2.5-fold higher proportion of dermatology visits among adult females compared to adult males in the United States: A study of the national ambulatory medical care survey from 2002-2016.

Acne vulgaris affects a significant number of females into adulthood. Juvenile acne and adult acne have different presentations and potentially distinctive pathogeneses. However, patterns in treatments specifically related to the adult female population have previously not been studied. Retrospective database analysis of healthcare utilization and medications prescribed for acne using the National Ambulatory Medical Care Survey (NAMCS) data from 2002-2016 was performed. After age 20, acne accounted for an almost 2.5-fold higher proportion of dermatology visits among females compared to males (10.1% vs. 4.1%, P < 0.001). Tetracycline-class antibiotics were the most prescribed therapy within all age groups of females between 2002-2016. However, there was also a substantial rise in prescriptions of spironolactone beginning in 2012. A significantly greater proportion of dermatology visits by adult females are for acne in comparison to adult males. Tetracycline-class antibiotics remain the most prescribed therapy in adult age groups despite a potentially different pathogenesis of adult acne. Therefore, there is a need for further studies comparing the effectiveness of therapies specifically for adult female acne.

Outpatient opioid prescribing by Alzheimer’s diagnosis among older adults with pain in United States

ObjectiveTo examine opioid prescribing practices for pain in older adults with and without Alzheimer’s Disease and Related Dementias (ADRD).MethodsThis cross-sectional study used National Ambulatory Medical Care Survey data (2014–2016, and 2018). Adults aged ≥ 50 years with pain were analyzed. Prescribing of opioid and concomitant sedative prescriptions (including benzodiazepines, Z-drugs, and barbiturates) were identified by the Multum lexicon code. Multivariable logistic regression evaluated the risk of opioid prescribing or co-prescribing of opioid and sedative associated with ADRD in older adults with pain.ResultsThere were 13,299 office visits in older adults with pain, representing 451.75 million visits. Opioid prescribing occurred in 27.19%; 30% involved co-prescribing of opioids and sedatives. ADRD was not associated with opioid prescribing or co-prescribing of opioid and sedative therapy.ConclusionsOpioid and sedatives are commonly prescribed in older adults with pain. Longitudinal studies need to understand the etiology and chronicity of opioid use in older patients, specifically with ADRD.

Still no differences in the length or scope of primary and ambulatory care for Medicaid and commercial patients.

Many seek to improve the quality of primary care in the United States, particularly for Medicaid patients. This paper revisits the question of whether Medicaid patients receive less primary care, such as the length or scope of services per visit, than commercial patients. Analyses of 2016-2019 National Ambulatory Medical Care Survey data, the most recent available, find there were no significant differences in the average length of ambulatory care visits, or of primary care visits in particular, between Medicaid and commercial care, nor differences in the scope, based on the number of diagnostic and treatment services, health education topics covered, or the number of medications prescribed in the visit. Only small differences were found for uninsured patients. The duration and scope of ambulatory and primary care visits were primarily related to the characteristics of patients, visits, and the physicians' practices. To improve primary and ambulatory care for disadvantaged patients, it may be more important to focus on increasing access to care by reducing insurance and cost-related barriers and on broad-based efforts to improve quality.

Adoption of emergency department crowding interventions among US hospitals between 2007 and 2020

BackgroundTo deal with emergency department (ED) crowding, the American College of Emergency Physicians (ACEP) established a task force to develop a list of low-cost, high-impact solutions. In this study, we report on the trend in the adoption rate of ACEP-recommended ED crowding interventions by US hospitals. MethodsWe analyzed the National Hospital Ambulatory Medical Care Survey data from 2007 to 2020 (N = 3874 hospitals). The primary outcome was whether a hospital adopted each of the ACEP-recommended interventions, which were grouped into three overlapping categories: technology-based, flow modifications, and physical-based (e.g., changing ED layout). ResultsOn average, the most frequently adopted intervention was bedside registration (85.1%) and the least frequently adopted intervention was kiosk check-in (8.3%). The adoption of ED crowding interventions increased significantly between 2007 and 2020, except for expanding ED treatment space which declined by 45.0% from 30.3% in 2007 to 15.7% in 2020. The largest adoption rate increase occurred in having a separate operating room for ED cases with a 188.5% increase in adoption rate followed by radio-frequency identification (RFID) tracking (151.2%), and kiosk check-in (144.2%). ConclusionsThe adoption rate of ED crowding interventions by hospitals has risen, however most effective ED crowding interventions are still underutilized. The trends for each intervention did not always increase linearly, with certain periods showing greater fluctuations in adoption rate. Hospitals tend to implement technology-based interventions, compared to physical-based interventions and flow modification interventions.

Cyclobenzaprine utilization for musculoskeletal back pain: Analysis of 2007–2019 National Hospital Ambulatory Medical Care Survey Data

BackgroundWith musculoskeletal back pain being one of the most common presentations in the emergency department, evidence-based management strategies are needed to address such complaints. Along with other medications, cyclobenzaprine is a muscle relaxant commonly prescribed for patients complaining of musculoskeletal pain, in particular, pain associated with muscle spasms. However, with recent literature questioning its efficacy, the role of cyclobenzaprine use in patients with musculoskeletal back pain remains unclear. ObjectivesThe objective of the study is to investigate trends of cyclobenzaprine utilization among patients presenting to the emergency department (ED) in the United States. MethodsThis is a retrospective cohort review of data obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) between 2007 and 2019. We analyzed ED visits of patients 18 years and older. Visits during which cyclobenzaprine was administered in the ED or prescribed at discharge were identified. Trends were described using a time series analysis of patients' visits who received administration and prescriptions of cyclobenzaprine. ResultsBetween 2007 and 2019, we identified an estimated 1.35 billion ED visits, 57.2% (772.6 million) were female. From that sample, 2.4% (32.7 million) of all visits received cyclobenzaprine prescription in the ED only, and 0.5% (6.6 million) of total visits were both given the drug in the ED and were prescribed the drug at discharge). Overall trend analysis shows a slight decrease in annual percentages of cyclobenzaprine administration and prescriptions during the study period. Visits of certain subgroups: 26–44 years, white showed relatively higher percentages of administration and prescription of cyclobenzaprine. ConclusionsAlthough there was a slight decrease, our study still shows significant cyclobenzaprine utilization in the ED, despite conflicting evidence demonstrating efficacy for patients with musculoskeletal complaints and the concern for adverse effects. Additional studies are needed to examine its overall effectiveness and risk-benefit analysis in treating patients with such conditions.

Hospitalization Risk Associated With Emergency Department Reasons for Visit and Patient Age: A Retrospective Evaluation of National Emergency Department Survey Data to Help Identify Potentially Avoidable Emergency Department Visits.

Patients often present to emergency departments (EDs) with concerns that do not require emergency care. Self-triage and other interventions may help some patients decide whether they should be seen in the ED. Symptoms associated with low risk of hospitalization can be identified in national ED data and can inform the design of interventions to reduce avoidable ED visits. We used the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from the United States National Health Care Statistics (NHCS) division of the Centers for Disease Control and Prevention (CDC). The ED datasets from 2011 through 2020 were combined. Primary reasons for ED visit and the binary field for hospital admission from the ED were used to estimate the proportion of ED patients admitted to the hospital for each reason for visit and age category. There were 221,027 surveyed ED visits during the 10-year data collection with 736 different primary reasons for visit and 23,228 hospitalizations. There were 145 million estimated hospitalizations from 1.37 billion estimated ED visits (10.6%). Inclusion criteria for this study were reasons for visit which had at least 30 ED visits in the sample; there were 396 separate reasons for visit which met this criteria. Of these 396 reasons for visit, 97 had admission percentages less than 2% and another 52 had hospital admissions estimated between 2% and 4%. However, there was a significant increase in hospitalizations within many of the ED reasons for visit in older adults. Reasons for visit from national ED data can be ranked by hospitalization risk. Low-risk symptoms may help healthcare institutions identify potentially avoidable ED visits. Healthcare systems can use this information to help manage potentially avoidable ED visits with interventions designed to apply to their patient population and healthcare access.

Critical Examination of Indications for Urinalysis in the United States.

Urinalysis is commonly performed in the United States. We critically evaluated urinalysis indications in the United States. We obtained an Institutional Review Board exemption for this study. 2015 National Ambulatory Medical Care Survey data were queried for urinalysis testing frequency and associated International Classification of Diseases, ninth edition diagnoses. 2018 MarketScan data were queried for urinalysis testing frequency and associated International Classification of Diseases, 10th edition diagnoses. We considered International Classification of Diseases, ninth edition codes for genitourinary disease, diabetes, hypertension, hyperparathyroidism, renal artery disease, substance abuse, or pregnancy as an appropriate indication for urinalysis. We considered International Classification of Diseases, 10th edition codes A (certain infections and parasitic diseases), C, D (neoplasms), E (endocrine, nutritional, and metabolic diseases), N (disease of the genitourinary system), and select R codes (symptoms, signs, and abnormal clinical laboratory findings, not elsewhere classified) as an appropriate indication for urinalysis. Of 99 million 2015 urinalysis encounters, 58.5% had an International Classification of Diseases, ninth edition code for genitourinary disease, diabetes, hypertension, hyperparathyroidism, renal artery disease, substance abuse, and pregnancy. Forty percent of the 2018 urinalysis encounters did not have an International Classification of Diseases, 10th edition diagnosis. Twenty-seven percent had an appropriate primary diagnosis code, and 51% had one of the appropriate codes. The most common International Classification of Diseases, 10th edition codes were encounter for general adult examination, urinary tract infection, essential hypertension, dysuria, unspecified abdominal pain, and encounter for general adult medical examination with abnormal findings. Urinalysis is commonly performed without an appropriate diagnosis. Widespread urinalysis leads to a large number of evaluations for asymptomatic microhematuria, with associated cost and morbidity. Closer examination for urinalysis indications is needed to reduce costs and morbidity.

Standardization of continuous and categorical covariates in sparse penalized regressions.

In sparse penalized regressions, candidate covariates of different units need to be standardized beforehand so that the coefficient sizes are directly comparable and reflect their relative impacts, which leads to fairer variable selection. However, when covariates of mixed data types (e.g. continuous, binary or categorical) exist in the same dataset, the commonly used standardization methods may lead to different selection probabilities even when the covariates have the same impact on or level of association with the outcome. In this paper, we propose a novel standardization method that targets at generating comparable selection probabilities in sparse penalized regressions for continuous, binary or categorical covariates with the same impact. We illustrate the advantages of the proposed method in simulation studies, and apply it to the National Ambulatory Medical Care Survey data to select factors related to the opioid prescription in the US.

Evaluation of Cough Medication Use Patterns in Ambulatory Care Settings in the United States: 2003-2018.

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%).

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

We examined trends in management of headache disorders in United States (US) emergency department (ED) visits. We conducted a cross-sectional study using 2007–2018 National Hospital Ambulatory Medical Care Survey data. We included adult patient visits (≥18 years) with a primary ED discharge diagnosis of headache. We classified headache medications by pharmacological group: opioids, butalbital, ergot alkaloids/triptans, acetaminophen/nonsteroidal anti-inflammatory drugs (NSAIDs), antiemetics, diphenhydramine, corticosteroids, and intravenous fluids. To obtain reliable estimates, we aggregated data into three time periods: 2007–2010, 2011–2014, and 2015–2018. Using multivariable logistic regression, we examined medication, neuroimaging, and outpatient referral trends, separately. Among headache-related ED visits, opioid use decreased from 54.1% in 2007–2010 to 28.3% in 2015–2018 (Ptrend < 0.001). There were statistically significant increasing trends in acetaminophen/NSAIDs, diphenhydramine, and corticosteroids use (all Ptrend < 0.001). Changes in butalbital (6.4%), ergot alkaloid/triptan (4.7%), antiemetic (59.2% in 2015–2018), and neuroimaging (37.3%) use over time were insignificant. Headache-related ED visits with outpatient referral for follow-up increased slightly from 73.3% in 2007–2010 to 79.7% in 2015–2018 (Ptrend = 0.02). Reflecting evidence-based guideline recommendations for headache management, opioid use substantially decreased from 2007 to 2018 among US headache-related ED visits. Future studies are warranted to identify strategies to promote evidence-based treatment for headaches (e.g., sumatriptan, dexamethasone) and appropriate outpatient referral and reduce unnecessary neuroimaging orders in EDs.

Substance Use-related Emergency Department Visits and Resource Utilization.

IntroductionSubstance use-related visits to the emergency department (ED) have been linked to higher service delivery costs, although little is known about the specific services used. Our goal In this study was to describe the recent trends of substance use-related ED visits and assess the association between substance use and specific ED resource utilization.MethodsWe performed a retrospective, cross-sectional study using the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2013–2018. All ED visits in the United States for patients ≥18 years of age were included. The primary exposure was having substance use included as a chief complaint or diagnosis, which we identified using the International Classification of Diseases, 9th and 10th revisions, codes. The primary outcome was the use of diagnostic services (including laboratory studies and cardiac monitoring) or imaging studies in the ED.ResultsThe study sample included 95,506 visits in the US, extrapolating to over 619 million ED visits nationwide. The total number of ED visits remained stable during the study period, but substance use-related visits increased by 45%, with these visits making up 2.93% of total ED visits in 2013 and 4.25% in 2018. This increase was primarily driven by stimulant-, sedative- (opioids and benzodiazepines), and hallucinogen-related visits. Mental health-related visits rose in parallel by 66% during the same period. Compared to non-substance use-related visits, substance use-related visits were more likely to undergo any diagnostic study (adjusted odds ratio [aOR] 1.28; 95% confidence interval (CI): 1.11–1.47; P = 0.001), toxicology screening (aOR 10.15; 95% CI: 8.84–11.66), but less likely to have imaging studies (aOR 0.62; 95% CI: 0.56–0.68; P <0.0001). In stratified analyses, substance use-related visits with concurrent mental health disorders were more likely to undergo imaging studies (aOR 1.56; 95% CI: 1.09–2.22), while findings were opposite for those without concurrent mental health disorders (aOR 0.64; 95% CI: 0.51–0.71; P for interaction <0.0001).ConclusionSubstance use- and mental health-related ED visits are rising, and they are associated with increased resource utilization. Further studies are needed to provide more guidance in the approach to acute services in this vulnerable population.

Racial disparities in opioid administration and prescribing in the emergency department for pain

Study objectiveTo investigate the holistic characteristics of patients administered or prescribed opioids to treat pain in the emergency department (ED). MethodsWe used National Hospital Ambulatory Medical Care Survey (NHAMCS) data for 2018 to examine the administration and prescribing of opioids for pain-related ED visits. Weighted logistic regression models were developed to evaluate the association between opioid administration and prescribing (OAP) in the ED and patients' pain/severity of conditions, demographic/socioeconomic factors, behavioral factors, contextual factors, and organizational factors. Then, subgroup analyses were conducted by type of pain. ResultsNearly 55% of the ED visits in 2018 involved pain as a main reason for visiting the ED. The odds of receiving opioids were 45% less in black patients than in white patients when other covariates were adjusted (OR: 0.55; CI: 0.430–0.703). Compared to patients with private insurance, Medicaid beneficiaries and uninsured/self-pay patients had a 45% (OR: 0.55; CI: 0.423–0.706) and 44% (OR: 0.56; CI: 0.386–0.813) lower chance of receiving or being prescribed opioids for a pain-related ED visit when all covariates were adjusted. Other significant predictors of OAP for pain in EDs included older age, higher pain level, ED arrival by ambulance, admission to hospital, ED arrival during a night shift, geographic region of the ED. Behavioral factors, such as ED return within 72 h and whether a patient has substance/alcohol abuse or dependence, were not significantly associated with OAP. The subgroup analysis indicated that black patients had lower odds of OAP than their white counterparts only for certain pain categories. ConclusionDespite increasing awareness of potential implicit bias in managing pain in the ED, racial disparities in OAP still existed. More education and training on implicit bias would help with reduce the disparities. Also, our study result indicated that non-clinical factors may play a role in emergency physicians' decision making in OAP. Increased recognition of the variation and systemic efforts to address factors affecting the variability are needed.

Emergency department visits and trends related to cocaine, psychostimulants, and opioids in the United States, 2008\u20132018

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.