Nationwide Emergency Department Sample Database Research Articles

Trends in home treatment and early discharge of patients with low-risk pulmonary embolism

Abstract Background A strategy of ambulatory treatment or early discharge (≤ 48 hours) of patients with acute low-risk pulmonary embolism (PE) has been adopted by the most recent guideline recommendations. However, the adoption of such a change of paradigm in PE care in the ‘real-world’ clinical setting, outside the concept of prospective cohort (management) studies, remains unknown. Aims To determine the proportion of patients with PE who fulfill eligibility criteria for home treatment or early discharge, to investigate in how many of them such a management strategy is actually followed, and to discover differences in early complications between early or later discharge among low-risk patients. Methods We used two nationwide databases, the US Nationwide Emergency Department Sample (NEDS) and Nationwide Readmission Database (NRD), to identify patients with low-risk PE (absence of the following at presentation: haemodynamic instability, cor pulmonale, tachycardia, dyspnea, hypothermia, altered mental status, and fulfilment of the Hestia critieria). We investigated the proportion of patients that were discharged entirely at home, or discharged early (hospital stay £ 2 days) and their association with predictor variables. We also studied the 90-day occurrence of venous thromboembolism recurrence and major bleeding. Results From 2016 to 2020, there were 2,099,390 emergency department visits for PE (NEDS Database), with 641,621 (30.6%) classified as low-risk. Home treatment was documented in 20.3% of all cases, with 31.5% of low-risk PE cases being treated at home and an increasing trend over time (Figure 1A). Factors associated with home treatment for low-risk PE included younger age, female sex, and absence of comorbidities; home treatment was more frequent at university hospitals, non-metropolitan hospitals, and those with higher emergency department volumes (Figure 2A). In the NRD Database, there were 1,950,708 PE hospitalizations during the same period with 481,321 classified as low-risk (24.7%). An early discharge strategy was followed in 22.6% of all cases, increasing to 45.9% for low-risk PE admissions, with a rising trend observed from 2016 (Figure 1B). Factors associated with early discharge for low-risk PE included younger age, male sex, and absence of comorbidities; here, university hospitals and metropolitan hospitals were less likely to implement early discharge (Figure 2B). The 90-day incidence of VTE recurrence among low-risk patients was lower with early discharge (1.3% vs. 1.8%, p<0.001), as was major bleeding (1.5% vs. 2.8%, p<0.001). Conclusion Our results reveal an increasing implementation of early discharge and home treatment for low-risk PE across recent years. Factors influencing these strategies are related to demographics and hospital type. Early discharge was associated with favourable outcomes in the real-world setting, thus supporting the results of previously performed prospective cohort studies and randomized trials.Figure 1Figure 2

Craniofacial Assault Against Women: A National Evaluation Defining At-risk Populations and Outcomes.

Few studies have analyzed epidemiologic factor associated with female patients presenting to the emergency department from facial fractures because of assault. Clearly understanding these factors may assist in developing effective strategies to decrease the incidence and sequelae of these injuries. To determine the epidemiology of facial fractures because of assault in the female population. All female facial fracture visits were queried in the 2019 Nationwide Emergency Department (ED) Sample database. The likelihood of a facial fracture encounter resulting from assault was modeled using logistic regression adjusting for demographics, insurance status, geographic region, location of patient residence, and income. Secondary outcomes analyzed hospitalization costs and adverse events. Of all facial fractures 12.4% of female encounters were due to assault were due to assault. Of assaulted females, 72.8% were between the ages of 20 and 40, and Black women experienced a disproportionate share of assault encounters (odds ratio [OR]=2.55; CI, 2.29-2.84). A large portion (46.4%) of encounters occurred in patients living in the lowest quartile of median household income, and 22.8% of patients were uninsured (OR=1.34; CI, 1.09-1.66). Assaulted patients were more likely to have fractures in nasal bone (58.1% vs. 42.5%), orbit (16.8% vs. 10.9%), zygoma (4.1% vs 3.6%), and mandible (8.7% vs. 4.8%) compared with their nonassaulted counterparts. Facial fractures were especially common in lower income, uninsured, urban, and Black populations. Examining the patterns of injury and presentation are critical to improve prevention strategies and screening tools, identifying critical patients, and develop a more efficient and effective system to treat and support female patients suffering facial fractures secondary to assault.

Estimating the ratio of fatal to non-fatal overdoses involving all drugs, all opioids, synthetic opioids, heroin or stimulants, USA, 2010–2020

IntroductionUS drug overdose deaths are at historic levels. For every fatal drug overdose, there are many more non-fatal; however, minimal nationally representative data exist on trends in the ratio of...

Upper Extremity Fractures in the Emergency Department: A Database Analysis of National Trends in the United States.

Upper extremity (UE) fractures are a common reason for emergency department (ED) visits, but recent data on their epidemiology are lacking. This study aimed to describe the incidence, demographics, patient characteristics, and associated health care factors of UE fractures, hypothesizing that they would remain prevalent in the ED setting. Using the Nationwide ED Sample database, patients presenting to the ED with UE fractures in 2016 were identified, and population estimates were used to calculate incidence rates. Data on insurance status, trauma designation, cost, and teaching status were analyzed. The study identified 2 118 568 patients with UE fractures, representing 1.5% of all ED visits in 2016. Men accounted for 54.2% of UE fractures, with phalangeal fractures being most common. Distal radius and/or ulna fractures were most common in women (30.4%). The greatest proportion of UE fractures (23.2%) occurred in patients aged 5 to 14 years (1195.5 per 100 000). Nontrauma centers were the most common treating institutions (50.4%), followed by level I (19.5%), II (15.3%), and III (12.8%) centers. The greatest proportion of fractures (38.3%) occurred in the southern United States. Emergency department cost of treatment was almost 2-fold in patients with open UE fractures compared with closed. This study provides important epidemiological information on UE fractures in 2016. The incidence rate of UE fractures in the ED has remained high, with most occurring in the distal radius, phalanges, and clavicle. In addition, UE fractures were most common in younger patients, men, and those in the southern United States during the summer. These findings can be useful for health care providers and policymakers when evaluating and treating patients with UE fractures.

Rural disparities in emergency department utilization for migraine care.

To evaluate differences in emergency department (ED) utilization and quality of care for migraine in patients with rural and nonrural residences. Migraine is a significant problem in the United States with direct health-care utilization cost amounting to US $4.2 billion annually. A considerable portion of this cost is attributed to more than 4 million annual ED visits for migraine and headache. Previous research has documented health disparities among rural populations in other disease states, which can be influenced by factors such as socioeconomic status and health-care access. Given these associations, it was hypothesized that patients with rural residence in a national sample would have increased ED utilization for migraine compared to patients with nonrural residence. This was a cross-sectional epidemiologic study to evaluate rural disparities in ED utilization and quality of care for migraine in the United States in 2019. ED encounter data were collected from the Healthcare Cost and Utilization Project (HCUP) Nationwide Emergency Department Sample (NEDS) and Kentucky State Emergency Department Database (KY-SEDD). The primary outcome was crude and age-adjusted rates of ED encounters for migraine per 10,000 population. ED encounters were included if they had a primary International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code of G43.xx. ED encounters lacking sufficient data to classify into a geographic group were excluded. Secondary outcomes examined differences in quality of care, including mean ED charges and the proportion of encounters with medication administration, imaging, and nerve block service codes between groups. One hundred eighty-three thousand two hundred eleven national ED discharges were classified as rural patient encounters and 627,176 were classified as nonrural. The rural group had significantly higher crude and age-adjusted rates of ED utilization for migraine (crude: rural 39.8, 95% confidence interval [CI] 36.9-42.7; nonrural 22.2, 95% CI 21-23.5 and age-adjusted: rural 41.8, 95% CI 38.8-44.8; nonrural 23.4, 95% CI 22.1-24.7). Opioid utilization was higher in rural encounters (rural n = 26,764, 14.6%; nonrural n = 50,367, 8%; p < 0.001). A Kentucky sub-analysis found 5210 ED discharges were classified as Appalachian and 12,551 as non-Appalachian. The Appalachian group had significantly higher ED utilization rates for migraine compared to the non-Appalachian and national rural groups (crude: Appalachian 44.9, 95% CI 43.7-46.2; age-adjusted: Appalachian 47.4, 95% CI 46.1-48.8). The Kentucky Appalachian group also demonstrated significantly higher opioid analgesia use compared to the national rural group (Appalachian n = 1031, 19.8%; p < 0.001). This study suggests rural populations, particularly in Appalachia, may experience significantly higher ED utilization for migraine compared to nonrural patients. Moreover, rural populations were more likely to receive suboptimal migraine management with opioid analgesia. Multimodal health-care interventions should be developed to improve access to outpatient migraine care and further investigate potential risk factors in the rural population. With high ED utilization, the Appalachian population may benefit most from such an intervention.

Emergency Department Utilization for Heavy Menstrual Bleeding (2016-2020): An Opportunity to Improve Care

Introduction: Heavy Menstrual Bleeding (HMB) is one of the most common indications for ambulatory gynecological visits amongst reproductive aged women. It can have significant physical, social, emotional, and economic impact. Two thirds of women who report HMB develop anemia. While the outpatient setting may represent the optimal setting for management of this condition, it is known that many patients are treated in the emergency room or inpatient setting. We sought to evaluate Emergency Department (ED) utilization and the associated health care charges of patients who present to the ED with HMB. We hypothesized that marginalized groups are more likely to use the ED for HMB and are more likely to be admitted for this condition. Methods: The Nationwide Emergency Department Sample (NEDS) Database of the Health Cost and Utilization Project (HCUP, Rockville, MD) was queried for all visits with primary ICD-10 diagnosis codes of N92.0 (Excessive and Frequent Menstruation with Regular Cycle) or N92.4 (Excessive bleeding in the premenopausal period) among females 21-50 years of age. Variables assessed included age, hospital type, medical insurance, household income quartile, visit charges, disposition, and race. Race data were only available for 2019 and 2020. Z-test and Chi-square analyses were performed to compare counts and proportions across groups and years. All analyses were performed using SAS 9.4 (Cary, NC). Results: Between 2016 and 2020, 195,499 emergency room visits with a primary diagnosis of HMB were identified out of 164,441,890 total ED visits (0.12% of visits). The patient mean (SD) age was 33.7 (0.1) years. Total ED visits per year for HMB declined from 42,462 in 2016 to 33,718 in 2020. Self-pay represents a disproportionately high share of admissions. Approximately 6% of patients who presented to the ED with HMB were admitted which was stable from 2016-2020. Patients age 21-25 years represented the highest proportion of ED visits for HMB with 21.5% versus 12.2% among those ages 46-50 years. However, patients age 46-50 years accounted for 24.6% of admissions versus 6.3% of admissions for those aged 21-25 years. Patients 46-50 years had the highest admission rate (13.2%) versus 1.9% for ages 21-25 years. HMB related charges were over $150,000,000 per year, with a median charge per visit of over $3,000. For the two years for which race data were available, White women (WW) represented 41.2% of HMB visits versus 50.6% of all other diagnoses visits; Black women (BW) represented 28.6% of HMB ED visits versus 25.6% of all other diagnoses, and Hispanic women (HW) 22.1% of HMB ED visits versus 17.2% of all other diagnoses. Of the patients that were admitted for HMB, 31% were White versus 51% of all other diagnoses admissions, 33% were Black compared to 23% of all other diagnoses admissions, and 28% were Hispanic versus 18% of all other diagnoses admissions. Admission rates were higher for Black/Hispanic/Asian-Pacific Islanders (7.6%, 8.2%, 9.1%) vs. WW (4.9%). Percentage of ED visits for HMB for BW and HW were 29% and 22% respectively which compared to 25.6% and 17.2% of visits for all other diagnoses. Conclusion: ED visits with HMB as a primary diagnosis represent a small percent of visits overall and are decreasing. However, Black and Hispanic patients make up a disproportionate percentage of HMB patients. In addition, there is an inverse relationship with respect to age between ED visits and admissions. Younger adults ages 21-25 years make up the highest percentage of ED visits by age, but they are the least likely to be admitted with an admission rate of 1.9% suggesting an opportunity to better leverage an outpatient visit setting for this demographic. This analysis serves as a first step to understand ED utilization for HMB, and suggest potential disparities in ED utilization and/or admissions for HMB by age and race. Given the overall low admission rate, there may be an opportunity to improve outpatient services for HMB in younger women and in Black and Hispanic women.

Abstract 11897: Admission Rates for Pediatric Supraventricular Tachycardia From the Emergency Department Are Affected by Primary Insurance Payor: An Analysis of the NEDS Database

Introduction: Supraventricular tachycardia (SVT) is the most common arrhythmia in children and often requires emergency department (ED) care. Recent data highlight disparities in access to care for pediatric patients with SVT, though the association of socioeconomic factors with ED outcomes remains unclear. Hypothesis: Outcomes of ED encounters for pediatric SVT will differ by insurance payor. Methods: We performed a retrospective cohort study utilizing encounter-level data from the 2006-2018 US Nationwide Emergency Department Sample (NEDS). All encounters for patients age 0-18 years with a primary diagnosis of SVT were evaluated, excluding those with diagnoses of congenital heart disease or cardiomyopathy. The primary exposure was insurance payor: private vs. public. The primary outcome was hospital admission/transfer. Secondary outcomes included inpatient length of stay (LOS), procedures (cardioversion, catheter ablation), and mortality. Logistic regression models evaluated the association of payor with outcomes, including the following covariates: age, hospital teaching status, hospital region, patient residence, and patient income. Results: A total of 38,896 ED encounters were analyzed: median age 11.5 years (IQR 6-15); 48% male; 53% private payor, 38% public payor. Encounters with public payor had a higher rate of admit/transfer than private (24% vs. 18%, p&lt;0.0001). There were no differences in LOS (2.5 days public vs. 1.8 days private, p= 0.6) or procedures by payor; there were no mortalities. In multivariate analysis, public payor was an independent predictor of admission/transfer (OR 1.6, 95% CI 1.2-2.2). Patient age was also associated with admission/transfer, with all age groups less likely to undergo admission/transfer compared to age &lt; 1 year: age 1-4, OR 0.3, 95% CI 0.2-0.6; age 5-8, OR 0.1, 95% CI 0.1-0.2; age 9-12, OR 0.1, 95% CI 0.1-0.2; age 13-18, OR 0.1, 95% CI 0.1-0.2. Conclusions: This analysis demonstrates that public payor is associated with higher rates of hospital admission/transfer for pediatric SVT, independent of age. Though we cannot evaluate why publicly insured patients are admitted more often, it may be due to more severe illness caused by delays in care for SVT. If so, this should be a target for intervention.

Impact of Obesity on Outcomes of Emergency Department Visits for Cardiac Chest Pain: Insights From a Nationwide Emergency Department Study.

Background Obesity, a widespread national epidemic that impacts one in three U.S. adults, is closely linked with the development and exacerbation of cardiovascular disease. The objective of this study was to assess and contrast the outcomes of adults, both obese and non-obese, who present with cardiac chest pain in the emergency department (ED). Methodology A retrospective analysis of the 2020 Nationwide Emergency Department Sample database was conducted. Multivariate regression models were utilized to examinethe association between obesity and mortality, discharge disposition, number of procedures, complications, and hospital costs. Results No significant difference in mortality odds was observed between obese and non-obese patients presenting with cardiac chest pain in the ED (adjusted odds ratio (aOR) = 0.92; 95% confidence interval (CI) = 0.59-1.46; p = 0.736). However, obesity was found to be associated with a decreased likelihood of being discharged home from the ED (aOR = 0.57; 95% CI = 0.52-0.63; p < 0.001), as well as an increased likelihood of hospital admission from the ED (aOR = 1.66; 95% CI = 1.53-1.81; p < 0.001). Obesity also correlated with higher odds of non-home discharge (aOR = 1.74; 95% CI = 1.54-1.97; p < 0.001), elevated mean total hospital costs (mean = $13,345 vs. $9,952; mean increase = $3,360; 95% CI = $2,816-$3,904; p < 0.001), and increased risks of cardiac arrests (aOR = 1.52; 95% CI = 1.05-1.88; p < 0.001) and acute respiratory failures (aOR = 1.43; 95% CI = 1.25-1.96; p < 0.001). Obese patients with cardiac pain underwent more procedures on average than non-obese patients (19 vs. 15; aOR = 3.57; 95% CI = 3.04-4.11; p < 0.001). Conclusions Obesity is associated with higher odds ofhospital admission from the ED, non-home discharges, higher total hospital costs, and a greater number of procedures.

Characteristics of Retrobulbar Hemorrhage Presentation in the Emergency Department.

To describe demographic and clinical features of emergency department patients presenting with fracture-associated (FA) or fracture-independent retrobulbar hemorrhage (RBH). The Nationwide Emergency Department Sample database 2018 and 2019 was used to compare demographic and clinical features of patients with fracture-independent RBH and FA RBH. A total of 444 fracture-independent and 359 FA RBH patients were identified. Demographics such as age distribution, gender, and payer type differed significantly, with young (21-44 years), privately insured males more likely to develop FA RBH and the elderly (65+ years) more likely to develop fracture-independent RBH. Prevalence of hypertension and anticoagulation did not differ, but substance use and ocular-related injuries were more prevalent in the FA RBH. Presentations of RBH differ in demographic and clinical features. Further research is needed to explore trends and guide decision-making in the emergency department.

33 Targeting Vulnerability in the Homeless–A National Analysis of Burn Injuries Presenting to the Emergency Department.

Abstract Introduction Burn management is complex and outcomes depend on injury severity, timing of presentation, and specialized multidisciplinary care. Burn injuries among the homeless are an increasing problem in the United States (US) as record numbers of people are unsheltered and using unsafe heating practices. This study aims to characterize mechanism, demographic, and social factors related to burn injuries in homeless persons. Methods Burn encounters were extracted from the 2019 Nationwide Emergency Department Sample (NEDS) database. Two cohorts were created comparing homeless and non-homeless encounters. Burn characteristics (size, depth, location and mechanism), comorbidities, demographics, and ED treatments were compared with univariate testing. Multivariable regression evaluated the likelihood of admission. Discharge weights were used to yield national estimates. Results Of 316,334 ED visits meeting criteria for burn injuries in 2019, 1,919 (0.6%) had a diagnosis code for homelessness. Homelessness burn encounters were significantly older (mean age 32.4 vs. 44.8), were more often male (71% vs. 52%), were more often White (59% vs. 54%) or Black (24% vs. 21%), were more often presenting to EDs in the Western region of the US (43% vs. 19%), and more often had Medicaid as primary payer (51% vs 33%). Burns in homeless encounters more commonly resulted from flame injury and more commonly involved the lower extremity (p&amp;lt; 0.001). Among homeless encounters, burn injuries were more often due to self-harm (12% vs. 2%) or assault (5% vs. 1%)(p&amp;lt; 0.001). In addition, homeless encounters had significantly greater mental illness related to substance abuse (69% vs 16%, p&amp;lt; 0.001) and had greater comorbidity burden (38% vs. 6% had Elixhauser index scores of 3 or higher; p&amp;lt; 0.001). Homeless encounters experienced higher rates of third degree burns and concomitant injuries (p≤0.003). 49% vs 7% of homeless and non-homeless encounters, respectively, required admission, and homelessness was associated with higher odds of admission (adjusted OR 4.58; 95% CI 3.066–6.828; p&amp;lt; 0.001). Conclusions Burn injuries in the homeless affect a vulnerable population who is older, has more comorbidities, and has deeper burns. Mental illness is over 4 times more likely in this population who is also at increased risk of getting burned through assault. Applicability of Research to Practice Burn injuries presenting to the ED should be screened for homelessness given the associated risk factors. Legal, medical, and mental health resources can then be appropriately targeted.

Pediatric firearm injury related emergency department visits and hospitalizations: a population-based study in the United States

Firearm injury (FI) is the leading cause of death in children and adolescents in the United States (US). We describe the epidemiology of pediatric FI-associated emergency department (ED) visits and hospitalizations in the US stratified by race and ethnicity. Data on pediatric (0-17-year-olds) FI were analyzed using the 2019 Nationwide Emergency Department Sample (NEDS) and Kids' Inpatient Database (KID), the largest all-payer databases in the US for ED visits and pediatric hospitalizations, respectively. FI encounters were stratified by race and ethnicity. Poisson regression was used to identify factors associated with in-hospital mortality. Sampling weights were applied to generate nationally representative estimates. There were 7017 pediatric ED visits with FI (NEDS); 85.0% (5961/7017) were male and 73.0% (5125/7017) were adolescents (15-17 years). Overall, 5.5% (384/7017) died in the ED; 53.1% (3727/7017) of ED encounters did not result in hospitalization. There were 2817 pediatric FI hospitalizations (KID); 84.1% (2369/2817) were male and 71.6% (2018/2817) were adolescents; 51.4% (1447/2817) of FI were unintentional, 42.8% (1207/2817) were assault-related, and 5.8% (163/2817) were self-inflicted. Black children had the highest proportion (52.6%; 1481/2817) of hospitalizations among all race and ethnicities (p<0.0001 vs. White). White children had the highest proportion of hospitalizations for self-inflicted injuries (16.6% [91/551] vs. 4.9% [25/504; p<0.0001] in Hispanics and 1.7% [24/1481] in Blacks; p<0.0001). The majority (56.5%; 1591/2817) of hospitalizations were patients from low-income zip codes (median annual-household-income <$44,000); 70% (1971/2817) had Medicaid as the primary insurance payer. Overall, 8.0% (225/2817) died during FI-associated hospitalizations. Self-inflicted injuries had the highest in-hospital mortality (prevalence ratio=8.20, 95% CI=6.06-11.10 vs. unintentional). Black children and children with lower household incomes were disproportionately impacted by FI resulting from assaults and accidents, while White children had the highest proportion of self-inflicted FI injuries. Public health and legal policy interventions are needed to prevent pediatric FI. US National Institutes of Health.

Association of open globe injury characteristics with outcome measures in the emergency department.

To evaluate the association of demographic and clinical features of emergency department (ED) patients presenting with open globe injuries (OG) with outcomes such as inpatient admission rate, length of stay (LOS), and total cost. The Nationwide Emergency Department Sample database 2018 and 2019 was used to analyze the association of demographic and clinical features of OG patients with outcome measures. 8404 OG patients were identified. Medicaid patients were associated with higher ED costs and a higher frequency of extended LOS. The 70+ age group was associated with higher inpatient admission. Frail patients were associated with significantly increased likelihood of inpatient admission, higher likelihood of extended LOS and higher total combined ED cost. Falls and being struck were associated with shorter LOS. This study describes the most common demographic and clinical characteristics of OGIs that present to the ED, as well as the association of these characteristics with outcome measures such as inpatient admission rates, LOS, and total cost. The study further identified potential high-risk patients for prolonged length of stay. The findings will better optimize patient care protocols to improve outcomes.

Predictors of Completed Suicides Among Emergency Department Visits for Attempted Suicides.

The objective of this study was to identify predictors of mortality among patients presenting to the emergency department (ED) with attempted suicides. We analyzed data on emergency department (ED) visits for attempted suicides from the Nationwide Emergency Department Sample (NEDS) database from January 2010 to December 2017. The predictors of mortality were determined in multivariate analysis including age, sex, insurance, annual income, region of the country, mechanism of injury, mental health conditions (schizophrenia; depression; and anxiety, bipolar, and personality disorders), chronic illnesses (hypertension, diabetes, obesity, and dementia), and social risk factors such as alcohol addiction, smoking, and substance abuse. From 2010 to 2017, there were 979,383 ED visits for attempted suicides in the NEDS database. Among these patients, 10,301 (1.1%) died. Of these completed suicides, 73.9% were male with the median age of 43 years (IQR, 30) while the unsuccessful suicide attempt group had a median age of 30 years (IQR, 24) and were 42.7% male. The most common mechanisms of suicide attempt were poisoning (58.8%) and cut injury (25.6%). Gunshot was the most lethal mechanism accounting 40.3% of the completed suicides despite representing 1.3% of the attempts who came to ED. After controlling for common risk factors for attempted suicide, significant predictors of completed suicide include higher income status, uninsured status, male sex, and higher age. Among US patients presenting to the ED following attempted suicide, factors associated with suicide completion include increasing age, male sex, higher income, gunshot injuries, and uninsured status.

Factors associated with weekend emergency department visits in patients with GI cancer.

813 Background: Gastrointestinal (GI) cancers account for highest ED revisits among cancer patients. Weekend ED visits are also associated with higher mortality. We aimed to analyze factors associated with weekend ED visits among GI cancer patients. Methods: Nationwide Emergency Department Sample (NEDS) database was queried from 2009 to 2017 for ED visits with GI primary tumor. ED visits were characterized by demographic, socioeconomic factors, hospital characteristics and primary cancer. Univariate and multivariate logistic regression were performed. Data was analyzed using Stata. Results: From 2009 to 2017, 6,862,077 ED visits associated with GI cancer were analyzed and 1,811,111(26.4%) visits were on weekend. Weekend visits were associated with increased in-hospital mortality (odds ratio [OR] 1.06; 95% Confidence Interval [CI] 1.04-1.). Weekday mortality was 3.8%, while weekend was 3.9%. Weekend visits were negatively associated with presentation in 2013-2017 as compared to 2009-2012 (OR 0.96; 0.95-0.97), Northeast hospitals (OR 0.89; 0.88-0.91) compared to Midwest, teaching hospital status (OR 0.96; 0.95-0.97) compared to non-teaching and metastatic cancer (OR 0.96; 0.95-0.97) compared to non-metastatic cancers. Compared to colon, weekend admissions were also negatively associated with anorectal (OR 0.96; 0.95-0.98) and hepatobiliary cancers (OR 0.96; 0.95-0.98). Conclusions: Presentation between 2013 to 2017, teaching hospital status, Northeast hospitals and metastatic stage were associated with fewer weekend ED visits. These findings could be potentially explained by increased and primary care utilization. There was a statistically significant association between mortality and weekend admissions, however the absolute difference was only 0.1%. Possible explanations include potential differences in staffing, interventions and procedures over the weekends compared to weekdays. In comparison to colon, anorectal and hepatobiliary cancer patients are less likely to have weekend ED visits while pancreatic cancer patients are more likely to have weekend ED visits. Our findings may help GI oncologists identify patients at risk of weekend ED visits.[Table: see text]

Emergency department burden of hyperemesis gravidarum in the United States from 2006 to 2014

Hyperemesis gravidarum is the most severe form of nausea and vomiting of pregnancy, potentially affecting both maternal and pregnancy health. Hyperemesis gravidarum often results in emergency department visits, although the exact frequency and costs associated with these visits have not been well studied. This study aimed to analyze the trends in hyperemesis gravidarum emergency department visits, inpatient admissions, and the associated costs between 2006 and 2014. Patients were identified from the 2006 and 2014 Nationwide Emergency Department Sample database files using International Classification of Diseases, Ninth Revision diagnosis codes. Patients with a primary diagnosis of hyperemesis gravidarum, nausea and vomiting of pregnancy, and all nondelivery pregnancy-related diagnoses (all antepartum visits) were identified. All groups were analyzed; trends in demographics, number of emergency department visits, and visit costs were compared. Costs were inflation-adjusted to 2021 US dollars. Emergency department visits for hyperemesis gravidarum increased by 28% from 2006 to 2014; however, the proportion of those who were subsequently admitted to the hospital decreased. The average cost of an emergency department visit for hyperemesis gravidarum increased by 65% ($2156 to $3549), as opposed to an increase of 60% for all antepartum visits ($2218 to $3543). The aggregate cost for all hyperemesis gravidarum visits increased by 110% ($383,681,346 to $806,696,513) from 2006 to 2014, which was similar to the increase observed for all antepartum emergency department visits. From 2006 to 2014, emergency department visits for hyperemesis gravidarum increased by 28%, with associated costs increasing by 110%, whereas the number of admissions from the emergency department for hyperemesis gravidarum decreased by 42%.

Intimate Partner Violence and Pregnancy: Nationwide Analysis of Injury Patterns and Risk Factors.

Intimate partner violence (IPV) is a significant cause of injury, and in pregnant patients (PIPV) poses a risk to both mother and fetus. Characteristics and outcomes for PIPV patients have not been well described. We hypothesize that PIPV patients have higher admission rates and mortality than non-IPV pregnant trauma (PT) patients and nonpregnant female IPV patients of childbearing age. We also hypothesize differences exist between PIPV and PT patient injury patterns, allowing for targeted IPV screening. The Nationwide Emergency Department Sample database was queried from 2010 to 2014 to identify IPV in adult women patients by injury code E967.3. Patients were compared in 2 ways, PIPV vs PT and PIPV vs nonpregnant female IPV patients. Demographics, injury mechanisms, and National Trauma Data Standard injury diagnoses were surveyed. Primary outcomes were hospital admissions and mortality. Logistic regression was used to estimate risk factors of the outcomes of hospitalization and IPV victimization in pregnant injured patients. There were 556 PIPV patients, 73,970 PT patients, and 56,543 nonpregnant female IPV patients. When comparing PIPV to PT, more PIPV patients had Medicaid coverage or were self-pay. Suffocation, head injuries, face/neck/scalp contusions, multiple contusions, and abrasions/friction burns were more prevalent in PIPV patients. Mortality and hospital admissions were scarce among all cohorts. Predictors of IPV victimization among injured pregnant patients include multiple injuries, head injuries, face/neck/scalp contusions, abrasions/friction burns, contusions of multiple sites, and those with Medicaid or self-pay coverage. Among injured pregnant patients, those with multiple injuries, head injuries, contusions of the face/neck/scalp, abrasions/friction burns, and multiple contusions should undergo IPV screening. Admissions and mortality are low; therefore, prevention measures should be implemented in the emergency department to reduce repeat victimization.

Emergency department utilization for ovarian hyperstimulation syndrome

BackgroundOvarian hyperstimulation syndrome (OHSS) is a rare, but serious, risk of assisted reproductive technologies. In severe cases, patients may present to the emergency department (ED) for assessment, treatment of related complications, and even in-patient admission. Significant effort has been made to reduce the incidence and complications of OHSS; however, it is unknown if these strategies have decreased patient presentation for treatment in the ED. PurposeTo assess ED utilization for OHSS over time and to examine admission rates, patient demographics, and charges. MethodsRetrospective longitudinal study utilizing data from the Nationwide Emergency Department Sample Database and the National ART Surveillance System. All ED visits between 2006 and 2016 with an ICD-9 or −10 diagnosis of OHSS were included. Demographics including age, geographic location, and income quartile and alternative diagnoses, admission rates, overall charges, and number of stimulation cycles annually were assessed. ResultsThe number of ovarian stimulation cycles steadily increased from 2006 (n = 110,183) to 2016 (n = 157,721), while the number of OHSS-related ED visits remained relatively stable (APC 2.08, p = 0.14). Admission rates for OHSS decreased from 52.7% in 2006 to 33.1% in 2016 (APC −4.43%, p < 0.01). The average charge for OHSS-related ED visits almost doubled from 2006 to 2016 (APC 8.53, p < 0.01) and was significantly higher than charges for non-OHSS-related visits for age-matched controls (p < 0.01). ConclusionDespite an increase in total stimulation cycles, there was no significant change in the estimated number of patients presenting to the ED; however, admission rates significantly declined. These observations suggest a possible shift in the severity and/or management of OHSS during the study period.

Assessment of Ethno-racial and Insurance-based Disparities in Pediatric Forearm and Tibial Fracture Care in the United States.

Despite growing attention to healthcare disparities and interventions to improve inequalities, additional identification of disparities is needed, particularly in the pediatric population. We used state and nationwide databases to identify factors associated with the surgical treatment of pediatric forearm and tibial fractures. The Healthcare Cost and Utilization Project State Inpatient, Emergency Department, and Ambulatory Surgery and Services Databases from four US states and the Nationwide Emergency Department Sample database were quarried using International Classification of Diseases codes to identify patients from 2006 to 2015. Multivariable regression models were used to determine factors associated with surgical treatment. State databases identified 130,006 forearm (1575 open) and 51,979 tibial fractures (1339 open). Surgical treatment was done in 2.6% of closed and 37.5% of open forearm fractures and 7.9% of closed and 60.5% of open tibial fractures. A national estimated total of 3,312,807 closed and 46,569 open forearm fractures were included, 59,024 (1.8%) of which were treated surgically. A total of 719,374 closed and 26,144 open tibial fractures were identified; 52,506 (7.0%) were treated surgically. Multivariable regression revealed that race and/or insurance status were independent predictors for the lower likelihood of surgery in 3 of 4 groups: Black patients were 43% and 35% less likely to have surgery after closed and open forearm fractures, respectively, and patients with Medicaid were less often treated surgically for open tibial fractures in state (17%) and nationwide (20%) databases. Disparities in pediatric forearm and tibial fracture care persist, especially for Black patients and those with Medicaid; identification of influencing factors and interventions to address them are important in improving equality and value of care.

Comorbid Patterns in the Homeless Population: A Theoretical Model to Enhance Patient Care.

IntroductionFrom the perspective of social determinants, homelessness perpetuates poor health and creates barriers to effective chronic disease management, necessitating frequent use of emergency department (ED) services. In this study we developed a screening algorithm (checklist) from common comorbidities observed in the homeless population in the United States. The result was a theoretical screening tool (checklist) to aid healthcare workers in the ED, including residents, medical students, and other trainees, to provide more efficacious treatment and referrals for discharge.MethodsIn this retrospective cohort study we used the Nationwide Emergency Department Sample (NEDS) to investigate comorbidities and ED utilization patterns relating to 23 injury-related, psychiatric, and frequent chronic medical conditions in the US adult (≥18 years of age) homeless population. Cases were identified from the NEDS database for 2014–2017 using International Classification of Diseases, 9th and 10 revisions, and Clinical Classification Software diagnosis codes. We performed a two-step cluster analysis including pathologies with ≥10% prevalence in the sample to identify shared comorbidities. We then compared the clusters by sociodemographic and ED-related characteristics, including age, gender, primary payer, and patient disposition from the ED. Chi-square analysis was used to evaluate categorical variables (ie, gender, primary payer, patient disposition from the ED), and analysis of variance for continuous variables (age).ResultsThe study included 1,715,777 weighted cases. The two-step cluster analysis identified nine groups denominated by most prevalent disease: 1) healthy; 2) mixed psychiatric; 3) major depressive disorder (MDD); 4) psychosis; 5) addiction; 6) essential hypertension; 7) chronic obstructive pulmonary disease (COPD); 8) infectious disease; and (9) injury. The MDD, COPD, infectious disease, and Injury clusters demonstrated the highest prevalence of co-occurring disease, with the MDD cluster displaying the highest proportion of comorbidities. Although the addiction cluster existed independently, substance use was pervasive in all except the healthy cluster (prevalence 36–100%). We used the extracted screening algorithm to establish a screening tool (checklist) for ED healthcare workers, with physicians as the first point of contact for the initial use of the screening tool.ConclusionHealthcare workers in the ED, including residents, medical students, and other trainees, provide services for homeless ED users. Screening tools (checklists) can help coordinate care to improve treatment, referrals, and follow-up care to reduce hospital readmissions. The screening tool may expedite targeted interventions for homeless patients with commonly occurring patterns of disease.

A National Analysis of Ophthalmic Features and Mortality in Abusive Head Trauma

It is important to recognize presenting features and factors associated with mortality in abusive head trauma (AHT) owing to the severity of the diagnosis and the necessity for prompt action. To describe the prevalence and economic burden of AHT and identify factors associated with mortality. This retrospective, cross-sectional study used the Nationwide Emergency Department Sample database to identify all emergency department visits in the US for patients younger than 5 years with a primary diagnosis of abusive head trauma between January 1, 2006, and December 31, 2018. This study was conducted in 2021. Prevalence, demographic characteristics, clinical characteristics, mortality, and economic burden associated with AHT. Weighted national estimates were calculated using sampling weights provided in the Nationwide Emergency Department Sample database. From 2006 to 2018, there were an estimated 12 287 cases of emergency department visits in the US for patients younger than 5 years with a primary diagnosis of AHT. The estimated number of AHT cases decreased by 672 (95% CI, 403-940; P < .001) from 2006 to 2018. The incidence decreased by 6.7% each year (incidence rate ratio, 0.93; 95% CI, 0.93-0.94; P < .001) between 2006 and 2018. During the course of a hospital visit, 646 patients (5.3%) died. The majority of patients with a diagnosis of AHT were younger than 1 year (n = 7046; 57.3%), were male (n = 7268; 59.2%) and had Medicaid insurance (n = 8585; 70.0%). After controlling for demographic characteristics, factors associated with increased mortality were age greater than 1 year (odds ratio [OR], 2.45; 95% CI, 1.50-3.99; P < .001), first or second income quartile (OR, 1.78; 95% CI, 1.08-2.91; P = .02), midwestern United States (OR, 2.04; 95% CI, 1.04-4.00; P = .04), level 1 trauma center (OR, 2.69; 95% CI, 1.07-6.75; P = .04), orbital fracture (OR, 15.38; 95% CI, 2.41-98.18; P = .004), cerebral edema (OR, 8.49; 95% CI, 5.57-12.93; P < .001), intracranial hemorrhage (OR, 4.27; 95% CI, 1.71-10.67; P = .002), hypoxic ischemic brain injury (OR, 4.16; 95% CI, 2.13-8.10; P < .001), skull fractures (OR, 3.20; 95% CI, 1.76-5.82; P < .001), subarachnoid hemorrhage (OR, 2.43; 95% CI, 1.22-4.83; P = .01), retinal hemorrhage (OR, 2.17; 95% CI, 1.40-3.38; P < .001), and subdural hemorrhage (OR, 2.05; 95% CI, 1.05-3.98; P = .04). This study's findings suggest that health care disparities may be present in the treatment of AHT. Recognizing factors suggested in this investigation to be associated with higher mortality, public health efforts should be targeted toward low-income areas and in the midwestern United States.