Recurrent Emergency Department Visits Research Articles

Rhythm Control Vs Rate Control in a Contemporary Ambulatory Atrial Fibrillation Cohort: Post Hoc Analysis of the IMPACT-AF Trial

BackgroundWe examined the characteristics and outcomes in a contemporary ambulatory population of patients with atrial fibrillation (AF), comparing rate control with rhythm control. MethodsThis is a post hoc analysis of a cluster-randomized trial (Integrated Management Program Advancing Community Treatment of Atrial Fibrillation [IMPACT-AF]) in ambulatory AF patients from 2016 to 2018, which compared use of a clinical decision support tool for general practitioners to usual care. This analysis compared patients managed with rate vs rhythm control, at entry into the study. Outcomes included AF-related emergency department (ED) visits, unplanned cardiovascular hospitalizations, and bleeding events at 12 months. ResultsA total of 870 patients were included in this analysis, 99 (11.4%) in the rhythm-control group, and 40% women. In the rhythm-control group, the mean age was younger (70 ± 11.4 vs 72.7 ± 9.5 years, P = 0.03), a higher number were paroxysmal (80% vs 43%, P < 0.001), and CHADS2 scores were lower. The rate of AF-related ED visits was higher in the rhythm-control group (17.2 vs 7.3%, P = 0.003), and repeat visits (rate ratio 3.03, 95% confidence interval [1.99-4.52], P < 0.001). The number of repeat ED visits was independently associated with female sex and being in the rhythm-control group. ConclusionsBoth rate- and rhythm-control patients have recurrent ED visits, with a higher rate in patients treated with rhythm control. These findings are observational, but taken in the context of current guidelines could help develop further therapies aimed at improving symptom burden in both rhythm- and rate-control patients to broadly improve healthcare utilization in the AF population.

Characteristics of pediatric emergency department frequent visitors and their risk of a return visit: A large observational study using electronic health record data.

Among pediatric emergency department (ED) visits, a subgroup of children repeatedly visits the ED, making them frequent visitors (FVs). The aim of this study is to get insight into the group of pediatric ED FVs and to determine risk factors associated with a revisit. Data of all children aged 0-18 years visiting the ED of a university hospital in the Netherlands between 2017 and 2020 were included in this observational study based on routine data extraction. Children with 4 or more ED visits within 365 days were classified as FVs. Descriptive analysis of the study cohort at patient- and visit-level were performed. Risk factors for a recurrent ED visit were determined using a Prentice Williams and Peterson gap time cox-based model. Our study population of 10,209 children with 16,397 ED visits contained 500 FVs (4.9%) accounting for 3,481 visits (21.2%). At patient-level, FVs were younger and more often suffered from chronic diseases (CDs). At visit-level, frequent visits were more often initiated by self-referral and were more often related to medical problems (compared to trauma's). Overall, FVs presented at the ED more often because of an infection (41.3%) compared to non-FVs (27.4%), either associated or not with the body system affected by the CD. We identified the presence of a comorbidity (non-complex CD HR 1.66; 1.52-1.81 and complex CD HR 2.00; 1.84-2.16) as determinants with the highest hazard for a return visit. Pediatric ED FVs are a small group of children but account for a large amount of the total ED visits. FVs are younger patients, suffering from (complex) comorbidities and present more often with infectious conditions compared to non-FVs. Healthcare pathways, including safety-netting strategies for acute manifestations from their comorbidity, or for infectious conditions in general may contribute to support parents and redirect some patients from the ED.

Experience of emergency department patients after a visit for hyperglycaemia: implications for communication and factors affecting adherence postdischarge

BackgroundWhile studies have reported factors affecting adherence to diabetic care plans from a chronic disease perspective, no studies have addressed issues with post-discharge adherence facing patients with diabetes after an...

Suicidal ideation is insensitive to suicide risk after emergency department discharge: Performance characteristics of the Columbia-Suicide Severity Rating Scale Screener.

We describe the Columbia-Suicide Severity Rating Scale (C-SSRS)-Clinical Practice Screener's ability to predict suicide and emergency department (ED) visits for self-harm in the year following an ED encounter. Screening data from adult patients' first ED encounter during a 27-month study period were analyzed. Patients were excluded if they died during the encounter or left without being identified. The outcomes were suicide as reported by the state health department and a recurrent ED visit for suicide attempt or self-harm reported by the state hospital association. Multivariable regression examined the screener's correlation with these outcomes. Among 92,643 patients analyzed, eleven (0.01%) patients died by suicide within a month after ED visit. The screener's sensitivity and specificity for suicide by 30days were 0.18 (95% confidence interval [CI]= 0.00 to 0.41) and 0.99 (95% CI= 0.99 to 0.99). Sensitivity and specificity were better for predicting self-harm by 30days: 0.53 (95% CI= 0.42 to 0.64) and 0.97 (95% CI= 0.97 to 0.97), respectively. Multivariable regression demonstrated that screening risk remained associated with both suicide and self-harm outcomes in the presence of covariates. Suicide risk was not mitigated by hospitalization or psychiatric intervention in the ED. The C-SSRS screener is insensitive to suicide risk after ED discharge. Most patients who died by suicide screened negative and did not receive psychiatric services in the ED. Moreover, most patients with suicidal ideation died by causes other than suicide. The screener was more sensitive for predicting nonfatal self-harm and may inform a comprehensive risk assessment. These results compel us to reimagine the provision of emergency psychiatric services.

Diagnosis and Management of Headaches in the Emergency Department (ED) in Adults and Children.

Headache accounts for a significant number of cases presenting to the Emergency Department (ED) and has a high societal cost, contributed by recurrent ED and clinic visits, and unnecessary diagnostic tests. This review article covers the important clinical tools needed to evaluate headaches in both adults and children in the ED. Medline/PubMed was searched using the keywords "Emergency department", "headache", "adult", "pediatric", "clinical assessment", "diagnosis" and "treatment", in the title or abstract. The search covers the period from 1 January 1990 to 31 December 2019. The articles selected were based on their relevancy to the objective of this review article. Additional relevant publications were identified from article references lists. The emergency physician plays a key role in differentiating between primary and secondary headaches. Within the limited ED resources, appropriate diagnostic testing should be used to identify the life-threatening headaches. This will ensure patients are given the appropriate evidence-based pharmacological therapy and holistic management.

Prediction of Recurrent Emergency Department Visits among Patients with Crohn's Disease: A Retrospective Study.

Patients with Crohn’s disease (CD) are frequently subject to symptoms causing them to seek medical care in emergency departments (ED). Recurrent ED visits are frequent after initial discharge. We aimed to identify the characteristics of patients with Crohn’s who tend to have recurrent visits to the ED. We created an electronic data repository of all patients with inflammatory bowel diseases who visited the ED in our tertiary medical center during the period 2012–2018. For this study, we retrieved consecutive Crohn’s patients who presented with CD-related symptoms to the ED and were eventually discharged. Patients who returned to the ED in 7 and 30 days were compared with those who did not. Overall, 2299 patients visited our ED with complaints related to Crohn’s disease exacerbation or complication. A total of 1259 (60% of the adult patients) were admitted for hospitalization. Of the 632 (33%) who were discharged from the ED, 53 (8.4%) and 110 (17.4%) re-visited the ED, in 7 and 30 days from discharge, respectively. In multivariable analysis, tachycardia (odds ratio (OR) = 2.19, 95% confidence interval (CI): 1.11–4.33, p value = 0.02), elevated alkaline phosphatase (OR = 2.09, 95% CI: 1.07–4.07, p value = 0.02), and hyponatremia (OR = 2.52, 95% CI: 1.24–5.10, p value = 0.01) were associated with revisiting the ED within 7 days. Tachycardia (OR 2.88 (95% CI 1.33–6.2)), anemia (OR 2.44 (95% CI 1.24–4.8)), and elevated alkaline phosphatase (OR 2.68 (95% CI 1.25–5.78)) were independently associated with ED returns in 30 days. Knowing these risk factors may assist in minimizing the burden of recurrent ED visits among patients with CD.

110 Improving Asthma Education in the Emergency Department: A Quality Improvement Initiative

Abstract Introduction/Background Asthma education and action plans have been shown to improve compliance and symptom control. Provincial guidelines, created in 2015, included asthma action plans, but use of these resources across our site was not consistent. Objectives The objectives of this study were to develop and implement an asthma education package, standardize discharge instructions and improve appropriate referrals to Asthma Clinics. Design/Methods Using process mapping, staff surveys and patient interviews, we undertook a current state analysis. The resulting change ideas were implemented between October 2018 and January 2020 in 5 PDSA (Plan Do Study Act) cycles, utilizing chart reviews and a standardized data tool to measure outcomes. Rates of repeat Emergency Department (ED) attendances, 2 weeks following the initial encounter and overall rates of ED asthma visits were assessed, using patient medical record data. Results Two-hundred-and-twenty-five ED presentations were reviewed, 65.2% (146/224) had a previous diagnosis of asthma. 48.9% (110/225) reported using an inhaled corticosteroid (ICS) at presentation. 89.7% (201/224) had not seen a healthcare provider during this acute illness. Asthma action plan utilization increased from 0% at baseline to an average of 60%, sustained over 2 years. 74.2% (167/225) had an ICS prescribed or advised at discharge. Only 3.8% (8/209) of patients re-presented to an ED within 2 weeks of this asthma visit. 57.3% (129/225) children were referred for ongoing pediatric care: either by a community pediatrician (72.9%; 94/129) or our hospital Asthma Clinic (34.8%; 32/129). Between 2017 and 2019, there was no significant change in total asthma presentations to our ED/per year (1300, 1395 and 1307, respectively) (Figure 1). Conclusion A standardized asthma education package including pre-printed discharge resources, asthma action plans, and a provincially adopted, multi-language education video was successfully implemented into our ED. This demonstrates a multi-disciplinary approach to asthma education that can be utilized across the province. Our data highlights the need for a strong community-based approach for asthma care, and further work is ongoing to assess the efficacy of this education package on medication compliance and recurrent ED visits.

Do Adult Patients With Type 1 or 2 Diabetes Who Present to the Emergency Department With Hyperglycemia Have Improved Outcomes if They Have Access to Specialized Diabetes Care?

ObjectivesFew studies have examined the effect of specialized care on patients with diabetes who present to the emergency department (ED) visits for acute hyperglycemia. The objective of this study was to characterize ED patients presenting with hyperglycemia and compare the 30-day outcomes of those followed by specialized diabetes clinics with those not followed. We hypothesized that patients followed by specialized clinics would have improved clinical outcomes compared with those who had no specialized follow up. MethodsWe conducted this single-centre retrospective cohort study of adults (≥18 years) with an ED visit for hyperglycemia over 1 year (January to December 2014). Data from ED visits were linked to specialized diabetes clinic records, which contained diabetes-specific clinical data not available in ED visit records. Descriptive statistics were summarized and comparisons between groups were performed, when appropriate. ResultsThere were 456 patients (55.0% men; mean age, 47.7 years; 46.3% with type 1 diabetes) with 250 followed by the specialized diabetes clinics. The 206 patients who were not followed by the diabetes clinics (45%) were more likely to have a recurrent hyperglycemia ED visit (32.5% vs 9.6%, p<0.001) and to require hospitalization for hyperglycemia (14.1% vs 5.2%, p=0.001) within 30 days of initial presentation. ConclusionsPatients followed by specialized diabetes clinics had fewer recurrent ED visits and hospital admissions for hyperglycemia at 30 days compared with those not followed, suggesting that greater continuity of care between endocrinology and emergency medicine may help reduce these adverse outcomes for patients with diabetes.

A multifaceted intervention to improve asthma control via asthma education, medical follow-up and regular self-monitoring after pediatric emergency department visits for asthma

BACKGROUND Repeated emergency department (ED) visits for acute asthma signal poor asthma control. OBJECTIVE We examined the effectiveness of a multifaceted intervention initiated in the ED to promote asthma education, medical visits and regular self-monitoring and to reduce morbidity following an acute care visit for asthma in children. METHODS We conducted a single-blind randomized controlled trial in children aged 5–17 years presenting for a second or more ED visits for asthma in the past year. The main outcome was the risk of asthma acute care visits. RESULTS We randomized 298 children to usual care (N = 127) and the intervention (N = 171); Children were mostly Caucasians with a median (25%, 75%) age of 8 (6, 11) years. Compared to usual care, significantly more intervention patients attended a medical follow-up visit (32% vs 20%, RR: 1.54 [95%CI: 1.03, 2.32]) and an asthma education session (28% vs 9%, RR: 3.24 [1.75, 5.99]) within 4 weeks of the ED visit. There was no significant group difference in the risk of acute care visits over the next year (RR: 0.92 [0.71, 1.19]). CONCLUSIONS In asthmatic children with recurrent ED visits, promotion of asthma education, medical follow-up visits, asthma control awareness and self-monitoring increased attendance to asthma education and medical follow-up within 4 weeks of the index visit, without reducing exacerbations requiring health care resources.

Prediction of Recurrent Emergency Department Visits in Patients With Mental Disorders.

BackgroundPatients with mental disorders are more likely to be frequent emergency department (ED) users than patients with somatic illnesses. There is little information about recurrent ED visitors (≥four ED visits/year) due to mental health problems in Switzerland. Therefore, our aim was to investigate the prevalence of recurrent ED visits due to mental disorders and to determine which mental disorders and risk factors were associated with recurrent ED visits.MethodsIn a retrospective analysis, we investigated patients suffering from mental health problems between January and December 2015 who presented more than once in the ED of a tertiary care hospital. ED patients who sought out the ED due to mental disorders were grouped in a recurrent group with at least four ED visits per year or in a control group visiting the ED twice or three times within a year. The primary endpoint was to assess the prevalence of recurrent ED patients due to acute symptoms of mental disorders. As secondary endpoints, we investigated which mental disorders and risk factors were associated with recurrent ED visits.ResultOf 33,335 primary ED visits, 642 ED visits (1.9%) were by 177 visitors suffering from acute mental health problems. Forty-five (25.4%) of these 177 patients were recurrent ED visitors; 132 (74.6%) visited the ED twice or three times (control). Patients with personality disorders had a four-times higher risk (p = 0.011) of being a recurrent ED visitor. Recurrent ED visitors with mental disorders had significantly more in-house admissions (p < 0.001), self-mutilations (p < 0.001), acute drug toxicity (p = 0.007) and were more often persons of single status (p = 0.045). Although recurrent ED visitors more often had an outpatient general physician or psychiatrist, they visited the ED more frequently within office hours (p < 0.001).ConclusionA quarter of frequent ED users with mental disorders are recurrent ED visitors and were more likely to suffer from personality disorders. Recurrent ED visits are associated with higher rates of self-mutilation, acute drug toxicity, and a greater number of in-house admissions.

P402 Prediction of emergency department re-visit among Crohn’s disease patients: a retrospective study

Abstract Background Patients with Crohn’s disease are frequently subject to symptoms causing them to seek medical care in emergency departments (ED). Recurrent ED visits are common after initial discharge. The burden of recurrent ED visits of Crohn’s patients is high for the patient and the health care system. We aimed to identify the characteristics of patients with Crohn’s disease who return to the ED within 30 days from discharge. Methods We created an electronic data repository of all IBD patients admitted to our tertiary medical centre in the time frame 2012 – 2018. Data included tabular demographic and clinical variables, as well as free-text physician records. For this study, we retrieved consecutive Crohn’s patients who were discharged from the ED. We included only patients with complains that can be attributed to Crohn’s disease exacerbation or complication. Patients without available blood test results were excluded, as well as pregnant women and patients under 18. Patients who returned to the ED in 30 days were compared with those who did not. Results Overall, 2148 patients visited our ED with complaints related to Crohn’s disease exacerbation or complication. 1435 (67%) were admitted for hospitalisation. Six hundred and ninety-five (33%) were discharged, of them, 110 (15.8%) returned to the ED within 30 days. Male gender, tachycardia (&amp;gt;100 bpm), pain score &amp;gt;4 (using numerical pain rating scale of 0–10), Albumin &amp;lt;3.5 gr/dl, elevated alkaline phosphatase (&amp;gt;120 IU/l), hyponatremia (&amp;lt;135 meq/l), and anaemia (defined as less than 13.5 gr/dl for males and less than 12.0 gr/dl for females) were found to be associated with ED returns. On multivariate analysis, anaemia (OR 2.44 [95% CI 1.24–4.8]), tachycardia (OR 2.88 [95% CI 1.33–6.2]), and elevated alkaline phosphatase (OR 2.68 [95% CI 1.25–5.78]) were independently associated with ED returns. Of patients with 0, 1, 2, and 3 risk factors for ED re-visits 10%, 17%, 30%, and 33% revisited the ED within 30 days from discharge, respectively. Conclusion In our large tertiary centre cohort, recurrent ED visits within 30 days occurred in 16% of the patients. Tachycardia, anaemia and elevated alkaline phosphatase were found to be independently associated with recurrent visits. This model, if validated in prospective studies, may be implemented in order to minimise the burden of recurrent ED visits.

Real-time utilisation of administrative data in the ED to identify older patients at risk: development and validation of the Dynamic Silver Code

ObjectiveIdentification of older patients at risk, among those accessing the emergency department (ED), may support clinical decision-making. To this purpose, we developed and validated the Dynamic Silver Code (DSC), a...

Evaluation of a New Clinical Endpoint for Moderate to Severe Influenza Disease in Children: A Prospective Cohort Study.

A moderate to severe (M/S) influenza clinical endpoint has been proposed in children, defined as fever >39°C, otitis media, lower respiratory tract infection, or serious extrapulmonary manifestations. The objective of the study was to evaluate the M/S measure against clinically relevant outcomes including hospitalization, emergency room visits, antimicrobial use, and child/parental absenteeism. We conducted a prospective observational study of children aged 6 months-8 years at the Children's Hospital Colorado emergency department (ED) and urgent care site during 2016-2017 and 2017-2018. Children with influenza-like illness (ILI) underwent influenza testing by polymerase chain reaction (PCR); children who tested positive and a subset of matched test-negative controls underwent follow-up at 2 weeks. The primary outcome was the proportion of children who were hospitalized. Secondary outcomes included recurrent ED visits, antimicrobial use, hospital charges, and child/parental absenteeism within 14 days. Among 1478 children enrolled with ILI, 411 (28%) tested positive for influenza by PCR. Of children with influenza illness, 313 (76%) met the M/S definition. Children with M/S influenza were younger (3.8 years vs 4.8 years), infected with influenza A (59% vs 44%), and more frequently hospitalized (unadjusted risk difference [RD], 6.3%; 95% confidence interval [CI], 2.1-10.4; P = .03) and treated with antibiotics (unadjusted RD, 13.3%; 95% CI, 4.3-22.4; P < .01) compared to those with mild disease. Children with M/S influenza have a higher risk of hospitalization and antibiotic use compared with mild disease. This proposed definition may be a useful clinical endpoint to study the public health and clinical impact of influenza interventions in children. NCT02979626.

Randomised clinical trial of an emergency department-based peer recovery support intervention to increase treatment uptake and reduce recurrent overdose among individuals at high risk for opioid overdose: study protocol for the navigator trial

IntroductionEffective approaches to increase engagement in treatment for opioid use disorder (OUD) and reduce the risk of recurrent overdose and death following emergency department (ED) presentation for opioid overdose remain...

P143: A prospective cohort study characterizing 30-day recurrent emergency department visits for hyperglycemia

Introduction: Hyperglycemic emergencies, including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), often recur in patients who have poorly controlled diabetes. Identification of those at risk for recurrent hyperglycemia visits may improve health care delivery and reduce ED utilization for these patients. The objective of this study was to prospectively characterize patients re-presenting to the emergency department (ED) for hyperglycemia within 30 days of an initial ED visit. Methods: This is a prospective cohort study of patients ≥18 years presenting to two tertiary care EDs (combined annual census 150,000 visits) with a discharge diagnosis of hyperglycemia, DKA or HHS from Jul 2016-Nov 2018. Trained research personnel collected data from medical records, telephoned patients at 10-14 days after the ED visit for follow-up, and completed an electronic review to determine if patients had a recurrent hyperglycemia visit to any of 11 EDs within our local health integration network within 30 days of the initial visit. Descriptive statistics were used where appropriate to summarize the data. Results: 240 patients were enrolled with a mean (SD) age of 53.9 (18.6) years and 126 (52.5%) were male. 77 (32.1%) patients were admitted from their initial ED visit. Of the 237 patients (98.8%) with 30-day data available, 55 (23.2%) had a recurrent ED visit for hyperglycemia within this time period. 21 (8.9%) were admitted on this subsequent visit, with one admission to intensive care and one death within 30 days. For all patients who had a recurrent 30-day hyperglycemia visit, 22/55 (40.0%) reported having outpatient follow-up with a physician for diabetes management within 10-14 days of their index ED visit. 7/21 (33.3%) patients who were admitted on the subsequent visit had received follow-up within the same 10-14 day period. Conclusion: This prospective study builds on our previous retrospective work and describes patients who present recurrently for hyperglycemia within 30 days of an index ED visit. Further research will attempt to determine if access to prompt follow-up after discharge can reduce recurrent hyperglycemia visits in patients presenting to the ED.

Children with poorly controlled asthma: Randomized controlled trial of a home-based environmental control intervention.

Few trials have tested targeted environmental control (EC) interventions based on biomarkers of second hand smoke (SHS) exposure and allergen sensitization in reducing asthma emergency department (ED) visits in children with poorly controlled asthma. Overall, 222 children with poorly controlled asthma were randomized into a home-based EC intervention (INT) or control (CON) group and followed for ED visits over 12 months. All children received allergen-specific IgE serologic testing and SHS exposure biomarker testing to inform the EC intervention. Pharmacy data was examined for asthma medication fills. Cox proportional hazards and multivariate regression models were performed to examine factors associated with repeat ED visits. There was no difference in increased risk of >1 ED visit at 12 months between INT and CON groups. Most children (75%) had moderate/severe persistent asthma. Over half (56%) had SHS exposure and 83% tested positive for >1 allergen sensitization. Among children without SHS exposure, the median time to first recurrent ED visit differed by group (CON: 195; INT: >365 days) after adjusting for child age, allergic sensitization, medication fills prior to baseline, controller medication use, and the interaction between group status and SHS exposure. Children who had positive allergic sensitizations, younger, had increased controller medication use and randomized to the CON group and had no SHS exposure had increased risk for a repeat ED visit over 12 months. In this study, a home-based EC intervention was not successful in reducing asthma ED revisits in children with poorly controlled asthma with SHS exposure. Allergic sensitization, young age, and increased controller medication use were important predictors of asthma ED visits.

Choosing wisely in the ED: The diagnostic cascade of needless medical testing in a two-level study

BackgroundThe diagnostic cascade in the emergency department (ED) has not been fully elucidated.AimTo inspect whether the usage of consulting medicine and imaging contributes to hospital outcomes. We also propose a theoretical model for better understanding the diagnostic cascade of needless medical testing. MethodsA two-level study was conducted. The first local phase was a retrospective archive study that was conducted between 2014 and 2017 in a tertiary hospital. We extracted the number of requested imaging and consultations for each patient, and main time lags were calculated. The second-phase (January–April 2018) was conducted on a national level. We examined 22 hospitals with the emphasis on five hospital outcomes: recurrent ED visits (within 24 h), median waiting time at the ED, rate of early discharge at the same day and day after and percentage of patients spending >4 h in the ED. ResultsA 5% upsurge in CT scans was observed (p = .032), and a significant increase was found in the number of consultations (14%, p = .002). On a national level, a linear regression model found that the proportion of patients discharged from the hospital on the same day and on the day after and the proportion of patients staying in the ED > 4 h predict ED recurrence visits within 24 h (p = .025; R2 = 46.3%). ConclusionsUpsurge in resource usage in the ED leads to a diagnostic cascade of health consumption. Further study is necessary to examine the proposed model in a global scale.

986. Evaluation of Moderate-to-Severe Influenza Disease in Children 6 Months to 8 Years of Age in Colorado

BackgroundA clinical endpoint of moderate-to-severe (M/S) influenza has been proposed in children, defined as fever >39°C, otitis media, lower respiratory tract infection, or serious extrapulmonary manifestations. This definition has not been evaluated against clinically relevant outcomes like hospitalization, emergency room care, antimicrobial use, and child/parental absenteeism.MethodsWe conducted a prospective observational study of children aged 6 months–8 years with influenza at the Children’s Hospital Colorado Emergency Department (ED) and its affiliates during two influenza seasons (2016–2017 and 2017–2018). Children with influenza-like-illness (ILI) were enrolled and tested for influenza by polymerase chain reaction (PCR). Parents of influenza cases and matched influenza-negative controls were contacted 2 weeks later for follow-up. The primary outcome was hospitalization for M/S influenza vs. mild influenza. Secondary outcomes included recurrent ED visits, antimicrobial use, child/parental absenteeism. Interim analyses were conducted using SAS v9.4.ResultsAmong the 1,480 enrolled children with ILI, 410 (28%) tested positive for influenza by PCR. The median age of influenza cases was 4.0 years (IQR 2.2–6.1), and 20% were considered high-risk for influenza complications. Of influenza cases, 284 (69%) met the definition for M/S influenza. Among M/S influenza subjects, 8.4% were hospitalized, compared with 1.6% with mild influenza (risk difference (RD) 6.9%; 95% CI: 3.0–10.8, P < 0.01). Subjects with M/S influenza were more likely to receive antibiotics (RD 12.0%, 95% CI: 3.4–20.6, P < 0.01) with a trend to higher antiviral use (RD 6.9%, 95% CI: −0.7–14.5, P = 0.09). There was no significant difference for recurrent ED visits nor child/parental absenteeism. After adjusting for comorbidities, age, and influenza strain, the relative risk (RR) of hospitalization or recurrent ED visits was higher among those with M/S influenza vs. mild influenza (RR 2.18, 95% CI: 1.02–4.64, P = 0.04).ConclusionChildren with M/S influenza have a higher risk of hospitalization compared with mild disease. This proposed definition is a useful clinical endpoint to study the public health and clinical impact of influenza interventions in children.Disclosures S. Rao, GSK: Investigator, Research grant. E. Yanni, GSK: Employee, Salary. R. Bekkat-Berkani, GSK: Employee, Salary. A. Schuind, GSK: Employee, Salary. B. Innis, GSK: Employee, Salary. R. Mistry, GSK: Investigator, Research support. E. J. Asturias, GSK: Investigator, Research grant and Research support.

Risk factors for recurrent anaphylaxis-related emergency department visits in the United States

BackgroundAnaphylaxis is a potentially life-threatening allergic reaction with a strong risk of recurrence. ObjectiveTo assess risk factors associated with recurrent anaphylaxis-related emergency department (ED) visits within 1 year of an ED visit for anaphylaxis in a large observational cohort study. MethodsWe used an administrative claims database to identify patients seen from 2008 through 2012 in the ED for anaphylaxis based on an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code algorithm. Patients with at least 2 years of continuous enrollment in a health plan were included. Multivariable logistic regression analysis was used to determine associations with recurrence of anaphylaxis within 1 year. ResultsDuring the 5-year study period, 7,367 patients (median age, 42 years; <18 years old, 23.3%) met the inclusion criteria. The most common anaphylaxis trigger was unspecified (56.2%), followed by food (25.3%), medication (14.6%), and venom (3.9%). Overall, 3.0% of patients had an additional anaphylaxis-related ED visit within 1 year (3.61 episodes per 100 patient-years). On multivariable analysis, risk factors associated with anaphylaxis recurrence were food trigger (odds ratio [OR], 2.31; 95% confidence interval [CI], 1.34-3.99), history of asthma (OR, 1.30; 95% CI, 1.13-1.51), and intensive care unit admission at the index anaphylaxis event (OR, 1.95; 95% CI, 1.41-2.69). ConclusionIn this contemporary cohort study, history of asthma, food trigger, and greater index anaphylaxis severity, as measured by intensive care unit admission, were associated with a higher likelihood of a recurrent anaphylaxis-related ED visit within 1 year.

Financial burden of emergency department visits for atopic dermatitis in the United States

Little is known about the usage and financial burden of emergency care visits for atopic dermatitis (AD) or eczema (AD-E) in the United States. To determine the prevalence, risk factors, and cost of emergency care for AD-E in the United States. Cross-sectional study of the 2006-2012 National Emergency Department Sample, including a 20% sample of emergency department (ED) visits throughout the United States (n=198,102,435). The mean annual incidence of ED visits with a primary diagnosis of AD-E was 3368.4-3553.0 cases/1 million persons. The prevalence of ED visits for AD-E increased significantly during 2006-2012 (survey logistic regression, P<.05). ED visits with a primary diagnosis of AD-E versus ED visits without were associated with younger patient age, Medicaid or no insurance, and lower household income quartile and more likely to occur during weekends and summer months. The geometric mean and total costs of ED visits for AD-E significantly increased from $369.07 and $127,275,080, respectively, in 2006 to $642.10 and $265,541,084, respectively, in 2012. The National Emergency Department Sample did not include data on AD severity, recurrent ED visits, race/ethnicity, or treatments provided. There is a substantial and increasing financial burden of ED visits for AD-E in the United States. Interventions are needed to decrease ED visits for AD.