Factors associated with Interhospital transfers of emergency general surgery patients from emergency departments

BackgroundEmergency general surgery (EGS) conditions account for over 3 million or 7.1% of hospitalizations per year in the US. Patients are increasingly transferred from community emergency departments (EDs) to larger centers for care, and a growing demand for treating EGS conditions mandates a better understanding of how ED clinicians transfer patients. We identify patient, clinical, and organizational characteristics associated with interhospital transfers of EGS patients originating from EDs in the United States.MethodWe analyze data from the Agency for Healthcare Research and Quality Nationwide Emergency Department Sample (NEDS) for the years 2010–2014. Patient-level sociodemographic characteristics, clinical factors, and hospital-level factors were examined as predictors of transfer from the ED to another acute care hospital. Multivariable logistic regression analysis includes patient and hospital characteristics as predictors of transfer from an ED to another acute care hospital.ResultsOf 47,442,892 ED encounters (weighted) between 2008 and 2014, 1.9% resulted in a transfer. Multivariable analysis indicates that men (Odds ratio (OR) 1.18 95% Confidence Interval (95% CI) 1.16–1.21) and older patients (OR 1.02 (95% CI 1.02–1.02)) were more likely to be transferred. Relative to patients with private health insurance, patients covered by Medicare (OR 1.09 (95% CI 1.03–1.15) or other insurance (OR 1.34 (95% CI 1.07–1.66)) had a higher odds of transfer. Odds of transfer increased with a greater number of comorbid conditions compared to patients with an EGS diagnosis alone. EGS diagnoses predicting transfer included resuscitation (OR 36.72 (95% CI 30.48–44.22)), cardiothoracic conditions (OR 8.47 (95% CI 7.44–9.63)), intestinal obstruction (OR 4.49 (95% CI 4.00–5.04)), and conditions of the upper gastrointestinal tract (OR 2.82 (95% CI 2.53–3.15)). Relative to Level I or II trauma centers, hospitals with a trauma designation III or IV had a 1.81 greater odds of transfer. Transfers were most likely to originate at rural hospitals (OR 1.69 (95% CI 1.43–2.00)) relative to urban non-teaching hospitals.ConclusionMedically complex and older patients who present at small, rural hospitals are more likely to be transferred. Future research on the unique needs of rural hospitals and timely transfer of EGS patients who require specialty surgical care have the potential to significantly improve outcomes and reduce costs.     

Evaluation of sex disparities in opioid use among ED patients with sickle cell disease, 2006–2015

BackgroundAcute pain from a vaso-occlusive crisis (VOC) is a leading reason patients with sickle cell disease (SCD) visit the emergency department (ED). Prior studies suggest that women and men receive disparate ED treatment for acute pain in EDs. We aim to determine sex differences in analgesic use among patients with SCD presenting to the ED.MethodsThis cross-sectional study uses data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2006–2015. We identified ED patients with a primary diagnosis of SCD. Among patients with SCD, we evaluated sex differences in the use of opioid analgesia using logistic regression (adjusting for patient and visit characteristics). Analyses accounted for survey design and weighting.ResultsWhen evaluating the effect of sex on any opioid medication use in this population, though not significant, the odds that male patients were prescribed opioids was 1.5 (95% CI 0.8–2.8) times that of female patients after adjusting for age, the reason for visit, region, insurance status, and pain score. There was no significant difference in pain scores between male patients, 8.1 (95% CI 7.55–8.68) compared to female patients, 7.4 (95% CI 6.7–8.12).ConclusionsIn this nationally representative sample of ED visits among patients with SCD, there was no conclusive evidence of sex disparities in opioid prescribing. Though there is evidence of a trend signaling that male patients with SCD were more likely than female patients to be prescribed an opioid.     

Epidemiology of Emergency Department Visits for Opioid Overdose: A Population-Based Study

ObjectivesTo evaluate the rate of emergency department (ED) visits for opioid overdose and to examine whether frequent ED visits for opioid overdose are associated with more hospitalizations, near-fatal events, and health care spending.Patients and MethodsRetrospective cohort study of adults with at least 1 ED visit for opioid overdose between January 1, 2010, and December 31, 2011, derived from population-based data of State Emergency Department Databases and State Inpatient Databases for 2 large and diverse states: California and Florida. Main outcome measures were hospitalizations for opioid overdose, near-fatal events (overdose involving mechanical ventilation), and hospital charges during the year after the first ED visit.ResultsThe analytic cohort comprised 19,831 unique patients with 21,609 ED visits for opioid overdose. During a 1-year period, 7% (95% CI, 7%-7%; n=1389 patients) of the patients had frequent (2 or more) ED visits, accounting for 15% (95% CI, 14%-15%; n=3167) of all opioid overdose ED visits. Middle age, male sex, public insurance, lower household income, and comorbidities (such as chronic pulmonary disease and neurological diseases) were associated with frequent ED visits (all P<.01). Overall, 53% (95% CI, 52%-54%; n=11,412) of the ED visits for opioid overdose resulted in hospitalizations; patients with frequent ED visits for opioid overdose had a higher likelihood of hospitalization (adjusted odds ratio, 3.98; 95% CI, 3.38-4.69). In addition, 10.0% (95% CI, 10%-10%; n=2161) of the ED visits led to near-fatal events; patients with frequent ED visits had a higher likelihood of a near-fatal event (adjusted odds ratio, 2.27; 95% CI, 1.96-2.66). Total charges in Florida were $208 million (95% CI, $200-$219 million).ConclusionIn this population-based cohort, we found that frequent ED visits for opioid overdose were associated with a higher likelihood of future hospitalizations and near-fatal events.     

Factors for return to emergency department and hospitalization in elderly urinary tract infection patients

BackgroundAppropriate decision of emergency department (ED) disposition is essential for improving the outcome of elderly urinary tract infection (UTI) patients. However, studies on early return visit (ERV) to the ED in elderly UTI patients are limited. Therefore, we aimed to identify factors for ERV and hospitalization after return visit (HRV) in this population.MethodsElderly patients discharged from the ED with International Classification of diseases 10th Revision codes of UTI were selected from the registry for evaluation of ED revisit in 6 urban teaching hospitals. Retrospective data were extracted from the electronic medical records and ERV and hospitalization to scheduled revisit (SRV) were compared.ResultAmong a total of 419 patients found in the study period, 45 were ERV patients and 24 were HRV patients. Absence of UTI-specific symptoms (odds ratio [OR] 2.789; 95% confidence interval [CI] 1.368–5.687; P = 0.005), C-reactive protein (CRP) levels >30 mg/L (OR 2.436; 95% CI 1.017–3.9; P = 0.024), and body temperature ≥ 38 °C (OR 1.992; 95% CI 1.017–3.9; P = 0.044) were independent risk factors for ERV, and absence of UTI-specific symptoms (OR 3.832; 95% CI 1.455–10.088; P = 0.007), CRP levels >30 mg/L (OR 3.224; 95% CI 1.235–8.419; P = 0.017), and systolic blood pressure ≤ 100 mmHg (OR 3.795;95% CI 1.156–12.462; P = 0.028) were independent risk factors for HRV. However, there was no significant difference in empirical antibiotic resistance in ERV and HRV patients, compared to SRV patients.ConclusionThe independent risk factors of ERV and HRV should be considered for ED disposition in elderly UTI patients; the resistance to empirical antibiotics was not found to affect ERV or HRV within 3 days.     

The Association Between Opioid Use and Outcomes in Infants Undergoing Pyloromyotomy

PurposeThe purpose of this study was to describe the frequency and variation of opioid use across hospitals in infants undergoing pyloromyotomy and to determine the impact of opioid use on postoperative outcomes.MethodsA retrospective cohort study (2005–2015) was conducted by using the Pediatric Health Information System (PHIS) database, including infants (aged <6 months) with pyloric stenosis who underwent pyloromyotomy. Infants with significant comorbidities were excluded. Opioid use was classified as a patient receiving at least 1 opioid medication during his or her hospital stay and categorized as preoperative, day of surgery, or postoperative (≥1 day after surgery). Outcomes included prolonged hospital length of stay (LOS; ≥3 days) and readmission within 30 days.FindingsOverall, 25,724 infants who underwent pyloromyotomy were analyzed. Opioids were administered to 6865 (26.7%) infants, with 1385 (5.4%) receiving opioids postoperatively. In 2015, there was significant variation in frequency of opioid use by hospital, with 0%–81% of infants within an individual hospital receiving opioids (P < 0.001). Infants only receiving opioids on the day of surgery exhibited decreased odds of prolonged hospital LOS (odds ratio [OR], 0.85; 95% CI, 0.78–0.92). Infants who received an opioid on both the day of surgery and postoperatively exhibited increased odds of a prolonged hospital LOS (OR, 1.71; 95% CI, 1.33–2.20). Thirty-day readmission was not associated with opioid use (OR, 1.03; 95% CI, 0.93–1.14).ImplicationsThere is national variability in opioid use for infants undergoing pyloromyotomy, and postoperative opioid use is associated with prolonged hospital stay. Nonopioid analgesic protocols may warrant future investigation.     

Post-exposure prophylaxis for human immunodeficiency virus after sexual assault in a Midwestern U.S. emergency department

BackgroundEmergency departments (EDs) play an essential role in the timely initiation of HIV post-exposure prophylaxis (PEP) for sexual assault victims.MethodsRetrospective analysis of sexual assault victims evaluated and offered HIV PEP in an urban academic ED between January 1, 2005 and January 1, 2018. Data on demographics, comorbidities, nature of sexual assault, initial ED care, subsequent healthcare utilization within 28 days of initial ED visit, and evidence of seroconversion within 6 months of the initial ED visit were obtained. Predictors of subsequent ED visit and follow-up in the infectious diseases clinic were evaluated using logistic regression analysis.ResultsFour hundred twenty-three ED visits met criteria for inclusion in this study. Median age at ED presentation was 25 years (IQR 21–34 years), with the majority of victims being female (95.5%), Black (63.4%), unemployed (66.3%) and uninsured (53.9%); psychiatric comorbidities (38.8%) and substance abuse (23.6%) were common. About 87% of the patients accepted HIV PEP (368 of 423 ED visits). Age (OR 0.97, 95% CI 0.94–0.99, p = 0.025) and sexual assault involving >1 assailant (OR 0.48, 95% CI 0.26–0.88, p = 0.018) were associated with lower likelihood of HIV PEP acceptance. Ten patients (2.7%) followed up with the infectious disease clinic within 28 days of starting HIV PEP; 70 patients (19%) returned to the ED for care during the same time period. Psychiatric comorbidity (OR 2.48, 95% CI 1.43–4.30, p = 0.001) and anal penetration (OR 2.02, 95% CI 1.10–3.70, p = 0.024) were associated with greater likelihood of repeat ED visit; female gender (OR 0.30, 95% CI 0.11–0.85, p = 0.023) was associated with lower likelihood of repeat visit. Completion of HIV PEP was documented for 14 (3.3%) individuals.ConclusionsWhile ED patient acceptance of HIV PEP after sexual assault was high, infectious disease clinic follow-up and documented completion of PEP remained low. Innovative care models bridging EDs to outpatient clinics and community support services are needed to optimize transitions of care for sexual assault victims, including those receiving HIV PEP.     

Medicaid expansion and resource utilization in the emergency department

BackgroundThe Affordable Care Act (ACA) has impacted the insurance mix of emergency department (ED) visits, yet the degree to which this has influenced provider behavior is not clear.MethodsThis was a difference-in-differences (DID) analysis of ED-visit data from five states in 2013 and 2014. Sample states included 3 expanding Medicaid under the ACA, 1 rejecting ACA funding and delaying an eligibility expansion, and 1 with no eligibility change. We included self-pay and Medicaid patients aged 27 to 64 years. A subsample analysis was done for chest pain visits. DID logistic models were estimated for likelihood of admission for given Medicaid-paid ED visits in expansion states as compared to non-expansion states. Among chest pain visits we assessed likelihood given visits resulted in admission or advanced cardiac imaging, where clinician discretion may be more significant.ResultsA total of 8,157,748 ED visits with primary payer Medicaid and self-pay were included, of which 331,422 were for chest pain. The proportion of visits paid for by Medicaid rose in expansion states by between 15.8% and 38.9%. Medicaid eligibility expansion was associated with increased odds of admission (OR 1.070 [95% CI 1.051–1.089]). Among chest pain visits, expansion was associated with increased odds of admission (OR 1.294 [95% CI 1.144–1.464]), but not advanced cardiac imaging (OR 1.099 [95% CI 0.983–1.229]).ConclusionMedicaid expansion was associated with small increases in ED visit admissions across the board and among the subgroup of patients presenting with chest pain.