A Comprehensive Statewide Analysis of Seatbelt Non-use with Injury and Hospital Admissions: New Data, Old Problem

Objectives: To investigate the association of seatbelt nonuse with injury patterns, injury severity, and in-patient hospital admission among adults presenting to emergency departments (EDs) in a statewide, population-based, sample of motor vehicle crashes.
Methods: Using data from the 2002 Crash Outcome Data Evaluation System (CODES) for Wisconsin, 23,920 occupants of motor vehicle crashes, aged 16 years or older, who were treated in an ED, were analyzed. Logistic regression was used to compare the odds ratio of having sustained an injury to specific body regions and of being admitted to an inpatient unit in unbelted individuals compared with those who were belted.
Results: Compared with belted occupants presenting to an ED, their unbelted counterparts were more likely to be male (56% vs. 40%) and to have used alcohol (17% vs. 4%). Unbelted occupants were younger (31 years vs. 38 years) and incurred higher ED charges ($681 vs. $509) than belted occupants. Additionally, unbelted occupants have a higher proportion of single-vehicle crashes, such as rollovers (44% vs. 22%), and rural crashes (56% vs. 44%). Unbelted occupants comprised 20% of study patients treated in the ED and discharged, 44% of patients treated in the ED and admitted, and 68% of patients dying in the ED. Unbelted occupants were more likely to be admitted (odds ratio [OR] = 2.6) than belted individuals and were more likely to suffer severe injuries to the head, face, thorax, abdomen, spine, upper and lower extremities (OR ranging from 1.6 to 3.9).
Conclusions: Among patients presenting to an ED after a motor vehicle crash, unbelted occupants are more likely to require inpatient admission and to have sustained a severe injury to numerous body regions than are belted occupants.     

Influence of the Unbelted Rear-seat Passenger on Driver Mortality: "The Backseat Bullet"

Objectives: This study examined whether unrestrained left rear‐seat passengers increase the risk of death of belted drivers involved in serious crashes with at least one fatality. Methods: The information from every fatal crash in the United States between 1995 and 2001 was analyzed. Variables such as point of impact, restraint use, seat position, vehicle type, occupant age, gender, and injury severity were extracted from the Fatality Analysis Reporting System. Results: The odds of death for a belted driver seated directly in front of an unrestrained passenger in a serious head‐on crash was 2.27 times higher (95% confidence interval [CI] = 1.94 to 2.66) than if seated in front of a restrained passenger. In contrast, a belted driver seated in front of an unrestrained passenger in a driver‐side lateral‐impact crash had no increase in mortality over a driver with a restrained rear‐seat passenger (odds ratio, 0.8; 95% CI = 0.6 to 1.06). Logistic regression showed that passenger restraint, point of impact, vehicle type, passenger age, and driver age had a statistically significant influence on the outcome (death) of belted drivers. Adjusting for confounders (other than point of impact), the odds of fatality for a belted driver in a head‐on crash was 2.28 times greater (95% CI = 1.93 to 2.7) with an unbelted rear‐seat passenger. The unbelted rear‐seat passenger also had an increased risk of death (odds ratio, 2.71; 95% CI = 2.44 to 3.01) when compared with restrained rear‐seat passengers. Conclusions: Unrestrained rear‐seat passengers place themselves and their driver at great risk of fatal injury when involved in a crash.     

Seatbelt use to save money: Impact on hospital costs of occupants who are involved in motor vehicle crashes

ObjectiveSeatbelt use is the single most effective way to save lives in motor vehicle crashes (MVC). However, although safety belt laws have been enacted in many countries, seatbelt usage throughout the world remains below optimal levels, and educational interventions may be needed to further increase seatbelt use. In addition to reducing crash-related injuries and deaths, reduced medical expenditures resulting from seatbelt use are an additional benefit that could make such interventions cost-effective. Accordingly, the objective of this study was to estimate the correlation between seatbelt use and hospital costs of injuries involved in MVC.MethodsThe data used in this study were from the Nebraska CODES database for motor vehicle crashes that occurred between 2004 and 2013. The hospital cost information and information about other factors were obtained by linking crash reports with hospital discharge data. A multivariable regression model was performed for the association between seatbelt use and hospital costs.ResultsMean hospital costs were significantly lower among motor vehicle occupants using a lap–shoulder seatbelt ($2909), lap-only seatbelt ($2289), children’s seatbelt ($1132), or booster ($1473) when compared with those not using any type of seatbelt ($7099). After adjusting for relevant factors, there were still significantly decreased hospital costs for motor vehicle occupants using a lap–shoulder seatbelt (84.7%), lap-only seatbelt (74.1%), shoulder-only seatbelt (40.6%), children’s seatbelt (95.9%), or booster (82.8%) compared to those not using a seatbelt.ConclusionSeatbelt use is significantly associated with reduced hospital costs among injured MVC occupants. The findings in this study will provide important educational information for emergency department nurses who can encourage safety belt use for vehicle occupants.     

Seat belt use among patients in motor vehicle collisions: Clinical and demographic factors

ObjectiveProper use of automobile seat belt in a motor vehicle crash is associated with reduced morbidity and mortality, shorter hospital stays, reduced resource utilization, and fewer missed work days. Seatbelt compliance nationwide is 86%. This study was undertaken to identify factors associated with noncompliance with seatbelt use among admitted patients following a motor vehicle crash.MethodsThis study was a retrospective analysis of motor vehicle crashes at an Urban Level 1 Trauma Center. Eligible subjects included patients age 18 and over, who were admitted by the Trauma Service following a motor vehicle crash from January to December 2017.ResultsAmong 766 participants, the overall rate of seatbelt noncompliance was 32% (N = 245). Some participants met the legal limit of intoxication (80 mg/dl) (N = 119 patients; 22%). Drug use was high among this population, including THC (30%), opiates (29%), benzodiazepines (24%), cocaine (10%), and methamphetamine (10%). Patients who did not wear seat belts were more likely to be male (62.4% no seat belt vs. 51.8% seat belt), intoxicated (30.5% vs. 17.0%), screen positive for cocaine (18.2% vs. 4.7%), THC (37.7% vs. 24.2%), and methamphetamine (15.6% vs. 5.9%). We did not detect significant differences by seat belt use with respect to ethnicity, mode of arrival, day of week, opiate use, or benzodiazepine use.ConclusionsIn this study, 32% of patients in motor vehicle crashes were not compliant with seat belt use. Noncompliance with seat belt use was higher among patients who were male, younger age, intoxicated, or who had positive screens for cocaine, THC, or methamphetamine.     

The impact of prehospital instant photography of motor vehicle crashes on receiving physician perception

Objectives. The study was conducted to determine whether the use of prehospital instant photography of motor vehicle crashes (MVCs) by paramedics altered receiving physician (RP) perception of the magnitude of crash severity, as compared with verbal reports of vehicle damage. In addition, the study sought to determine whether altered RP perception resulted in any subsequent changes in emergency department (ED) management.

Methods. A prospective questionnaire and retrospective chart review were used at a Level I suburban trauma center receiving MVC patients from a single municipal paramedic agency. Patients injured in MVCs who required advanced life support (ALS) interventions and were subsequently evaluated by either surgical residents, emergency medicine residents, or attending emergency physicians in the ED were eligible for study enrollment. Instant photographs of interior and exterior vehicle damage were obtained by paramedics who then provided a verbal report of vehicle damage to the RP. Initially blinded from the photographs, the RP was then asked to rate the severity of the crash based on the verbal report and list planned interventions (laboratory tests, blood products, radiographs, and probable patient disposition). The RP was then shown the crash photographs and once again asked to rate the crash severity based on the addition of the photos and list changes in patient management based on any alterations in his or her perception. Hospital records were then examined to determine costs billed to patients and the length of hospital stay for those patients who were admitted.

Results. Instant photographs resulted in changes in physician perception in 47% (27 of 58) of the cases. Eighty-five percent of these physicians rated the MVC as more severe than the verbal report had indicated (p < 0.05 by multiple and logistic regression). The RPs who did alter their perceptions based upon the addition of MVC photos then changed their ED management in 59% (16 of 27) of the cases. Patients whose crash photographs altered RP perception of crash severity and who were subsequently released from the ED had average ED costs of $686, as compared with average ED charges of $595 for released patients whose crash photos did not alter physician perception of crash severity (p > 0.05 by Student's t-test). Inpatient charges and lengths of stay were also similar between the two groups for admitted patients: $21,363/14 days for the perception-change group and $24,726/8 days for the nochange-in-perception group (p > 0.05 for all comparisons).

Conclusion. The augmentation of verbal paramedic reports with prehospital instant photographs frequently altered both physician perception of MVC severity and subsequent ED management of these trauma patients. However, cost to the patient and length of hospital stay were not significantly altered as a result of the change in physician perception.     

Seatbelt law enforcement and motor vehicle crash fatalities among blacks and whites in Louisiana and Mississippi

BACKGROUND: Seatbelt laws save lives. Primary enforcement (allowing citations solely for seatbelt nonuse) is a more effective means of saving lives, yet seven southern states have no primary laws, due in part to concern about racial profiling. METHODS: Non-Hispanic, black:white (B:W), occupant motor vehicle crash mortality rate ratios (MRRs) were compared across the 15 to 64 age range over two time periods in two demographically comparable southern states (Louisiana and Mississippi). RESULTS: From 1992 to 1994 (when neither state had primary law) to 1996 to 1998 (when Louisiana had primary law) B:W MRRs were 0.73 (95% confidence interval = 0.61, 0.88) and 0.72 (0.60, 0.86) in Louisiana and 1.01 (0.9, 1.12) and 1.22 (1.10, 1.35) in Mississippi. CONCLUSIONS: Successful opposition to primary seat belt enforcement may have the unintended effect of producing racial disparities in motor vehicle crash mortality that adversely affects blacks.     

Seatbelt effectiveness and cost of noncompliance among drivers admitted to a trauma center

Enactment of seatbelt legislation in Maryland presented the opportunity to compare seatbelt compliance among seriously injured drivers admitted to a Level I trauma center and to establish levels of severity, length of stay, and hospital cost differences among the study population. Fifty-five randomly selected drivers were examined from a total surgical population of 689. Seatbelt compliance rate was 41.8%, reflecting the rate in the community. Seatbelts reduced the total number of injuries by 34%, major injuries by 57%, and minor injuries by 20%. No deaths occurred among the belted group. The unbelted group had a mean Injury Severity Score two times as great as the belted group and were hospitalized 1.6 times longer at double the cost. Major injuries to the face, chest, and pelvic regions were prevented by the seatbelt. Among the belted group, severe injuries did occur to the head, neck, and abdominal regions. It is recommended that both air bags and automatic restraining devices be required for all drivers if the trauma occurring daily on highways is to be eliminated and acute hospital cost minimized.     

A staged management diabetes foot program versus standard care: a 1-year cost and utilization comparison in a state public hospital system

OBJECTIVE: To determine whether staged management of foot ulcers reduces health care costs and utilization. DESIGN: Nonrandomized retrospective study using data from 1998-1999 in the Louisiana public hospital system. SETTING: Louisiana public hospital system. PARTICIPANTS: Forty-five patients with diabetes foot ulcer who received staged management foot care and 169 patients with diabetes foot ulcer who received standard foot care. INTERVENTIONS: Staged management of foot ulcers consisting of devices to offload pressure; self-care education; and, after healing, custom-fabricated orthoses and footwear, and monitored progressive ambulation. MAIN OUTCOME MEASURES: One-year levels of the number of foot-related inpatient hospitalizations, number of amputation-related hospitalizations, total number of foot-related inpatient days, total charges for foot-related inpatient hospitalizations, all-cause outpatient visits, total charges for all-cause outpatient visits, and combined outpatient and foot-related inpatient charges. RESULTS: Over the 12-month study period, the staged management group had a lower foot-related hospitalization rate than did the comparison group (.09 admissions per person vs.50 admissions per person, P=.0002); lower foot-related inpatient days (.91d per person vs 3.97d per person, P=.0289); lower foot-related inpatient charges ($1321 per person vs $5411 per person, P=.0151); fewer amputation-related hospitalizations (.04 per person vs.19 per person, P=.0351); fewer emergency department visits (.60 visits per person vs 1.22 visits per person, P=.0043); lower emergency department charges ($104 per person vs $208 per person, P=.0057); and lower total charges ($4776 per person vs $9402 per person, P=.0141). The staged management group had a higher number of outpatient visits (24.91 per person vs 8.04 per person, P<.0001) and higher outpatient charges ($2169 per person vs $1471 per person, P<.0001). CONCLUSIONS: A staged management diabetes foot program significantly reduced emergency department and hospital utilization and charges in a statewide public hospital system.     

Trends in Charges and Payments for Nonhospitalized Emergency Department Pediatric Visits, 1996–2003

Objectives:  To compare charges and payments for outpatient pediatric emergency visits across payer groups to provide information on reimbursement trends.
Methods:  Total charges and payments for emergency department (ED) visits Medicaid/State Children's Health Insurance Program (SCHIP), privately insured, and uninsured pediatric patients from 1996 to 2003 using data from the Medical Expenditure Panel Survey. Average charges per visit and average payments per visit were also tracked, using regression analysis to adjust for changes in patient characteristics.
Results:  While charges for pediatric ED visits rose over time, payments did not keep pace. This led to a decrease in reimbursement rates from 63% in 1996 to 48% in 2003. For all years, Medicaid/SCHIP visits had the lowest reimbursement rates, reaching 35% in 2003. The proportion of visits from children insured by Medicaid/SCHIP also increased over the period examined. In 2003, after adjustment, charges were $792 per visit from children covered by Medicaid/SCHIP, $913 for visits from uninsured children, and $952 for visits from privately insured children.
Conclusions:  Reimbursements for outpatient ED visits in the pediatric population have decreased from the period of 1996 to 2003 in all payer groups: public (Medicaid/SCHIP), private, and the uninsured. Medicaid/SCHIP has consistently paid less per visit than the privately insured and the uninsured. Further research on the effects of these declining reimbursements on the financial viability of ED services for children is warranted.     

A Comparison of Data Sources for Motor Vehicle Crash Characteristic Accuracy

OBJECTIVE: To determine the accuracy of police reports (PRs), ambulance reports (ARs), and emergency department records (EDRs) in describing motor vehicle crash (MVC) characteristics when compared with an investigation performed by an experienced crash investigator trained in impact biomechanics. METHODS: This was a cross-sectional, observational study. Ninety-one patients transported by ambulance to a university emergency department (ED) directly from the scene of an MVC from August 1997 to April 1998 were enrolled. Potential patients were identified from the ED log and consent was obtained to investigate the crash vehicle. Data describing MVC characteristics were abstracted from the PR, AR, and medical record. Variables of interest included restraint use (RU), air bag deployment (AD), and type of impact (TI). Agreements between the variables and the independent crash investigation were compared using kappa. Interrater reliability was determined using kappa by comparing a random sample of 20 abstracted reports for each data source with the originally abstracted data. RESULTS: Agreement using kappa between the crash investigation and each data source was 0.588 (95% CI = 0.508 to 0.667) for the PR, 0.330 (95% CI = 0.252 to 0.407) for the AR, and 0.492 (95% CI = 0.413 to 0.572) for the EDR. Variable agreement was 0.239 (95% CI = 0.164 to 0.314) for RU, 0.350 (95% CI = 0.268 to 0.432) for AD, and 0.631 (95% = 0.563 to 0.698) for TI. Interrater reliability was excellent (kappa > 0.8) for all data sources. CONCLUSIONS: The strength of the agreement between the independent crash investigation and the data sources that were measured by kappa was fair to moderate, indicating inaccuracies. This presents ramifications for researchers and necessitates consideration of the validity and accuracy of crash characteristics contained in these data sources.     

Spontaneous spinal epidural hematoma: a case report

A 59-year-old man presented to the emergency department (ED) the day after a minor motor vehicle crash for evaluation of bilateral shoulder pain. He underwent ED evaluation for his back pain two more times before it was found that he had a spontaneous spinal epidural hematoma (SSEH). On the third visit, the patient had waxing and waning neurologic symptoms including lower extremity weakness and urinary retention. The diagnosis was made by MRI, and the patient was successfully treated with cervical hemilaminectomy at the cervicothoracic junction for evacuation of the epidural hematoma 5 days after the onset of back pain.     

A reduction in hospitalization, length of stay, and hospital charges for croup with the institution of a pediatric observation unit

OBJECTIVES: The aim of the study was to assess the impact of an observation unit (OU) on hospital resource utilization for patients with croup. METHODS: A retrospective review with the use of a historical control was performed for 2 years of nondischargeable emergency department (ED) patients with croup. RESULTS: The total number of ED patients with croup was 694 in the first year and 789 in the second year. Hundred seventy patients were enrolled, 66 in the first year and 104 in the second year (76 admitted to the OU and 33 admitted to the ward). There was a reduction in the ward admission rate from 9.5% to 4.2% (P < .0001) from the first to the second year. The median length of stay for the pre-OU group was 27.2 vs 21.3 hours for the post-OU group (P = .03). The median charge for the pre-OU group was $1685 vs $1327 for the post-OU group (P = .03). CONCLUSIONS: After the introduction of the OU, hospitalization was reduced, and the overall resource utilization for the care of nondischargeable ED patients with croup was reduced.     

Crash Scene Photography in Motor Vehicle Crashes without Air Bag Deployment

OBJECTIVE: To determine whether vehicle characteristics, measured using crash scene photography, are associated with anatomic patterns of injury and severity of injury sustained in motor vehicle crashes (MVCs) without air bag deployment. METHODS: A prospective observational study was conducted over 22 months, using 12 fire departments serving two hospitals. Two vehicle photographs (exterior and interior) were taken at each MVC. Vehicular variables were assigned by grading the photographs with a standardized scoring system, and outcome information on each patient was collected by chart review. RESULTS: Five hundred fifty-nine patients were entered into the study. Frontal crashes and increasing passenger space intrusion (PSI) were associated with head, facial, and lower-extremity injuries, while rear crashes were associated with spinal injuries. Restraint use had a protective effect in head, facial, and upper and lower extremity injuries, yet was associated with higher odds of spinal injury. Lack of restraint use, increasing PSI, and steering wheel deformity were associated with an increased hospital length of stay and hospital charges, yet only steering wheel deformity was associated with increasing injury severity when adjusting for other crash variables. CONCLUSIONS: Out-of-hospital variables, as obtained from crash vehicle photography, are associated with injury site, injury severity, hospital length of stay, and hospital charges in patients involved in MVCs without air bag deployment.     

Weekend Emergency Department Visits in Nebraska: Higher Utilization,Lower Acuity

Background: We know very little about differences in Emergency Department (ED) utilization and acuity on weekends compared with weekdays. Understanding such differences may help elucidate the role of the ED in the health care delivery system. Study Objective: To compare patterns of ED use on weekends with weekdays and analyze the differences between these two groups. Methods: The Health Care Utilization Project (HCUP) is a national state-by-state billing database from acute-care, non-federal hospitals. Data from Nebraska in 2004 was used to compare ED-only patient visits (patients discharged home or transferred to another health care facility) and ED-admitted visits (patients admitted to the same hospital after an ED visit) for weekend vs. weekday frequency, billed charges, sex, age, and primary payer. Results: Of all non-admitted patients who visited the ED, 34.5% came in on weekends. This yielded ED utilization rates of 25 visits/1000 people on weekdays and 33 visits/1000 people on weekends, an increase of 32% on weekends. Weekend-only ED patients of all ages and payer categories were charged lower hospital facility fees than weekday-only ED patients; $777 vs. $921, respectively (p < 0.001). Weekend ED patients were less likely to be admitted and less likely to die while in the ED (2 deaths/1000 ED visits for weekend-only patients vs. 3 deaths/1000 ED visits for weekday-only [p < 0.001]). Conclusions: In Nebraska, EDs care for a greater number of low-acuity patients on weekends than on weekdays. This highlights the important role EDs play within the ambulatory care delivery system.     

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.     

Does Gender Influence Emergency Department Management and Outcomes in Geriatric Abdominal Pain?

Prior studies have suggested gender-based differences in the care of elderly patients with acute medical conditions such as myocardial infarction and stroke, but it is unknown whether these differences are seen in the care of abdominal pain. The objective of this study was to examine differences in evaluation, management, and diagnoses between elderly men and women presenting to the Emergency Department (ED) with abdominal pain. For this observational cohort study, a chart review was conducted of consecutive patients aged 70 years or older presenting with a chief complaint of abdominal pain. Primary outcomes were care processes (e.g., receipt of pain medications, imaging) and clinical outcomes (e.g., hospitalization, etiology of pain, and mortality). Of 131 patients evaluated, 60% were women. Groups were similar in age, ethnicity, insurance status, and predicted mortality. Men and women did not differ in the frequency of medical (56% vs. 57%, respectively), surgical (25% vs. 18%, respectively), or non-specific abdominal pain (19% vs. 25%, respectively, p = 0.52) diagnoses. Similar proportions underwent abdominal imaging (62% vs. 68%, respectively, p = 0.42), received antibiotics (29% vs. 30%, respectively, p = 0.85), and opiates for pain (35% vs. 41%, respectively, p = 0.50). Men had a higher rate of death within 3 months of the visit (19% vs. 1%, respectively, p < 0.001). Unlike prior research in younger patients with abdominal pain and among elders with other acute conditions, we noted no difference in management and diagnoses between older men and women who presented with abdominal pain. Despite a similar predicted mortality and ED evaluation, men had a higher rate of death within 3 months.     

Alcohol and Tobacco Use in the Elder Emergency Department Patient: Assessment of Rates and Medical Care Utilization

OBJECTIVES: To determine rates of alcohol and tobacco use among independent elder emergency department (ED) patients and assess the extent of health care use of this population. METHODS: A convenience sample of independent elders (age > or =65 years) in an urban academic ED was enrolled. Patients were excluded if they were medically unstable or had a change in mental status. The Fagerstrom Test for Nicotine Dependence, and the Alcohol Use Disorders Identification Test (AUDIT) scales were used to measure tobacco and alcohol use. Subjects completed questionnaires about their health and use of the health care system. Data were analyzed by using t-tests to compare independent variables. RESULTS: A total of 565 subjects completed the study. Of these, 296 (52.4%) were male and 269 (47.6%) were female; mean age was 77.1 years. Fifty-four (9.5%) were smokers, and 22 (3.9%) were nicotine-dependent by the Fagerstrom test (Fagerstrom+). Alcohol use was reported at least once monthly by 176 (31.2%) and twice monthly by 76 (13.5%) patients; 12 (2.1%) were alcohol-dependent by the AUDIT scale (AUDIT+). Two (0.35%) were both Fagerstrom+ and AUDIT+. Fagerstrom+ subjects visited a physician less often than Fagerstrom- subjects (3.9 vs. 4.6 annual visits, p < 0.0009). AUDIT+ subjects visited a primary care physician less (3.3 vs. 4.2 annual visits, p < 0.007) or "any" physician less (3.9 vs. 4.6 annual visits, p < 0.01) than AUDIT- subjects. AUDIT+ and Fagerstrom+ subjects did not differ from AUDIT- and Fagerstrom- subjects in number of annual ED visits, self-reported general health, physical symptoms (except nervousness, p < 0.004), comorbid illnesses, hospital admissions, and injuries requiring treatment. CONCLUSIONS: Elder ED patients have low rates of nicotine and alcohol dependence. Nicotine- or alcohol-dependent elders use outpatient providers less often than nondependent elders but use EDs at the same rate and report similar health patterns.