Risk of falls is associated with 30-day mortality among older adults in the emergency department

OBJECTIVE

Falls in older adults correlate with heightened morbidity and mortality. Assessing fall risk in the emergency department (ED) not only aids in identifying candidates for prevention interventions but may also offer insights into overall mortality risk. We sought to examine the link between fall risk and 30-day mortality in older ED adults.

METHODS

Observational cohort study of adults aged ≥ 75years who presented to an academic ED and who were assessed for fall risk using the Memorial Emergency Department Fall Risk Assessment Tool (MEDFRAT), a validated, ED-specific screening tool. The fall risk was classified as low (0-2 points), moderate (3-4 points), or high (≥5) risk. The primary outcome was 30-day mortality. Hazard ratios (HR) with 95% confidence intervals (CIs) were calculated.

RESULTS

A total of 941 patients whose fall risk was assessed in the ED were included in the study. Median age was 83.7 years; 45.6% were male, 75.6% lived in private residences, and 62.7% were admitted. Mortality at 30 days among the high fall risk group was four times that of the low fall risk group (11.8% vs 3.1%; HR 4.00, 95% CI 2.18 to 7.34, p < 0.001). Moderate fall risk individuals had nearly double the mortality rate of the low-risk group (6.0% vs 3.1%), but the difference was not statistically significant (HR 1.98, 95% CI 0.91 to 4.32, p = 0.087).

CONCLUSION

ED fall risk assessments are linked to 30-day mortality. Screening may facilitate the stratification of older adults at risk for health deterioration.

Quantifying EHR and Policy Factors Associated with the Gender Productivity Gap in Ambulatory, General Internal Medicine

BACKGROUND

The gender gap in physician compensation has persisted for decades. Little is known about how differences in use of the electronic health record (EHR) may contribute.

OBJECTIVE

To characterize how time on clinical activities, time on the EHR, and clinical productivity vary by physician gender and to identify factors associated with physician productivity.

DESIGN, SETTING, AND PARTICIPANTS

This longitudinal study included general internal medicine physicians employed by a large ambulatory practice network in the Northeastern United States from August 2018 to June 2021.

MAIN MEASURES

Monthly data on physician work relative value units (wRVUs), physician and practice characteristics, metrics of EHR use and note content, and temporal trend variables.

KEY RESULTS

The analysis included 3227 physician-months of data for 108 physicians (44% women). Compared with men physicians, women physicians generated 23.8% fewer wRVUs per month, completed 22.1% fewer visits per month, spent 4.0 more minutes/visit and 8.72 more minutes on the EHR per hour worked (all p < 0.001), and typed or dictated 36.4% more note characters per note (p = 0.006). With multivariable adjustment for physician age, practice characteristics, EHR use, and temporal trends, physician gender was no longer associated with productivity (men 4.20 vs. women 3.88 wRVUs/hour, p = 0.31). Typing/dictating fewer characters per note, relying on greater teamwork to manage orders, and spending less time on documentation were associated with higher wRVUs/hour. The 2021 E/M code change was associated with higher wRVUs/hour for all physicians: 10% higher for men physicians and 18% higher for women physicians (p < 0.001 and p = 0.009, respectively).

CONCLUSIONS

Increased team support, briefer documentation, and the 2021 E/M code change were associated with higher physician productivity. The E/M code change may have preferentially benefited women physicians by incentivizing time-intensive activities such as medical decision-making, preventive care discussion, and patient counseling that women physicians have historically spent more time performing.

Trends in new and persistent opioid use in older adults with and without cancer

BACKGROUND

The impact of ongoing efforts to decrease opioid use on patients with cancer remains undefined. Our objective was to determine trends in new and additional opioid use in patients with and without cancer.

METHODS

This retrospective cohort study used data from Surveillance, Epidemiology, and End Results program-Medicare for opioid-naive patients with solid tumor malignancies diagnosed from 2012 through 2017 and a random sample of patients without cancer. We identified 238 470 eligible patients with cancer and further focused on 4 clinical strata: patients without cancer, patients with metastatic cancer, patients with nonmetastatic cancer treated with surgery alone ("surgery alone"), and patients with nonmetastatic cancer treated with surgery plus chemotherapy or radiation therapy ("surgery+"). We identified new, early additional, and long-term additional opioid use and calculated the change in predicted probability of these outcomes from 2012 to 2017.

RESULTS

New opioid use was higher in patients with cancer (46.4%) than in those without (6.9%) (P < .001). From 2012 to 2017, the predicted probability of new opioid use was more stable in the cancer strata (relative declines: 0.1% surgery alone; 2.4% surgery+; 8.8% metastatic cancer), than in the noncancer stratum (20.0%) (P < .001 for each cancer to noncancer comparison). Early additional use declined among surgery patients (‒14.9% and ‒17.5% for surgery alone and surgery+, respectively) but was stable among patients with metastatic disease (‒2.8%, P = .50).

CONCLUSIONS

Opioid prescribing declined over time at a slower rate in patients with cancer than in patients without cancer. Our study suggests important but tempered effects of the changing opioid climate on patients with cancer.

Uptake of Biosimilar Among Privately Insured Patients Undergoing Infliximab Treatment

BACKGROUND

Recent literature has found rapid uptake of short-acting filgrastim biosimilars but slower uptake of other biosimilars, such as infliximab, in both Medicare and privately insured enrollees.

OBJECTIVES

To describe patient, provider, and health plan characteristics associated with a switch to biosimilar among existing infliximab patients.

RESEARCH DESIGN

We constructed a retrospective panel dataset of patients undergoing active infliximab treatments and the choice of infliximab drug for each infusion. We used mixed logit regression controlling for patient, provider, and health plan characteristics as well as time-fixed effects.

SUBJECTS

Medicare Advantage and privately insured enrollees with evidence of active infliximab treatments between 2016 and 2020 (n=357,430).

MEASURES

Our primary outcome of interest was to switch from infliximab originator to one of the infliximab biosimilars. Exposure variables of interest variables such as out-of-pocket, site of care, and in-network deductible.

RESULTS

Our study found nominally low switching among existing infliximab originator users (3.4%). We found that patients who previously received 1 infliximab originator infusion were 63.7% more likely to switch to biosimilar compared with patients who previously received administration of 20 infliximab originators. We found that biosimilar's placement as health's plan preferred drug was attributed to higher likelihood of biosimilar use (odds ratio: 1.666; P -value=0.001). We did not observe any statistically significant effect among out-of-pocket amount or deductible with respect to switch to infliximab biosimilar.

CONCLUSIONS

To encourage uptake and switch to biosimilar, policymakers should consider targeted policies that include leveraging health plan tools such as placement of biosimilar as preferred drug and aim to educate patients on the clinical equivalence between infliximab biosimilar and originator.

Longitudinal Patterns in Testosterone Prescribing After US FDA Safety Communication in 2014

BACKGROUND

The objective of this study was to describe changes in testosterone prescribing following a 2014 US Food and Drug Administration (FDA) safety communication and how changes varied by physician characteristics.

METHODS

Data were extracted from a 20% random sample of Medicare fee-for-service administrative claims data from 2011 through 2019. The sample included 1,544,604 unique male beneficiaries who received evaluation and management (E&M) services from 58,819 unique physicians that prescribed testosterone between 2011 and 2013. Patients were categorized based on presence of coronary artery disease (CAD) and non-age-related hypogonadism. Physician characteristics were identified in the OneKey database and included specialty and affiliations with teaching hospitals, for-profit hospitals, hospitals in integrated delivery networks, and hospitals in the top decile of case mix index. Linear segmented models described how testosterone prescriptions changed following a 2014 FDA safety communication and how changes were associated with physician and organizational characteristics.

RESULTS

Among 65,089,560 physician-patient-quarter-year observations, mean (standard deviation) age ranged from 72.16 (5.84) years for observations without CAD or non-age-related hypogonadism to 75.73 (6.92) years with CAD and without non-age-related hypogonadism. Following the safety communication, immediate changes in off-label testosterone prescription levels fell by 0.22 percentage points (pp) (95% confidence interval [CI] -0.33 to -0.11) for patients with CAD and by -0.16 pp (95% CI -0.19 to -0.16) for patients without CAD. A similar change was noticed in on-label prescribing levels. Off-label testosterone prescription quarterly trend, however, increased for patients with CAD and without CAD; on-label testosterone prescription trends declined for both groups. Declines in off-label prescribing were larger when treated by primary care physicians vs. non-primary care physicians, and physicians affiliated with teaching compared to nonteaching hospitals. Physician and organizational characteristics were not associated with changes in on-label prescribing.

CONCLUSION

On-label and off-label testosterone therapy declined following the FDA safety communication. Certain physician characteristics were associated with changes in off-label, but not on-label, prescribing.

Racial and ethnic disparities in emergency department-initiated buprenorphine across five health care systems

BACKGROUND

Opioid overdose deaths have disproportionately impacted Black and Hispanic populations, in part due to disparities in treatment access. Emergency departments (EDs) serve as a resource for patients with opioid use disorder (OUD), many of whom have difficulty accessing outpatient addiction programs. However, inequities in ED treatment for OUD remain poorly understood.

METHODS

This secondary analysis examined racial and ethnic differences in buprenorphine access using data from EMBED, a study of 21 EDs across five health care systems evaluating a clinical decision support system for initiating ED buprenorphine. The primary outcome was receipt of buprenorphine, ED administered or prescribed. Hospital type (academic vs. community) was evaluated as an effect modifier. Hierarchical models with cluster effects for site and clinician were used to assess buprenorphine receipt by race and ethnicity.

RESULTS

Black patients were less likely to receive buprenorphine (6.4% [51/801] vs. White patients 8.5% [268/3154], odds ratio [OR] 0.59, 95% confidence interval [CI] 0.45-0.78). This association persisted after adjusting for age, insurance, gender, clinician X-waiver, hospital type, and urbanicity (adjusted OR [aOR] 0.64, 95% CI 0.48-0.84) but not when discharge diagnosis was included (aOR 0.75, 95% CI 0.56-1.02). Hispanic patients were more likely to receive buprenorphine (14.8% [122/822] vs. non-Hispanic patients, 11.6% [475/4098]) in unadjusted (OR 1.57, 95% CI 1.09-1.83) and adjusted models (aOR 1.41, 95% CI 1.08-1.83) but not including discharge diagnosis (aOR 1.32, 95% CI 0.99-1.77). Odds of buprenorphine were similar in academic and community EDs by race (interaction p = 0.97) and ethnicity (interaction p = 0.64).

CONCLUSIONS

Black patients with OUD were less likely to receive buprenorphine whereas Hispanic patients were more likely to receive buprenorphine in academic and community EDs. Differences were attenuated with discharge diagnosis, as fewer Black and non-Hispanic patients were diagnosed with opioid withdrawal. Barriers to medication treatment are heterogenous among patients with OUD; research must continue to address the multiple drivers of health inequities at the patient, clinician, and community level.

Association of delirium with increased short-term mortality among older emergency department patients: A cohort study

STUDY OBJECTIVE

To evaluate the association between delirium and subsequent short-term mortality in geriatric patients presenting to the emergency department (ED).

METHODS

This was an observational cohort study of adults age ≥75 years who presented to an academic ED and were screened for delirium during their ED visit. The Delirium Triage Screen followed by the Brief Confusion Assessment Method were used to ascertain the presence of delirium. In-hospital, 7-day, and 30-day mortality were compared between patients with and without ED delirium. Odds ratios with 95% confidence intervals (CIs) were calculated through logistic regression after adjusting for confounders including age, sex, history of dementia, ED disposition, and acuity.

RESULTS

A total of 967 ED visits were included for analysis among which delirium was detected in 107 (11.1%). The median age of the cohort was 83 years (IQR 79, 88), 526 (54.4%) were female, 285 (29.5%) had documented dementia, and 171 (17.7%) had a high acuity Emergency Severity Index triage level 1 or 2. During the hospitalization, 5/107 (4.7%) of those with delirium and 4/860 (0.5%) of those without delirium died. Within 7 days of ED departure, 6/107 (5.6%) of those with delirium and 6/860 (0.7%) of those without delirium died (unadjusted OR 8.46, 95% CI 2.68-26.71). Within 30 days, 18/107 (16.8%) of those with delirium and 37/860 (4.3%) of those without delirium died (unadjusted OR 4.50, 95% CI 2.46-8.23). ED delirium remained associated with higher 7-day (adjusted OR 5.23, 95% CI 1.44-19.05, p = 0.008) and 30-day mortality (adjusted OR 2.82, 95% CI 1.45-5.46, p = 0.002).

CONCLUSION

Delirium is an important prognostic factor that ED clinicians and nurses must be aware of to optimize delirium prevention, management, disposition, and communication with patients and families.

Long-Term Opioid Therapy Among Patients With Systemic Lupus Erythematosus in the Community: A Lupus Midwest Network (LUMEN) Study

OBJECTIVE

There is little information about the epidemiology and factors associated with opioid therapy in systemic lupus erythematosus (SLE). We aimed to assess the prevalence of opioid therapy and explore factors associated with long-term opioid therapy (LTOT) in patients with SLE.

METHODS

Patients with SLE were matched with controls without SLE in a population-based cohort on January 1, 2015. We captured demographics, manifestations of SLE, comorbidities (ie, fibromyalgia, mood disorders, osteoarthritis, chronic low back pain [CLBP], chronic kidney disease (CKD), avascular necrosis, osteoporosis, fragility fractures, and cancer), and the Area Deprivation Index (ADI). Opioid prescription data were used to assess the prevalence of LTOT, defined as contiguous prescriptions (gaps of < 30 days between prescriptions) and receiving opioid therapy for ≥ 90 days or ≥ 10 prescriptions before the index date.

RESULTS

A total of 465 patients with SLE and 465 controls without SLE were included. In total, 13% of patients with SLE and 3% of controls without SLE were receiving opioid therapy (P < 0.001), and 11% of patients with SLE were on LTOT vs 1% of controls without SLE. Among patients with SLE, acute pericarditis (odds ratio [OR] 3.92, 95% CI 1.78-8.66), fibromyalgia (OR 7.78, 95% CI 3.89-15.55), fragility fractures (OR 3.72, 95% CI 1.25-11.07), CLBP (OR 4.00, 95% CI 2.13-7.51), and mood disorders (OR 2.76, 95% CI 1.47-5.16) were associated with LTOT. We did not find an association between opioid therapy and ADI.

CONCLUSION

Patients with SLE are more likely to receive LTOT than controls. Among patients with SLE, LTOT was associated with pericarditis and several comorbidities. However, LTOT was not associated with CKD despite the limited pain control options among these patients.

A prediction model for asthma exacerbations after stopping asthma biologics

BACKGROUND

Little is known regarding the prediction of the risks of asthma exacerbation after stopping asthma biologics.

OBJECTIVE

To develop and validate a predictive model for the risk of asthma exacerbations after stopping asthma biologics using machine learning models.

METHODS

We identified 3057 people with asthma who stopped asthma biologics in the OptumLabs Database Warehouse and considered a wide range of demographic and clinical risk factors to predict subsequent outcomes. The primary outcome used to assess success after stopping was having no exacerbations in the 6 months after stopping the biologic. Elastic-net logistic regression (GLMnet), random forest, and gradient boosting machine models were used with 10-fold cross-validation within a development (80%) cohort and validation cohort (20%).

RESULTS

The mean age of the total cohort was 47.1 (SD, 17.1) years, 1859 (60.8%) were women, 2261 (74.0%) were White, and 1475 (48.3%) were in the Southern region of the United States. The elastic-net logistic regression model yielded an area under the curve (AUC) of 0.75 (95% confidence interval [CI], 0.71-0.78) in the development and an AUC of 0.72 in the validation cohort. The random forest model yielded an AUC of 0.75 (95% CI, 0.68-0.79) in the development cohort and an AUC of 0.72 in the validation cohort. The gradient boosting machine model yielded an AUC of 0.76 (95% CI, 0.72-0.80) in the development cohort and an AUC of 0.74 in the validation cohort.

CONCLUSION

Outcomes after stopping asthma biologics can be predicted with moderate accuracy using machine learning methods.

Development of a machine learning algorithm based on administrative claims data for identification of ED anaphylaxis patient visits

Background

Epidemiologic studies of anaphylaxis commonly rely on International Classification of Diseases (ICD) codes to identify anaphylaxis cases, which may lead to suboptimal epidemiologic classification.

Objective

We sought to develop and assess the accuracy of a machine learning algorithm using ICD codes and other administrative data compared with ICD code-only algorithms to identify emergency department (ED) anaphylaxis visits.

Methods

We conducted a retrospective review of ED visits from January 2013 to September 2017. Potential ED anaphylaxis visits were identified using 3 methods: anaphylaxis ICD diagnostic codes (method 1), ICD symptom-based codes with or without a code indicating an allergic trigger (method 2), and ICD codes indicating a potential allergic reaction only (method 3). A machine learning algorithm was developed from administrative data, and test characteristics were compared with ICD code-only algorithms.

Results

A total of 699 of 2191 (31.9%) potential ED anaphylaxis visits were classified as anaphylaxis. The sensitivity and specificity of method 1 were 49.1% and 87.5%, respectively. Method 1 used in combination with method 2 resulted in a sensitivity of 53.9% and a specificity of 68.7%. Method 1 used in combination with method 3 resulted in a sensitivity of 98.4% and a specificity of 15.1%. The sensitivity and specificity of the machine learning algorithm were 87.3% and 79.1%, respectively.

Conclusions

ICD coding alone demonstrated poor sensitivity in identifying cases of anaphylaxis, with venom-related anaphylaxis missing 96% of cases. The machine learning algorithm resulted in a better balance of sensitivity and specificity and improves upon previous strategies to identify ED anaphylaxis visits.

Changes in all-cause and cause-specific mortality during the first year of the COVID-19 pandemic in Minnesota: population-based study

BACKGROUND

The COVID-19 pandemic resulted in unprecedented increases in mortality in the U.S. and worldwide. To better understand the impact of the COVID-19 pandemic on mortality in the state of Minnesota, U.S.A., we characterize the changes in the causes of death during 2020 (COVID-19 period), compared to 2018-2019 (baseline period), assessing for differences across ages, races, ethnicities, sexes, and geographic characteristics.

METHODS

Longitudinal population-based study using Minnesota death certificate data, 2018-2020. Using Poisson regression models adjusted for age and sex, we calculated all-cause and cause-specific (by underlying causes of death) mortality rates per 100,000 Minnesotans, the demographics of the deceased, and years of life lost (YLL) using the Chiang's life table method in 2020 relative to 2018-2019.

RESULTS

We identified 89,910 deaths in 2018-2019 and 52,030 deaths in 2020. The mean daily mortality rate increased from 123.1 (SD 11.7) in 2018-2019 to 144.2 (SD 22.1) in 2020. COVID-19 comprised 9.9% of deaths in 2020. Other categories of causes of death with significant increases in 2020 compared to 2018-2019 included assault by firearms (RR 1.68, 95% CI 1.34-2.11), accidental poisonings (RR 1.49, 95% CI 1.37-1.61), malnutrition (RR 1.48, 95% CI 1.17-1.87), alcoholic liver disease (RR, 95% CI 1.14-1.40), and cirrhosis and other chronic liver diseases (RR 1.28, 95% CI 1.09-1.50). Mortality rates due to COVID-19 and non-COVID-19 causes were higher among racial and ethnic minority groups, older adults, and non-rural residents.

CONCLUSIONS

The COVID-19 pandemic was associated with a 17% increase in the death rate in Minnesota relative to 2018-2019, driven by both COVID-19 and non-COVID-19 causes. As the COVID-19 pandemic enters its third year, it is imperative to examine and address the factors contributing to excess mortality in the short-term and monitor for additional morbidity and mortality in the years to come.

Asthma biologic trial eligibility and real-world outcomes in the United States

OBJECTIVE

To compare the outcomes of real-world patients who would have been eligible for asthma biologics to those who would not have been eligible.

METHODS

We used data from the OptumLabs Data Warehouse (OLDW) to categorize patients into eligible and ineligible groups based on clinical trials (n = 19 trials) used for Food and Drug Administration (FDA) approval. We then compared the change in the number of asthma exacerbations before and after biological initiation between the two groups.

RESULTS

The percentage of people who would have been eligible for asthma biologic clinical trials ranged from 0-10.2%. The eligible group had a greater reduction in number of asthma exacerbations compared to the ineligible group based on eligibility criteria from 1 omalizumab trial (1.52, 95% CI 1.25, 1.8 in eligible vs. 0.47, 95% CI 0.43, 0.52 in ineligible) and from 1 dupilumab trial (1.6, 95% CI 0.92, 2.28 in eligible vs. 0.52, 95% CI 0.38, 0.65 ineligible). Notably, 15 of the 19 trials had fewer than 11 eligible people, limiting additional comparisons.

CONCLUSIONS

Fewer than 1 in 10 people in the United States treated with asthma biologics would have been eligible to participate in the trial for the biologic they used. Where comparisons could be made, trial eligible people have a greater reduction in exacerbations.

Supplemental data for this article is available online at https://doi.org/10.1080/02770903.2021.2010749 .

Demographic Trends in Emergency Department Visits for Psychiatric Concerns During the COVID-19 Pandemic

Objective

To describe changes in emergency department (ED) psychiatric visits during the pandemic in both rural and nonrural regions in the United States.

Methods

This cohort study was performed across 22 EDs in the Midwest and Southern United States from January 1, 2019 to April 22, 2021. Prevalence of psychiatric visits before and after the COVID-19 pandemic, defined as starting on March 1, 2020, were compared. Psychiatric and nonpsychiatric visits were defined on the basis of primary clinician-assigned diagnosis. The primary end point was average daily visits normalized to the average daily visit count before the pandemic, labeled as relative mean daily visits (RMDVs).

Results

Psychiatric visits decreased by 9% [RMDVs, 0.91; 95% confidence interval (CI), 0.89-0.93] during the pandemic period, whereas nonpsychiatric visits decreased by 17% (RMDVs, 0.83; 95% CI, 0.81-0.84). Black patients were the only demographic group with a significant increase in psychiatric visits during the pandemic (RMDVs, 1.12; 95% CI, 1.04-1.19). Periods of outbreaks of psychiatric emergencies were identified in most demographic groups, including among male and pediatric patients. However, the outbreaks detected among Black patients sustained the longest at 6 months. Unlike older adults who experienced outbreaks in the spring and fall of 2020, outbreaks among pediatric patients were detected later in 2021.

Conclusion

In this multisite study, total ED visits declined during the pandemic; however, psychiatric visits declined less than nonpsychiatric visits. Black patients experienced a greater increase in psychiatric emergencies than other demographic groups. There is also a concern for increasing outbreaks of pediatric psychiatric visits as the pandemic progresses.

Comparison of emergency department throughput and process times between male and female patients: A retrospective cohort investigation by the Reducing Disparities Increasing Equity in Emergency Medicine Study Group

Introduction

Health equity for all patients is an important characteristic of an effective healthcare system. Bias has the potential to create inequities. In this study, we examine emergency department (ED) throughput and care measures for sex‐based differences, including metrics such as door‐to‐room (DTR) and door‐to‐healthcare practitioner (DTP) times to look for potential signs of systemic bias.

Methods

We conducted an observational cohort study of all adult patients presenting to the ED between July 2015 and June 2017. We collected ED operational, throughput, clinical, and demographic data. Differences in the findings for male and female patients were assessed using Poisson regression and generalized estimating equations (GEEs). A priori, a clinically significant time difference was defined as 10 min.

Results

A total of 106,011 adult visits to the ED were investigated. Female patients had 8‐min longer median length‐of‐stay (LOS) than males (P < 0.01). Females had longer DTR (2‐min median difference, P < 0.01), and longer DTP (5‐min median difference, P < 0.01). Females had longer median door‐to‐over‐the‐counter analgesia time (84 vs. 80, P = 0.58), door‐to‐advanced analgesia (95 vs. 84, P < 0.01), door‐to‐PO (by mouth) ondansetron (70 vs. 62, P = 0.02), and door‐to‐intramuscular/intravenous antiemetic (76 vs. 69, P = 0.02) times compared with males.

Conclusion

Numerous statistically significant differences were identified in throughput and care measures—mostly these differences favored male patients. Few of these comparisons met our criteria for clinical significance.

User centered clinical decision support to implement initiation of buprenorphine for opioid use disorder in the emergency department: EMBED pragmatic cluster randomized controlled trial

OBJECTIVE

To determine the effect of a user centered clinical decision support tool versus usual care on rates of initiation of buprenorphine in the routine emergency care of individuals with opioid use disorder.

DESIGN

Pragmatic cluster randomized controlled trial (EMBED).

SETTING

18 emergency department clusters across five healthcare systems in five states representing the north east, south east, and western regions of the US, ranging from community hospitals to tertiary care centers, using either the Epic or Cerner electronic health record platform.

PARTICIPANTS

599 attending emergency physicians caring for 5047 adult patients presenting with opioid use disorder.

INTERVENTION

A user centered, physician facing clinical decision support system seamlessly integrated into user workflows in the electronic health record to support initiating buprenorphine in the emergency department by helping clinicians to diagnose opioid use disorder, assess the severity of withdrawal, motivate patients to accept treatment, and complete electronic health record tasks by automating clinical and after visit documentation, order entry, prescribing, and referral.

MAIN OUTCOME MEASURES

Rate of initiation of buprenorphine (administration or prescription of buprenorphine) in the emergency department among patients with opioid use disorder. Secondary implementation outcomes were measured with the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework.

RESULTS

1 413 693 visits to the emergency department (775 873 in the intervention arm and 637 820 in the usual care arm) from November 2019 to May 2021 were assessed for eligibility, resulting in 5047 patients with opioid use disorder (2787 intervention arm, 2260 usual care arm) under the care of 599 attending physicians (340 intervention arm, 259 usual care arm) for analysis. Buprenorphine was initiated in 347 (12.5%) patients in the intervention arm and in 271 (12.0%) patients in the usual care arm (adjusted generalized estimating equations odds ratio 1.22, 95% confidence interval 0.61 to 2.43, P=0.58). Buprenorphine was initiated at least once by 151 (44.4%) physicians in the intervention arm and by 88 (34.0%) in the usual care arm (1.83, 1.16 to 2.89, P=0.01).

CONCLUSIONS

User centered clinical decision support did not increase patient level rates of initiating buprenorphine in the emergency department. Although streamlining and automating electronic health record workflows can potentially increase adoption of complex, unfamiliar evidence based practices, more interventions are needed to look at other barriers to the treatment of addiction and increase the rate of initiating buprenorphine in the emergency department in patients with opioid use disorder.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03658642.

REcognizing DElirium in geriatric Emergency Medicine: The REDEEM risk stratification score

OBJECTIVE

The objective was to derive a risk score that uses variables available early during the emergency department (ED) encounter to identify high-risk geriatric patients who may benefit from delirium screening.

METHODS

This was an observational study of older adults age ≥ 75 years who presented to an academic ED and who were screened for delirium during their ED visit. Variable selection from candidate predictors was performed through a LASSO-penalized logistic regression. A risk score was derived from the final prediction model, and predictive accuracy characteristics were calculated with 95% confidence intervals (CIs).

RESULTS

From the 967 eligible ED visits, delirium was detected in 107 (11.1%). The area under the curve for the REcognizing DElirium in Emergency Medicine (REDEEM) score was 0.901 (95% CI = 0.864-0.938). The REEDEM risk score included 10 different variables (seven based on triage information and three obtained during early history taking) with a score ranging from -3 to 66. Using an optimal cutoff of ≥11, we found a sensitivity of 84.1% (90 of 107 ED delirium patients, 95% CI = 75.5%-90.2%) and a specificity of 86.6% (745 of 860 non-ED delirium patients, 95% CI = 84.1%-88.8%). A lower cutoff of ≥5 was found to minimize false negatives with an improved sensitivity at 91.6% (98 of 107 ED delirium patients, 95% CI = 84.2%-95.8%).

CONCLUSION

A risk stratification score was derived with the potential to augment delirium recognition in geriatric ED patients. This has the potential to assist on delirium-targeted screening of high-risk patients in the ED. Validation of REDEEM, however, is needed prior to implementation.

Do all outpatient spine surgeries cost the same? Comparison of economic outcomes data from a state-level database for outpatient lumbar decompression performed in an ambulatory surgery center or hospital outpatient setting

OBJECTIVE

Spinal procedures are increasingly conducted as outpatient procedures, with a growing proportion conducted in ambulatory surgery centers (ASCs). To date, studies reporting outcomes and cost analyses for outpatient spinal procedures in the US have not distinguished the various outpatient settings from each other. In this study, the authors used a state-level administrative database to compare rates of overnight stays and nonroutine discharges as well as index admission charges and cumulative 7-, 30-, and 90-day charges for patients undergoing outpatient lumbar decompression in freestanding ASCs and hospital outpatient (HO) settings.

METHODS

For this project, the authors used the Florida State Ambulatory Surgery Database (SASD), offered by the Healthcare Cost and Utilization Project (HCUP), for the years 2013 and 2014. Patients undergoing outpatient lumbar decompression for degenerative diseases were identified using CPT (Current Procedural Terminology) and ICD-9 codes. Outcomes of interest included rates of overnight stays, rate of nonroutine discharges, index admission charges, and subsequent admission cumulative charges at 7, 30, and 90 days. Multivariable analysis was performed to assess the impact of outpatient type on index admission charges. Marginal effect analysis was employed to study the difference in predicted dollar margins between ASCs and HOs for each insurance type.

RESULTS

A total of 25,486 patients were identified; of these, 7067 patients (27.7%) underwent lumbar decompression in a freestanding ASC and 18,419 (72.3%) in an HO. No patient in the ASC group required an overnight stay compared to 9.2% (n = 1691) in the HO group (p < 0.001). No clinically significant difference in the rate of nonroutine discharge was observed between the two groups. The mean index admission charge for the ASC group was found to be significantly higher than that for the HO group ($35,017.28 ± $14,335.60 vs $33,881.50 ± $15,023.70; p < 0.001). Patients in ASCs were also found to have higher mean 7-day (p < 0.001), 30-day (p < 0.001), and 90-day (p = 0.001) readmission charges. ASC procedures were associated with increased charges compared to HO procedures for patients on Medicare or Medicaid (mean index admission charge increase $4049.27, 95% CI $2577.87-$5520.67, p < 0.001) and for patients on private insurance ($4775.72, 95% CI $4171.06-$5380.38, p < 0.001). For patients on self-pay or no charge, a lumbar decompression procedure at an ASC was associated with a decrease in index admission charge of -$10,995.38 (95% CI -$12124.76 to -$9866.01, p < 0.001) compared to a lumbar decompression procedure at an HO.

CONCLUSIONS

These "real-world" results from an all-payer statewide database indicate that for outpatient spine surgery, ASCs may be associated with higher index admission and subsequent 7-, 30-, and 90-day charges. Given that ASCs are touted to have lower overall costs for patients and better profit margins for physicians, these analyses warrant further investigation into whether this cost benefit is applicable to outpatient spine procedures.

Variations in Postoperative Opioid Prescription Practices and Impact on Refill Prescriptions Following Lumbar Spine Surgery

OBJECTIVE

Understanding postsurgical prescribing patterns and their impact on persistent opioid use is important for establishing reasonable opioid prescribing protocols. We aimed to determine national variation in postoperative opioid prescription practices following elective lumbar spine surgery and their impact on short-term refill prescriptions.

METHODS

The OptumLabs Data Warehouse was queried from 2016 to 2017 for adults undergoing anterior lumbar fusion, posterior lumbar fusion, circumferential lumbar fusion, and lumbar decompression/discectomy for degenerative spine disease. Discharge opioid prescription fills were obtained and converted to morphine milligram equivalents (MMEs). Age- and sex-adjusted MMEs and frequency of discharge prescriptions >200 MMEs were determined for each U.S. census division and procedure type.

RESULTS

The study included 43,572 patients with 37,894 postdischarge opioid prescription fills. There was wide variation in mean filled MMEs across all census divisions (anterior lumbar fusion: 774-1147 MMEs; posterior lumbar fusion: 717-1280 MMEs; circumferential lumbar fusion: 817-1271 MMEs; lumbar decompression/discectomy: 619-787 MMEs). A significant proportion of cases were found to have filled discharge prescriptions >200 MMEs (posterior lumbar fusion: 78.6%-95%; anterior lumbar fusion: 87.5%-95.6%; circumferential lumbar fusion: 81.4%-96.5%; lumbar decompression/discectomy: 80.5%-91%). Multivariable logistic regression showed that female sex and inpatient surgery were associated with a top-quartile discharge prescription and a short-term second opioid prescription fill, while the opposite was noted for elderly and opioid-naïve patients (all P ≤ 0.05). Prescriptions with long-acting opioids were associated with higher odds of a second opioid prescription fill (reference: nontramadol short-acting opioid).

CONCLUSIONS

In analysis of filled opioid prescriptions, we observed a significant proportion of prescriptions >200 MMEs and wide regional variation in postdischarge opioid prescribing patterns following elective lumbar spine surgery.

Persistence of asthma biologic use in a US claims database

BACKGROUND

Little is known on the persistence of asthma biologic use in clinical practice.

OBJECTIVE

To evaluate the persistence of asthma biologic use and time to clinical response in clinical practice.

METHODS

A cohort of people with asthma who used at least 1 asthma biologic was constructed using data from 2003 to 2019 in the OptumLabs Data Warehouse. Treatment persistence was defined by the length of time that a person continuously used an asthma biologic, allowing for a lapse in use up to 4 months before confirming that a person stopped. Clinical response to treatment (defined as a decline in asthma exacerbations of at least 50% compared with the 6 months before starting an asthma biologic) was described over time and in relation to biologic persistence.

RESULTS

There were 9575 people who had at least 1 episode of asthma biologic use. There were 5319 people (64%, 95% confidence interval, 63%-65%) who completed 6 months or more on an asthma biologic and 3284 (45%, 95% confidence interval, 44%-46%) who completed 12 months or more. Of people with 1 or more asthma exacerbation 6 months before index biologic use, 63%, 76%, 80%, and 81% realized a 50% or more reduction in postindex asthma exacerbations in the first 6 months, 6 to 12 months, 12 to 18 months, and 18 to 24 months, respectively.

CONCLUSION

Between 48% and 64% of people remained on an asthma biologic for 6 months or more after first use. Most people who achieved a reduction in asthma exacerbations did so in the first 6 months of treatment.

Characterizing Chronic Pain Episodes in Clinical Text at Two Health Care Systems: Comprehensive Annotation and Corpus Analysis

BACKGROUND

Chronic pain affects more than 20% of adults in the United States and is associated with substantial physical, mental, and social burden. Clinical text contains rich information about chronic pain, but no systematic appraisal has been performed to assess the electronic health record (EHR) narratives for these patients. A formal content analysis of the unstructured EHR data can inform clinical practice and research in chronic pain.

OBJECTIVE

We characterized individual episodes of chronic pain by annotating and analyzing EHR notes for a stratified cohort of adults with known chronic pain.

METHODS

We used the Rochester Epidemiology Project infrastructure to screen all residents of Olmsted County, Minnesota, for evidence of chronic pain, between January 1, 2005, and September 30, 2015. Diagnosis codes were used to assemble a cohort of 6586 chronic pain patients; people with cancer were excluded. The records of an age- and sex-stratified random sample of 62 patients from the cohort were annotated using an iteratively developed guideline. The annotated concepts included date, location, severity, causes, effects on quality of life, diagnostic procedures, medications, and other treatment modalities.

RESULTS

A total of 94 chronic pain episodes from 62 distinct patients were identified by reviewing 3272 clinical notes. Documentation was written by clinicians across a wide spectrum of specialties. Most patients (40/62, 65%) had 1 pain episode during the study period. Interannotator agreement ranged from 0.78 to 1.00 across the annotated concepts. Some pain-related concepts (eg, body location) had 100% (94/94) coverage among all the episodes, while others had moderate coverage (eg, effects on quality of life) (55/94, 59%). Back pain and leg pain were the most common types of chronic pain in the annotated cohort. Musculoskeletal issues like arthritis were annotated as the most common causes. Opioids were the most commonly captured medication, while physical and occupational therapies were the most common nonpharmacological treatments.

CONCLUSIONS

We systematically annotated chronic pain episodes in clinical text. The rich content analysis results revealed complexity of the chronic pain episodes and of their management, as well as the challenges in extracting pertinent information, even for humans. Despite the pilot study nature of the work, the annotation guideline and corpus should be able to serve as informative references for other institutions with shared interest in chronic pain research using EHRs.

Should age be incorporated into the adult triage algorithm in the emergency department?

OBJECTIVE

To compare resource utilization and mortality between older and younger adult patients with similar ED chief complaints and ESI triage levels.

METHODS

This was an observational study of consecutive adult patients (age ≥ 40) who presented to an academic ED over a 1-year period with chest pain, abdominal pain, altered mental status, generalized weakness, or headache. Patients were categorized into 40-64, 65-79, and ≥ 80-year old groups. Mortality and utilization outcomes were compared between age groups through logistic regression models or Cox proportional hazards adjusting for ESI level and chief complaint. Odds ratios (OR) and hazard ratios (HR) were calculated with 95% confidence intervals (CI).

RESULTS

A total of 9798 ED visits were included. As compared to younger adults (age 40-64), older adults, independently of ESI level and chief complaint, had higher ED laboratory use (OR 1.46 [CI 1.29, 1.66] for age 65-80; OR 1.33 [CI 1.15, 1.55] for age ≥ 80), ED radiology use (OR 1.40 [CI 1.26, 1.56]; OR 1.48 [CI 1.30, 1.69]), hospital admission (OR 1.56 [CI 1.42, 1.72]; OR 1.97 [CI 1.75, 2.21]), and ICU admission (OR 1.38 [CI 1.15, 1.65]; OR 1.23 [CI 0.99, 1.52]). Despite similar ESI and chief complaint, patients age 65-79 and ≥ 80 had higher 30-day mortality rates (HR 1.87 [CI 1.39 to 2.51] and 2.47 [CI 1.81 to 3.37], respectively).

CONCLUSIONS

Older adults with similar chief complaints and ESI levels than younger adults, have significantly higher ED resource use, hospitalization rates, and mortality.

Adherence to Asthma Biologics: Implications for Patient Selection, Step Therapy, and Outcomes

BACKGROUND

Little is known about adherence to asthma biologics.

RESEARCH QUESTION

Is adherence to inhaled corticosteroid (ICS) associated with subsequent asthma biologic adherence?

STUDY DESIGN AND METHODS

We analyzed individuals with asthma who started asthma biologics in the OptumLab Data Warehouse and used that data until October 2019. We calculated proportion days covered (PDC) for ICS ± long-acting β-agonists in the 6 months before and after asthma biologics were started and asthma biologic PDC for the first 6 months of use. We performed a multivariable analysis to identify factors associated with asthma biologic PDC ≥0.75, ICS PDC ≥0.75 during the 6-month period after asthma biologic were started, and achievement of a ≥50% reduction in asthma exacerbations during the first 6 months of asthma biologic use.

RESULTS

We identified 5,319 people who started asthma biologics. The mean PDC for asthma biologics was 0.76 (95% CI, 0.75-0.77) in the first 6 months after starting, higher than the mean PDCs for ICS in the 6 months before (0.44 [95% CI, 0.43-0.45]) and after (0.40 [95% CI, 0.39-0.40]) starting the asthma biologic. PDC ≥0.75 for ICS 6 months before index biologic use is associated with PDC for asthma biologics ≥0.75 (OR, 1.25; 95% CI, 1.10-1.43) and for ICS during the first 6 months of biologic use (OR, 9.93; 95% CI, 8.55-11.53). Neither ICS PDC ≥0.75 (OR, 0.92; 95% CI, 0.74-1.14) nor asthma biologic PDC ≥0.75 (OR, 1.15; 95% CI, 0.97-1.36) is associated with a statistically significant reduction in asthma exacerbations during the first 6 months of asthma biologic use among people with any exacerbation in the 6 months before first use.

INTERPRETATION

Adherence to asthma biologic is higher than to ICS and is associated with different factors.

Predictors of return visits to the emergency department among different age groups of older adults

OBJECTIVE

To identify predictors of 30-day emergency department (ED) return visits in patients age 65-79 years and age ≥ 80 years.

METHODS

This was a cohort study of older adults who presented to the ED over a 1-year period. A mixed-effects logistic regression model was used to identify predictors for returning to the ED within 30 days. We stratified the cohort into those aged 65-79 years and aged ≥80 years. Adjusted odds ratios (aORs) with 95% confidence intervals (CI) were reported. This study adhered to the STROBE reporting guidelines.

RESULTS

A total of 21,460 ED visits representing 14,528 unique patients were included. The overall return rate was 15% (1998/13,300 visits) for age 65-79 years, and 16% (1306/8160 visits) for age ≥ 80 years. A history of congestive heart failure (CHF), dementia, or prior hospitalization within 2 years were associated with increased odds of returning in both age groups (for age 65-79: CHF aOR 1.36 [CI 1.16-1.59], dementia aOR 1.27 [CI 1.07-1.49], prior hospitalization aOR 1.36 [CI 1.19-1.56]; for age ≥ 80: CHF aOR 1.32 [CI 1.13-1.55], dementia aOR 1.22 [CI 1.04-1.42], and prior hospitalization aOR 1.27 [CI 1.09-1.47]). Being admitted from the ED was associated with decreased odds of returning to the ED within 30 days (aOR 0.72 [CI 0.64-0.80] for age 65-79 years and 0.72 [CI 0.63-0.82] for age ≥ 80).

CONCLUSION

Age alone was not an independent predictor of return visits. Prior hospitalization, dementia and CHF were predictors of 30-day ED return. The identification of predictors of return visits may help to optimize care transition in the ED.

Trends in Emergency Department Visits and Hospital Admissions in Health Care Systems in 5 States in the First Months of the COVID-19 Pandemic in the US

IMPORTANCE

As coronavirus disease 2019 (COVID-19) spread throughout the US in the early months of 2020, acute care delivery changed to accommodate an influx of patients with a highly contagious infection about which little was known.

OBJECTIVE

To examine trends in emergency department (ED) visits and visits that led to hospitalizations covering a 4-month period leading up to and during the COVID-19 outbreak in the US.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, observational, cross-sectional study of 24 EDs in 5 large health care systems in Colorado (n = 4), Connecticut (n = 5), Massachusetts (n = 5), New York (n = 5), and North Carolina (n = 5) examined daily ED visit and hospital admission rates from January 1 to April 30, 2020, in relation to national and the 5 states' COVID-19 case counts.

EXPOSURES

Time (day) as a continuous variable.

MAIN OUTCOMES AND MEASURES

Daily counts of ED visits, hospital admissions, and COVID-19 cases.

RESULTS

A total of 24 EDs were studied. The annual ED volume before the COVID-19 pandemic ranged from 13 000 to 115 000 visits per year; the decrease in ED visits ranged from 41.5% in Colorado to 63.5% in New York. The weeks with the most rapid rates of decrease in visits were in March 2020, which corresponded with national public health messaging about COVID-19. Hospital admission rates from the ED were stable until new COVID-19 case rates began to increase locally; the largest relative increase in admission rates was 149.0% in New York, followed by 51.7% in Massachusetts, 36.2% in Connecticut, 29.4% in Colorado, and 22.0% in North Carolina.

CONCLUSIONS AND RELEVANCE

From January through April 2020, as the COVID-19 pandemic intensified in the US, temporal associations were observed with a decrease in ED visits and an increase in hospital admission rates in 5 health care systems in 5 states. These findings suggest that practitioners and public health officials should emphasize the importance of visiting the ED during the COVID-19 pandemic for serious symptoms, illnesses, and injuries that cannot be managed in other settings.

Trends in Emergency Department Visits and Hospital Admissions in Health Care Systems in 5 States in the First Months of the COVID-19 Pandemic in the US

IMPORTANCE

As coronavirus disease 2019 (COVID-19) spread throughout the US in the early months of 2020, acute care delivery changed to accommodate an influx of patients with a highly contagious infection about which little was known.

OBJECTIVE

To examine trends in emergency department (ED) visits and visits that led to hospitalizations covering a 4-month period leading up to and during the COVID-19 outbreak in the US.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, observational, cross-sectional study of 24 EDs in 5 large health care systems in Colorado (n = 4), Connecticut (n = 5), Massachusetts (n = 5), New York (n = 5), and North Carolina (n = 5) examined daily ED visit and hospital admission rates from January 1 to April 30, 2020, in relation to national and the 5 states' COVID-19 case counts.

EXPOSURES

Time (day) as a continuous variable.

MAIN OUTCOMES AND MEASURES

Daily counts of ED visits, hospital admissions, and COVID-19 cases.

RESULTS

A total of 24 EDs were studied. The annual ED volume before the COVID-19 pandemic ranged from 13 000 to 115 000 visits per year; the decrease in ED visits ranged from 41.5% in Colorado to 63.5% in New York. The weeks with the most rapid rates of decrease in visits were in March 2020, which corresponded with national public health messaging about COVID-19. Hospital admission rates from the ED were stable until new COVID-19 case rates began to increase locally; the largest relative increase in admission rates was 149.0% in New York, followed by 51.7% in Massachusetts, 36.2% in Connecticut, 29.4% in Colorado, and 22.0% in North Carolina.

CONCLUSIONS AND RELEVANCE

From January through April 2020, as the COVID-19 pandemic intensified in the US, temporal associations were observed with a decrease in ED visits and an increase in hospital admission rates in 5 health care systems in 5 states. These findings suggest that practitioners and public health officials should emphasize the importance of visiting the ED during the COVID-19 pandemic for serious symptoms, illnesses, and injuries that cannot be managed in other settings.

Pediatric Ice Pop Administration to Improve Patient Experience Scores

OBJECTIVE

To assess the impact on patient experience scores of giving an ice pop (Popsicle, Good Humor-Breyers, Oakland, CA) to patients in a pediatric emergency department (ED).

PATIENTS AND METHODS

A prospective two-center trial was conducted at a tertiary academic pediatric ED and a community ED from January 1, 2018, through March 31, 2018. The intervention arm gave an ice pop to all eligible patients 0 to 14 years of age on even-numbered days versus conventional practice on odd-numbered days. Press Ganey top box scores were then compared.

RESULTS

Of 4574 pediatric (0 to 14 years of age) patient visits, patient experience surveys were delivered to 1346 families (29.4%) and 152 were returned (11.3%). Eighty-four surveys were returned for even-numbered day visits and 68 for odd-numbered day visits. There was a significant increase in patient experience scores associated with ice pop administration days for questions that asked about doctor's concern for comfort 70.2% versus 57.4% (P=.05), doctor's courtesy 76.2% versus 61.8% (P=.04), and doctor taking time to listen 72.6% versus 57.4% (P=.03).

CONCLUSION

A low-cost intervention resulted in significantly increased patient experience scores in select domains. Popsicle administration was a simple intervention which was easily instituted in both academic and community ED settings. Further study should explore the durability of the effect.

Patient Length of Stay Under the Two-Midnight Rule: Assessing the Accuracy of Providers' Predictions

EXECUTIVE SUMMARY

We sought to determine emergency medicine physicians' accuracy in designating patients' disposition status as "inpatient" or "observation" at the time of hospital admission in the context of Medicare's Two-Midnight rule and to identify characteristics that may improve the providers' predictions. We conducted a 90-day observational study of emergency department (ED) admissions involving adults aged 65 years and older and assessed the accuracy of physicians' disposition decisions. Logistic regression models were fit to explore associations and predictors of disposition. A total of 2,257 patients 65 and older were admitted through the ED. The overall error rate in physician designation of observation or inpatient was 36%. Diagnoses most strongly associated with stays lasting less than two midnights included diverticulitis, syncope, and nonspecific chest pain. Diagnoses most strongly associated with stays lasting two or more midnights included orthopedic fractures, biliary tract disease, and back pain. ED physicians inaccurately predicted patient length of stay in more than one third of all patients. Under the Two-Midnight rule, these inaccurate predictions place hospitals at risk of underpayment and patients at risk of significant financial liability. Further work is needed to increase providers' awareness of the financial repercussions of their admission designations and to identify interventions that can improve prediction accuracy.

Increasing Allergy-Related Emergency Department Visits in the United States, 2007 to 2015

BACKGROUND

Allergic reactions, angioedema, and anaphylaxis are commonly treated in the emergency department (ED). Contemporary evidence suggests that these conditions may be increasing in the United States.

OBJECTIVE

To evaluate the contemporary epidemiology and trends of ED visits for allergic reactions, angioedema, and anaphylaxis in the United States from 2007 to 2015.

METHODS

Using de-identified data from the National Hospital Ambulatory Medical Care Survey from 2007 to 2015, we identified cases of acute allergic reactions, angioedema, and anaphylaxis through International Classification of Diseases, 9th Revision, Clinical Modification codes and conducted a retrospective analysis of rates and trends of these allergy-related ED visits.

RESULTS

There was a 14% overall increase in allergy-related ED visits between 2007 and 2015. Approximately 10 million ED visits in this time frame were associated with allergy-related conditions accounting for 0.85% (95% CI, 0.79-0.90) of all ED visits in the United States. Almost 3% of allergy-related ED visits were coded as anaphylaxis of which 46.1% (95% CI, 27.5-64.6) received epinephrine. Patients younger than 10 years had a higher relative risk (1.3; 95% CI, 1.0-1.6; P = .027) of allergy-related ED visits per 1000 ED visits than patients 65 years and older, and women also had a higher relative risk (1.4; 95% CI, 1.2-1.5; P < .001) than men.

CONCLUSIONS

Allergy-related ED visits increased 14% from 2007 to 2015, with the highest relative risk occurring in patients younger than 10 years. These data provide further evidence of increasing allergic conditions in the United States.

Non-pharmacologic interventions improve comfort and experience among older adults in the Emergency Department

OBJECTIVE

Determine if a comfort cart would improve older adults' comfort and facilitate communication during Emergency Department (ED) visits.

METHODS

A comfort cart containing low-cost, non-pharmacological interventions to improve patient comfort and ability to communicate (e.g., hearing amplifiers, reading glasses) were made available to patients aged ≥65 years. Patients and clinicians were surveyed to assess effectiveness. We followed the Standards for Quality Improvement Reporting Excellence: SQUIRE 2.0 guidelines.

RESULTS

Three hundred patients and 100 providers were surveyed. Among patients, 98.0%, 95.1%, and 67.5% somewhat or strongly agreed that the comfort cart improved comfort, overall experience, and independence, respectively. Among providers, 97.0%, 95.0%, 87.0%, and 83% somewhat or strongly agreed that the comfort cart provided comfort, improved patient satisfaction, increased ability to give compassionate care, and increased patient orientation.

CONCLUSION

The comfort cart was an affordable and effective intervention that improved patients' comfort by facilitating communication, wellbeing, and compassionate care delivery.

Validation of the Elderly Risk Assessment Index in the Emergency Department

OBJECTIVES

The Elderly Risk Assessment (ERA) score is a validated index for primary care patients that predict hospitalizations, mortality, and Emergency Department (ED) visits. The score incorporates age, prior hospital days, marital status, and comorbidities. Our aim was to validate the ERA score in ED patients.

METHODS

Observational cohort study of patients age ≥ 60 presenting to an academic ED over a 1-year period. Regression analyses were performed for associations with outcomes (hospitalization, return visits and death). Medians, interquartile range (IQR), odds ratios (OR) and 95% confidence intervals (CI) were calculated.

RESULTS

The cohort included 27,397 visits among 18,607 patients. Median age 74 years (66-82), 48% were female and 59% were married. Patients from 54% of visits were admitted to the hospital, 16% returned to the ED within 30 days, and 18% died within one year. Higher ERA scores were associated with: hospital admission (score 10 [4-16] vs 5 [1-11], p < 0.0001), return visits (11 [5-17] vs 7 [2-13], p < 0.0001); and death within one year (14 [7-20] vs 6 [2-13], p < 0.0001). Patients with ERA score ≥ 16 were more likely to be admitted to the hospital, OR 2.14 (2.02-2.28, p < 0.0001), return within 30 days OR 1.99 (1.85-2.14), and to die within a year, OR 2.69 (2.54-2.85).

CONCLUSION

The ERA score can be automatically calculated within the electronic health record and helps identify patients at increased risk of death, hospitalization and return ED visits. The ERA score can be applied to ED patients, and may help prognosticate the need for advanced care planning.

Validation of the Elderly Risk Assessment Index in the Emergency Department

OBJECTIVES

The Elderly Risk Assessment (ERA) score is a validated index for primary care patients that predict hospitalizations, mortality, and Emergency Department (ED) visits. The score incorporates age, prior hospital days, marital status, and comorbidities. Our aim was to validate the ERA score in ED patients.

METHODS

Observational cohort study of patients age ≥ 60 presenting to an academic ED over a 1-year period. Regression analyses were performed for associations with outcomes (hospitalization, return visits and death). Medians, interquartile range (IQR), odds ratios (OR) and 95% confidence intervals (CI) were calculated.

RESULTS

The cohort included 27,397 visits among 18,607 patients. Median age 74 years (66-82), 48% were female and 59% were married. Patients from 54% of visits were admitted to the hospital, 16% returned to the ED within 30 days, and 18% died within one year. Higher ERA scores were associated with: hospital admission (score 10 [4-16] vs 5 [1-11], p < 0.0001), return visits (11 [5-17] vs 7 [2-13], p < 0.0001); and death within one year (14 [7-20] vs 6 [2-13], p < 0.0001). Patients with ERA score ≥ 16 were more likely to be admitted to the hospital, OR 2.14 (2.02-2.28, p < 0.0001), return within 30 days OR 1.99 (1.85-2.14), and to die within a year, OR 2.69 (2.54-2.85).

CONCLUSION

The ERA score can be automatically calculated within the electronic health record and helps identify patients at increased risk of death, hospitalization and return ED visits. The ERA score can be applied to ED patients, and may help prognosticate the need for advanced care planning.

Identifying Opioid Use Disorder in the Emergency Department: Multi-System Electronic Health Record-Based Computable Phenotype Derivation and Validation Study

BACKGROUND

Deploying accurate computable phenotypes in pragmatic trials requires a trade-off between precise and clinically sensical variable selection. In particular, evaluating the medical encounter to assess a pattern leading to clinically significant impairment or distress indicative of disease is a difficult modeling challenge for the emergency department.

OBJECTIVE

This study aimed to derive and validate an electronic health record-based computable phenotype to identify emergency department patients with opioid use disorder using physician chart review as a reference standard.

METHODS

A two-algorithm computable phenotype was developed and evaluated using structured clinical data across 13 emergency departments in two large health care systems. Algorithm 1 combined clinician and billing codes. Algorithm 2 used chief complaint structured data suggestive of opioid use disorder. To evaluate the algorithms in both internal and external validation phases, two emergency medicine physicians, with a third acting as adjudicator, reviewed a pragmatic sample of 231 charts: 125 internal validation (75 positive and 50 negative), 106 external validation (56 positive and 50 negative).

RESULTS

Cohen kappa, measuring agreement between reviewers, for the internal and external validation cohorts was 0.95 and 0.93, respectively. In the internal validation phase, Algorithm 1 had a positive predictive value (PPV) of 0.96 (95% CI 0.863-0.995) and a negative predictive value (NPV) of 0.98 (95% CI 0.893-0.999), and Algorithm 2 had a PPV of 0.8 (95% CI 0.593-0.932) and an NPV of 1.0 (one-sided 97.5% CI 0.863-1). In the external validation phase, the phenotype had a PPV of 0.95 (95% CI 0.851-0.989) and an NPV of 0.92 (95% CI 0.807-0.978).

CONCLUSIONS

This phenotype detected emergency department patients with opioid use disorder with high predictive values and reliability. Its algorithms were transportable across health care systems and have potential value for both clinical and research purposes.

Survival outcomes for patients with surgically induced end-stage renal disease

INTRODUCTION

While medically induced end-stage renal disease (m-ESRD) has been well-studied, outcomes in patients with surgically induced ESRD (s-ESRD) are unknown. We sought to quantitatively compare the non-oncological outcomes for s-ESRD and m-ESRD in a large, population-based cohort.

METHODS

Medicare patients >65 years old initiating hemodialysis were identified using the U.S. Renal Data System database (2000-2012). Metastatic cancer, prior transplant history, and nephrectomy for polycystic kidney disease were exclusion criteria. Patients were classified as having s-ESRD or m-ESRD based on hospital and physician claims for nephrectomy within a year preceding the onset of maintenance hemodialysis. Outcomes included non-cancer mortality (NCM), overall survival (OS), cardiovascular event (CVE), and renal transplantation. Time-to-event analyses were performed using Kaplan-Meier and cumulative incidence curves, and multivariable Cox and Fine-and-Grey regression models.

RESULTS

The cohort included 312 612 patients, of whom 1648 (0.53%) had s-ESRD. Compared to m-ESRD patients, s-ESRD patients had a significantly lower five-year cumulative incidence of NCM (68% vs. 80%; p<0.001) and CVE (62% vs. 68%; p<0.001), with a correspondingly higher probability of OS (22% vs. 17%; p<0.001) and rate of renal transplantation (3.6% vs. 2.0%; p<0.001). On multivariable analyses, s-ESRD remained associated with lower risks of NCM (p<0.001) and CVE (p<0.001), improved OS (p<0.001), and higher chance of renal transplantation (p<0.001).

CONCLUSIONS

While outcomes for s-ESRD appear more favorable than m-ESRD, s-ESRD is still associated with a substantial risk of NCM and CVE, and a low incidence of renal transplantation in Medicare patients >65 years old. These non-oncological outcomes are worth considering in patients potentially facing postoperative ESRD.

Rates of Physician Coprescribing of Opioids and Benzodiazepines After the Release of the Centers for Disease Control and Prevention Guidelines in 2016

IMPORTANCE

The Centers for Disease Control and Prevention guidelines in 2016 recommended avoiding concurrent use of opioids and benzodiazepines.

OBJECTIVE

To determine whether the release of the guidelines was associated with changes in coprescription of opioids and benzodiazepines.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used claims data obtained from a US national database of medical and pharmacy claims for 3 598 322 adult commercially insured patients and 1 299 142 Medicare Advantage (MA) beneficiaries with no recent history of cancer, sickle cell disease, or hospice care who ever used prescribed opioids during the study period, January 1, 2014, through March 31, 2018.

EXPOSURES

Overlapping opioid and benzodiazepine prescriptions filled.

MAIN OUTCOMES AND MEASURES

The extent (proportion of person-months with any overlapping days of prescription of opioids and benzodiazepines) and intensity (proportion of days with opioids prescribed where benzodiazepines were also available) of coprescription.

RESULTS

Of 4 897 464 patients (with 13.4 million person-months of opioid use), the total number of unique commercially insured individuals was 3 598 322 (1 974 731 women [54.9%]), and the total number of unique MA beneficiaries was 1 299 142 (770 256 women [59.3%]). Among 128 576 participants experiencing chronic pain episodes, more than one-half of person-months of long-term opioid use occurred in women (52.7% of person-months among those with commercial insurance and 62.4% of person-months among MA beneficiaries). The median (interquartile range) age of the participants was 51 (41-58) years for patients in the commercial insurance group and 70 (61-77) years for those in the MA group. The mean (SE) extent of coprescription was 23.0% (0.18%) for the commercial insurance group and 25.7% (0.18%) for the MA group. The extent of coprescription decreased in the targeted guideline population-individuals with long-term opioid use-after the guideline release (postguideline slope, -0.95 percentages point per year [95% CI, -1.44 to -0.46 percentage points per year] for the commercial insurance group and -1.06 percentage points per year [95% CI, -1.49 to -0.63 percentage points per year] for the MA group). Nontargeted short-term episodes of opioid use were associated with no change or small declines in trend (for the MA group, postguideline slope of 0.47 percentage point per year [95% CI, 0.35-0.59 percentage point per year]; for the commercial insurance group, postguideline slope of -0.05 percentage point per year [95% CI, -0.12 to 0.02 percentage point per year]). High coprescribing intensity was seen, with 79.3% (95% CI, 78.9%-79.6%) of opioid prescription days in the commercial insurance group and 83.9% (95% CI, 83.7%-84.2%) in the MA group overlapping with benzodiazepines. There was no change in the intensity of coprescribing. Intensity of coprescription was higher when the same clinician prescribed opioids and benzodiazepines.

CONCLUSION AND RELEVANCE

This study observed a reduction in the extent but not intensity of coprescribing of benzodiazepines for patients with long-term opioid use.

Chronic use of tramadol after acute pain episode: cohort study

OBJECTIVE

To determine the risk of prolonged opioid use in patients receiving tramadol compared with other short acting opioids.

DESIGN

Observational study of administrative claims data.

SETTING

United States commercial and Medicare Advantage insurance claims (OptumLabs Data Warehouse) January 1, 2009 through June 30, 2018.

PARTICIPANTS

Opioid-naive patients undergoing elective surgery.

MAIN OUTCOME MEASURE

Risk of persistent opioid use after discharge for patients treated with tramadol alone compared with other short acting opioids, using three commonly used definitions of prolonged opioid use from the literature: additional opioid use (defined as at least one opioid fill 90-180 days after surgery); persistent opioid use (any span of opioid use starting in the 180 days after surgery and lasting ≥90 days); and CONSORT definition (an opioid use episode starting in the 180 days after surgery that spans ≥90 days and includes either ≥10 opioid fills or ≥120 days' supply of opioids).

RESULTS

Of 444 764 patients who met the inclusion criteria, 357 884 filled a discharge prescription for one or more opioids associated with one of 20 included operations. The most commonly prescribed post-surgery opioid was hydrocodone (53.0% of those filling a single opioid), followed by short acting oxycodone (37.5%) and tramadol (4.0%). The unadjusted risk of prolonged opioid use after surgery was 7.1% (n=31 431) with additional opioid use, 1.0% (n=4457) with persistent opioid use, and 0.5% (n=2027) meeting the CONSORT definition. Receipt of tramadol alone was associated with a 6% increase in the risk of additional opioid use relative to people receiving other short acting opioids (incidence rate ratio 95% confidence interval 1.00 to 1.13; risk difference 0.5 percentage points; P=0.049), 47% increase in the adjusted risk of persistent opioid use (1.25 to 1.69; 0.5 percentage points; P<0.001), and 41% increase in the adjusted risk of a CONSORT chronic opioid use episode (1.08 to 1.75; 0.2 percentage points; P=0.013).

CONCLUSIONS

People receiving tramadol alone after surgery had similar to somewhat higher risks of prolonged opioid use compared with those receiving other short acting opioids. Federal governing bodies should consider reclassifying tramadol, and providers should use as much caution when prescribing tramadol in the setting of acute pain as for other short acting opioids.

Computerized Clinical Decision Support System for Emergency Department-Initiated Buprenorphine for Opioid Use Disorder: User-Centered Design

BACKGROUND

Emergency departments (EDs) frequently care for individuals with opioid use disorder (OUD). Buprenorphine (BUP) is an effective treatment option for patients with OUD that can safely be initiated in the ED. At present, BUP is rarely initiated as a part of routine ED care. Clinical decision support (CDS) could accelerate adoption of ED-initiated BUP into routine emergency care.

OBJECTIVE

This study aimed to design and formatively evaluate a user-centered decision support tool for ED initiation of BUP for patients with OUD.

METHODS

User-centered design with iterative prototype development was used. Initial observations and interviews identified workflows and information needs. The design team and key stakeholders reviewed prototype designs to ensure accuracy. A total of 5 prototypes were evaluated and iteratively refined based on input from 26 attending and resident physicians.

RESULTS

Early feedback identified concerns with the initial CDS design: an alert with several screens. The timing of the alert led to quick dismissal without using the tool. User feedback on subsequent iterations informed the development of a flexible tool to support clinicians with varied levels of experience with the intervention by providing both one-click options for direct activation of care pathways and user-activated support for critical decision points. The final design resolved challenging navigation issues through targeted placement, color, and design of the decision support modules and care pathways. In final testing, users expressed that the tool could be easily learned without training and was reasonable for use during routine emergency care.

CONCLUSIONS

A user-centered design process helped designers to better understand users' needs for a Web-based clinical decision tool to support ED initiation of BUP for OUD. The process identified varying needs across user experience and familiarity with the protocol, leading to a flexible design supporting both direct care pathways and user-initiated decision support.

Pediatric emergency medical services in privately insured patients: A 10-year national claims analysis

OBJECTIVE

To characterize pediatric Emergency Medicine Service (EMS) transports to the Emergency Department (ED) using a national claims database.

METHODS

We included children, 18 years and younger, transported by EMS to an ED, from 2007 to 2016 in the OptumLabs Data Warehouse. ICD-9 and ICD-10 diagnosis codes were used to categorize disease system involvement. Interventions performed were extracted using procedure codes. ED visit severity was measured by the Minnesota Algorithm.

RESULTS

Over a 10-year period, 239,243 children were transported. Trauma was the most frequent diagnosis category for transport for children ≥5 years of age, 35.1% (age 6-13) and 32.7% (age 14-18). The most common diagnosis category in children <6 years of age was neurologic (29.3%), followed by respiratory (23.1%). Over 10 years, transports for mental disorders represented 15.3% in children age 14 to 18, and had the greatest absolute increase (rate difference + 10.4 per 10,000) across all diagnoses categories. Neurologic transports also significantly increased in children age 14 to 18 (rate difference + 6.9 per 10,000). Trauma rates decreased across all age groups and had its greatest reduction among children age 14 to 18 (rate difference - 6.8 per 10,000). Across all age groups, an intervention was performed in 15.6%. Most children (83.3%) were deemed to have ED care needed type of visit, and 15.8% of the transports resulted in a hospital admission.

CONCLUSION

Trauma is the most frequent diagnosis for transport in children older than 5 years of age. Mental health and neurologic transports have markedly increased, while trauma transports have decreased. Most children arriving by ambulance were classified as requiring ED level of care. These changes might have significant implication for EMS personnel and policy makers.

Risk Factors Associated With Health Care Utilization and Costs of Patients Undergoing Lower Extremity Joint Replacement

BACKGROUND

The Comprehensive Care for Joint Replacement program implemented by the Centers for Medicare and Medicaid Services did not incorporate risk adjustment for lower extremity joint replacement (LEJR). Lack of adjustment places hospitals at financial risk and creates incentives for adverse patient selection.

OBJECTIVE

To identify patient-level risk factors associated with health care utilization and costs of patients undergoing LEJR.

METHODS

A comprehensive search of research databases from January 1, 1990, through January 31, 2016, was conducted. The databases included Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and SCOPUS and is reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The search identified 2020 studies. Eligible studies focused on primary unilateral and bilateral LEJR. Independent reviewers determined study eligibility and extracted utilization and cost data.

RESULTS

Seventy-nine of 330 studies (24%) were included and were abstracted for analysis. Comorbidities, age, disease severity, and obesity were associated with increased costs. Increased number of comorbidities and age, presence of specific comorbidities, lower socioeconomic status, and female sex had evidence of increased length of stay. We found no significant association between indication for surgery and the likelihood of readmission.

CONCLUSION

Developing a risk adjustment model for LEJR that incorporates clinical variables may serve to reduce the likelihood of adverse patient selection and enhance appropriate reimbursement aligned with procedural complexity.

Access to primary care and computed tomography use in the emergency department

Background

The decision to obtain a computed tomography CT scan in the emergency department (ED) is complex, including a consideration of the risk posed by the test itself weighed against the importance of obtaining the result. In patients with limited access to primary care follow up the consequences of not making a diagnosis may be greater than for patients with ready access to primary care, impacting diagnostic reasoning. We set out to determine if there is an association between CT utilization in the ED and patient access to primary care.

Methods

We performed a cross-sectional study of all ED visits in which a CT scan was obtained between 2003 and 2012 at an academic, tertiary-care center. Data were abstracted from the electronic medical record and administrative databases and included type of CT obtained, demographics, comorbidities, and access to a local primary care provider (PCP). CT utilization rates were determined per 1000 patients.

Results

A total of 595,895 ED visits, including 98,001 visits in which a CT was obtained (16.4%) were included. Patients with an assigned PCP accounted for 55% of all visits. Overall, CT use per 1000 ED visits increased from 142.0 in 2003 to 169.2 in 2012 (p < 0.001), while the number of annual ED visits remained stable. CT use per 1000 ED visits increased from 169.4 to 205.8 over the 10-year period for patients without a PCP and from 118.9 to 142.0 for patients with a PCP. Patients without a PCP were more likely to have a CT performed compared to those with a PCP (OR 1.57, 95%CI 1.54 to 1.58; p < 0.001). After adjusting for age, gender, year of visit and number of comorbidities, patients without a PCP were more likely to have a CT performed (OR 1.20, 95% CI 1.18 to 1.21, p < 0.001).

Conclusions

The overall rate of CT utilization in the ED increased over the past 10 years. CT utilization was significantly higher among patients without a PCP. Increased availability of primary care, particularly for follow-up from the ED, could reduce CT utilization and therefore decrease costs, ED lengths of stay, and radiation exposure.

Care of the dialysis patient: Primary provider involvement and resource utilization patterns - a cohort study

Background

Efficient and safe delivery of care to dialysis patients is essential. Concerns have been raised regarding the ability of accountable care organizations to adequately serve this high-risk population. Little is known about primary care involvement in the care of dialysis patients. This study sought to describe the extent of primary care provider (PCP) involvement in the care of hemodialysis patients and the outcomes associated with that involvement.

Methods

In a retrospective cohort study, patients accessing a Midwestern dialysis network from 2001 to 2010 linked to United States Renal Database System and with >90 days follow up were identified (n = 2985). Outpatient visits were identified using Current Procedural Terminology (CPT)-4 codes, provider specialty, and grouped into quartiles-based on proportion of PCP visits per person-year (ppy). Top and bottom quartiles represented patients with high primary care (HPC) or low primary care (LPC), respectively. Patient characteristics and health care utilization were measured and compared across patient groups.

Results

Dialysis patients had an overall average of 4.5 PCP visits ppy, ranging from 0.6 in the LPC group to 6.9 in the HPC group. HPC patients were more likely female (43.4% vs. 35.3%), older (64.0 yrs. vs. 60.0 yrs), and with more comorbidities (Charlson 7.0 vs 6.0). HPC patients had higher utilization (hospitalizations 2.2 vs. 1.8 ppy; emergency department visits 1.6 vs 1.2 ppy) and worse survival (3.9 vs 4.3 yrs) and transplant rates (16.3 vs. 31.5).

Conclusions

PCPs are significantly involved in the care of hemodialysis patients. Patients with HPC are older, sicker, and utilize more resources than those managed primarily by nephrologists. After adjusting for confounders, there is no difference in outcomes between the groups. Further studies are needed to better understand whether there is causal impact of primary care involvement on patient survival.

Electronic supplementary material

The online version of this article (10.1186/s12882-017-0728-x) contains supplementary material, which is available to authorized users.