Demographics and Outcomes of Pulmonary Hypertension Patients in United States Emergency Departments

Introduction: Pulmonary hypertension (PH) is a common, yet under-diagnosed, contributor to morbidity and mortality. Our objective was to characterize the prevalence of PH among adult patients presenting to United States (US) emergency departments (ED) and to identify demographic patterns and outcomes of PH patients in the ED.Methods: We analyzed the Nationwide Emergency Department Sample (NEDS) database, with a focus on ED patients aged 18 years and older, with any International Classification of Diseases, Clinical Modification (ICD)-9-CM or ICD-10-CM diagnosis code for PH from 2011 to 2015. The primary outcome was inpatient, all-cause mortality. The secondary outcomes were hospital admission rates and hospital length of stay (LOS).Results: From 2011 to 2015, in a sample of 121,503,743 ED visits, representing a weighted estimate of 545,500,486 US ED visits, patients with a diagnosis of PH accounted for 0.78% (95% confidence interval [CI], 0.75- 0.80%) of all US ED visits. Of the PH visits, 86.9% were admitted to the hospital, compared to 16.3% for all other ED visits (P <0.001). Likewise, hospital LOS and hospital-based mortality were higher in the PH group than for other ED patients (e.g., inpatient mortality 4.5% vs 2.6%, P < 0.001) with an adjusted odds ratio (aOR) of 1.34 (95% CI, 1.31–1.37). Age had the strongest association with mortality, with an aOR of 10.6 for PH patients over 80 years (95% CI, 10.06–11.22), compared to a reference of ages 18 to 30 years.Conclusion: In this nationally representative sample, presentations by patients with PH were relatively common, accounting for nearly 0.8% of US ED visits. Patients with PH were significantly more likely to be admitted to the hospital than all other patients, had longer hospital LOS, and increased risk of inpatient mortality

Latitude, Sunlight, Vitamin D, and Childhood Food Allergy/Anaphylaxis

Vitamin D is widely known for its role in bone metabolism, but this sterol hormone also has important immunomodulatory properties. Vitamin D is produced by the conversion of D3 in the skin following UVB exposure, or after ingestion of D2 or D3. At the extremes of latitude, there is insufficient UVB intensity in the autumn and winter months for adequate synthesis of vitamin D to occur. Growing evidence implicates vitamin D deficiency in early life in the pathogenesis of nonskeletal disorders (e. g., type 1 diabetes and multiple sclerosis) and, more recently, atopic disorders. Several studies have reported higher rates of food allergy/anaphylaxis or proxy measures at higher absolute latitudes. Although causality remains to be determined, these studies suggest a possible role for sunlight and/or vitamin D in the pathogenesis of food allergy/anaphylaxis

What is a Freestanding Emergency Department? Definitions Differ Across Major United States Data Sources

Introduction: Despite the growing number of freestanding emergency departments (FSED) in the United States (US), FSED definitions differ across major US data sources of healthcare facilities and use. We compare these sources and propose a universal definition of FSED (and its two major types) to improve communications regarding these facilities and their patients.Methods: We collected definitions of FSEDs from 11 national data sources using their websites, email, and telephone communications. For each source, we asked how they define FSEDs, whether being open 24/7 is a requirement to be called an ED, and whether they maintain a dataset of FSEDs.Results: Definitions varied across the data sources. All sources recognize FSEDs in their definitions, regardless of type; only one (the National Health Intervew Survey) does not differentiate them from other EDs. Five of the 11 sources (45%) omit autonomous FSEDs from their definitions and do not separately identify satellite FSEDs from their affiliated hospitals. One source does separately identify satellite FSEDs from their affiliated hospitals, but also omits autonomous FSEDs. Furthermore, three of the 11 sources (27%) do not require being open 24/7, while all others (73%) employ this criterion. Six of the 11 (55%) maintain datasets of FSEDs using their definition.Conclusion: As FSEDs continue to change the landscape of emergency care, it is important that they also be represented in national ED data sources. The current differences in the definition of an FSED make it difficult to provide accurate and longitudinal analysis for these facilities and patients who receive services at these facilities. We propose a universal definition of FSEDs as described by both the American College of Emergency Physicians and the National Emergency Department Inventory. Implementing a standard definition would facilitate a more accurate representation of FSEDs in national data sources and enhance ongoing efforts to improve the quality of emergency care delivered in FSEDs

Near-universal hospitalization of US emergency department patients with cancer and febrile neutropenia

IMPORTANCE: Febrile neutropenia (FN) is the most common oncologic emergency and is among the most deadly. Guidelines recommend risk stratification and outpatient management of both pediatric and adult FN patients deemed to be at low risk of complications or mortality, but our prior single-center research demonstrated that the vast majority (95%) are hospitalized. OBJECTIVE: From a nationwide perspective, to determine the proportion of cancer patients of all ages hospitalized after an emergency department (ED) visit for FN, and to analyze variability in hospitalization rates. Our a priori hypothesis was that >90% of US cancer-associated ED FN visits would end in hospitalization. DESIGN: Analysis of data from the Nationwide Emergency Department Sample, 2006-2014. SETTING: Stratified probability sample of all US ED visits. PARTICIPANTS: Inclusion criteria were: (1) Clinical Classification Software code indicating cancer, (2) diagnostic code indicating fever, and (3) diagnostic code indicating neutropenia. We excluded visits ending in transfer. EXPOSURE: The hospital at which the visit took place. MAIN OUTCOMES AND MEASURES: Our main outcome is the proportion of ED FN visits ending in hospitalization, with an a priori hypothesis of >90%. Our secondary outcomes are: (a) hospitalization rates among subsets, and (b) proportion of variability in the hospitalization rate attributable to which hospital the patient visited, as measured by the intra-class correlation coefficient (ICC). RESULTS: Of 348,868 visits selected to be representative of all US ED visits, 94% ended in hospitalization (95% Confidence Interval [CI] 93-94%). Each additional decade of age conferred 1.23x increased odds of hospitalization. Those with private (92%), self-pay (92%), and other (93%) insurance were less likely to be hospitalized than those with public insurance (95%, odds ratios [OR] 0.74-0.76). Hospitalization was least likely at non-metropolitan hospitals (84%, OR 0.15 relative to metropolitan teaching hospitals), and was also less likely at metropolitan non-teaching hospitals (94%, OR 0.64 relative to metropolitan teaching hospitals). The ICC adjusted for hospital random effects and patient and hospital characteristics was 26% (95%CI 23-29%), indicating that 26% of the variability in hospitalization rate was attributable to which hospital the patient visited. CONCLUSIONS AND RELEVANCE: Nearly all cancer-associated ED FN visits in the US end in hospitalization. Inter-hospital variation in hospitalization practices explains 26% of the limited variability in hospitalization decisions. Simple, objective tools are needed to improve risk stratification for ED FN patients

Regional variation in epinephrine autoinjector prescriptions in Australia: more evidence for the vitamin D-anaphylaxis hypothesis

Background: There is little information on the regional distribution of anaphylaxis in Australia. Objective: To examine the influence of latitude (a marker of sunlight/vitamin D status) as a contributor to anaphylaxis in Australia, with a focus on children from birth to the age of 4 years. Methods: Epinephrine autoinjector (EpiPen) prescriptions (2006 -2007) in 59 statistical divisions and anaphylaxis hospital admission rates (2002-2007) in 10 regions were used as surrogate markers of anaphylaxis. Results: EpiPen prescription rates (per 100,000 population per year) were higher in children from birth to the age of 4 years (mean, 951) than in the overall population (mean, 324). In an unadjusted model of children from birth to the age of 4 years, decreasing absolute latitude was associated with a decrease in EpiPen prescription rates, such that rates were higher in southern compared with northern regions of Australia (β, -44.4; 95% confidence interval, -57.0 to -31.8; P < .001). Adjusting for age, sex, ethnicity, indexes of affluence, education, or access to medical care (general, specialist allergy, or pediatric) did not attenuate the finding (β, -51.9; 95% confidence interval, -71.0 to -32.9; P < .001). Although statistical power was limited, anaphylaxis admission rates (most prominent in children aged 0-4 years) showed a similar south-north gradient, such that admission rates were higher in southern compared with northern regions of Australia. Conclusions: EpiPen prescription rates and anaphylaxis admissions are more common in southern regions of Australia. These data provide additional support for a possible role of vitamin D in the pathogenesis of anaphylaxis

Detecting and Intervening on Suicidality in Emergency Departments: The ED-SAFE Study [English and Spanish versions]

A Spanish translation of this publication is available to download under Additional Files. In 2016, there were 44,695 deaths by suicide in the United States. Suicide accounts for 1.6% of all deaths and is the tenth leading cause of death in the United States. Suicide attempts are much more common, with more than 1 million people per year attempting suicide. In response to this critical need in 2009, the National Institute for Mental Health funded ED Safety Assessment and Follow-up Evaluation (ED-SAFE). ED-SAFE was a large, three-phase suicide intervention trial designed to determine if an ED-initiated intervention could reduce subsequent suicidal behavior. Read more about the how the ED-SAFE study developed and tested a feasible approach to universal emergency department-based screening for suicide risk, as well as effective interventions that can be initiated at the emergency department visit

Vitamin D Status and Community-Acquired Pneumonia: Results from the Third National Health and Nutrition Examination Survey

Objective: To investigate the association between serum 25-hydroxyvitamin D [25(OH)D] level and history of community-acquired pneumonia (CAP). Patients and Methods We identified 16,975 individuals (≥17 years) from the third National Health and Nutrition Examination Survey (NHANES III) with documented 25(OH)D levels. To investigate the association of 25(OH)D with history of CAP in these participants, we developed a multivariable logistic regression model, adjusting for demographic factors (age, sex, race, poverty-to-income ratio, and geographic location), clinical data (body mass index, smoking status, asthma, chronic obstructive pulmonary disease, congestive heart failure, diabetes mellitus, stroke, chronic kidney disease, neutropenia, and alcohol consumption), and season. Locally weighted scatterplot smoothing (LOWESS) was used to depict the relationship between increasing 25(OH)D levels and the cumulative frequency of CAP in the study cohort. Results: The median [interquartile range (IQR)] serum 25(OH)D level was 24 (IQR 18–32) ng/mL. 2.1% [95% confidence interval (CI): 1.9–2.3] of participants reported experiencing a CAP within one year of their participation in the national survey. After adjusting for demographic factors, clinical data, and season, 25(OH)D levels <30 ng/mL were associated with 56% higher odds of CAP [odds ratio 1.56; 95% confidence interval: 1.17–2.07] compared to levels ≥30 ng/mL. LOWESS analysis revealed a near linear relationship between vitamin D status and the cumulative frequency of CAP up to 25(OH)D levels around 30 ng/mL. Conclusion: Among 16,975 participants in NHANES III, 25(OH)D levels were inversely associated with history of CAP. Randomized controlled trials are warranted to determine the effect of optimizing vitamin D status on the risk of CAP

Emergency department visits for acute asthma by adults who ran out of their inhaled medications

This study was designed to determine the percentage of asthma-related emergency department (ED) visits made by patients who recently ran out of their inhaled short-acting beta-agonists or inhaled corticosteroids and to characterize this understudied patient population. A secondary analysis was performed of data from four ED-based multicenter studies of acute asthma during 1996–1998 (n = 64 EDs). In each study, consecutive adult patients, aged 18–54 years, with acute asthma underwent a structured interview that assessed running out of inhaled medications. The analytic cohort comprised 1095 adults. Overall, 324 patients (30%; 95% confidence interval [CI], 27–32%) ran out of either of their inhaled beta-agonists or inhaled corticosteroids during the week before their index ED visit; 311 (28%; 95% CI, 26–31%) ran out of inhaled beta-agonists per se. Among a subset of 518 patients on inhaled corticosteroids, 55 patients (11%; 95% CI, 8–14%) ran out of inhaled corticosteroids. In the multivariable model, predictors of running out of an asthma medication were male sex, non-Hispanic black race, Hispanic ethnicity, no insurance, lower household income, and use of EDs as the preferred source of asthma prescriptions (all p < 0.05). Among patients who ran out of medications, 49% (95% CI, 43–55%) ran out of inhaled beta-agonists and 72% (95% CI, 58–84%) ran out of inhaled corticosteroids, before onset of their acute asthma symptoms. In 1095 adult ED patients with acute asthma, we found that 30% ran out of their inhaled asthma medications before the ED visit. Asthma patients who ran out of medications had sociodemographic characteristics that may help with identification of preventable ED visits. Multifaceted strategies needed to ensure optimal use of inhaled medications are warranted

Validation of ICD-9-CM coding algorithm for improved identification of hypoglycemia visits

<p>Abstract</p> <p>Background</p> <p>Accurate identification of hypoglycemia cases by <it>International Classification of Diseases, Ninth Revision, Clinical Modification </it>(ICD-9-CM) codes will help to describe epidemiology, monitor trends, and propose interventions for this important complication in patients with diabetes. Prior hypoglycemia studies utilized incomplete search strategies and may be methodologically flawed. We sought to validate a new ICD-9-CM coding algorithm for accurate identification of hypoglycemia visits.</p> <p>Methods</p> <p>This was a multicenter, retrospective cohort study using a structured medical record review at three academic emergency departments from July 1, 2005 to June 30, 2006. We prospectively derived a coding algorithm to identify hypoglycemia visits using ICD-9-CM codes (250.3, 250.8, 251.0, 251.1, 251.2, 270.3, 775.0, 775.6, and 962.3). We confirmed hypoglycemia cases by chart review identified by candidate ICD-9-CM codes during the study period. The case definition for hypoglycemia was documented blood glucose 3.9 mmol/l or emergency physician charted diagnosis of hypoglycemia. We evaluated individual components and calculated the positive predictive value.</p> <p>Results</p> <p>We reviewed 636 charts identified by the candidate ICD-9-CM codes and confirmed 436 (64%) cases of hypoglycemia by chart review. Diabetes with other specified manifestations (250.8), often excluded in prior hypoglycemia analyses, identified 83% of hypoglycemia visits, and unspecified hypoglycemia (251.2) identified 13% of hypoglycemia visits. The absence of any predetermined co-diagnosis codes improved the positive predictive value of code 250.8 from 62% to 92%, while excluding only 10 (2%) true hypoglycemia visits. Although prior analyses included only the first-listed ICD-9 code, more than one-quarter of identified hypoglycemia visits were outside this primary diagnosis field. Overall, the proposed algorithm had 89% positive predictive value (95% confidence interval, 86–92) for detecting hypoglycemia visits.</p> <p>Conclusion</p> <p>The proposed algorithm improves on prior strategies to identify hypoglycemia visits in administrative data sets and will enhance the ability to study the epidemiology and design interventions for this important complication of diabetes care.</p