Andrea J. Pelletier

Increased US Emergency Department Visits for Skin and Soft Tissue Infections, and Changes in Antibiotic Choices, During the Emergence of Community-Associated Methicillin-Resistant Staphylococcus aureus

STUDY OBJECTIVE Test the hypotheses that emergency department (ED) visits for skin and soft tissue infections became more frequent during the emergence of community-associated methicillin-resistant Staphylococcus aureus (MRSA), and that antibiotics typically active against community-associated MRSA were chosen increasingly. METHODS From merged National Hospital Ambulatory Medical Care Survey data for 1993-2005, we identified ED visits with diagnosis of cellulitis, abscess, felon, impetigo, hidradenitis, folliculitis, infective mastitis, nonpurulent mastitis, breast abscess, or carbuncle and furuncle. Main outcomes were change over time in rate of ED visits with such a diagnosis and proportion of antibiotic regimens including an agent typically active against community-associated MRSA. We report national estimates derived from sample weights. We tested trends with least squares linear regression. RESULTS In 1993, infections of interest were diagnosed at 1.2 million visits (95% confidence interval [CI] 0.96 to 1.5 million) versus 3.4 million in 2005 (95% CI 2.8 to 4.1 million; P for trend <.001). As a proportion of all ED visits, such infections were diagnosed at 1.35% in 1993 (95% CI 1.07% to 1.64%) versus 2.98% in 2005 (95% CI 2.40% to 3.56%; P for trend <.001). When antibiotics were prescribed at such visits, an antibiotic typically active against community-associated MRSA was chosen rarely from 1993 to 2001 but increasingly thereafter, reaching 38% in 2005 (95% CI 30% to 45%; P for trend <.001). In 2005, trimethoprim-sulfamethoxazole was used in 51% of regimens active against community-associated MRSA. CONCLUSION US ED visits for skin and soft tissue infections increased markedly from 1993 to 2005, contemporaneously with the emergence of community-associated MRSA. ED clinicians prescribed more antibiotics typically active against community-associated MRSA, especially trimethoprim-sulfamethoxazole. Possible confounders are discussed, such as increasing diabetes or shifts in locus of care.

Direct Medical Costs of Bronchiolitis Hospitalizations in the United States

OBJECTIVES. Although bronchiolitis is the leading cause of hospitalization for infants, there are limited data describing the epidemiology of bronchiolitis hospitalizations, and the associated cost is unknown. Our objective was to determine nationally representative estimates of the frequency of bronchiolitis hospitalizations and its associated costs. PATIENTS AND METHODS. We analyzed the 2002 Health Care Utilization Project-National Inpatient Sample, a federal, stratified random survey of hospital discharges. For admissions age <2 years with a discharge diagnosis of bronchiolitis (International Classification of Diseases, Ninth Revision, Clinical Modification, code 466.1), we used nationally representative weighted estimates to determine frequency and total hospital charges. Costs were estimated from reported charges by applying hospital-specific cost/charge ratios based on all-payer inpatient cost. RESULTS. In 2002, an estimated 149000 patients were hospitalized with bronchiolitis. Frequency of hospitalizations was higher among children age <1 year of age, male gender, and nonwhite race. Mean length of stay was 3.3 days. Total annual costs for bronchiolitis-related hospitalizations were

Spectrum of Dizziness Visits to US Emergency Departments: Cross-Sectional Analysis From a Nationally Representative Sample

543 million, with a mean cost of

Headache in United States emergency departments: demographics, work-up and frequency of pathological diagnoses.

3799 per hospitalization. Mean cost of bronchiolitis with a codiagnosis of pneumonia was

National study of US emergency department visits for acute allergic reactions, 1993 to 2004

6191. In a multivariate analysis controlling for 3 confounding factors (including length of stay), cost per hospitalization was higher for children ≥1 year and lower for those in the South versus Northeast. CONCLUSIONS. Bronchiolitis admissions cost more than

Seizure visits in US emergency departments: epidemiology and potential disparities in care

500 million annually. A codiagnosis of bronchiolitis and pneumonia almost doubles the cost of the hospitalization. Inpatient health care costs of bronchiolitis are higher than estimated previously and highlight the need for initiatives to safely reduce bronchiolitis hospitalizations and thereby decrease health care costs.

Disconnect Between Charted Vestibular Diagnoses and Emergency Department Management Decisions: A Cross‐sectional Analysis From a Nationally Representative Sample

OBJECTIVE To describe the spectrum of visits to US emergency departments (EDs) for acute dizziness and determine whether ED patients with dizziness are diagnosed as having a range of benign and dangerous medical disorders, rather than predominantly vestibular ones. PATIENTS AND METHODS A cross-sectional study of ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS) used a weighted sample of US ED visits (1993-2005) to measure patient and hospital demographics, ED diagnoses, and resource use in cases vs controls without dizziness. Dizziness in patients 16 years or older was defined as an NHAMCS reason-for-visit code of dizziness/vertigo (1225.0) or a final International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of dizziness/vertigo (780.4) or of a vestibular disorder (386.x). RESULTS A total of 9472 dizziness cases (3.3% of visits) were sampled over 13 years (weighted 33.6 million). Top diagnostic groups were otologic/vestibular (32.9%), cardiovascular (21.1%), respiratory (11.5%), neurologic (11.2%, including 4% cerebrovascular), metabolic (11.0%), injury/poisoning (10.6%), psychiatric (7.2%), digestive (7.0%), genitourinary (5.1%), and infectious (2.9%). Nearly half of the cases (49.2%) were given a medical diagnosis, and 22.1% were given only a symptom diagnosis. Predefined dangerous disorders were diagnosed in 15%, especially among those older than 50 years (20.9% vs 9.3%; P<.001). Dizziness cases were evaluated longer (mean 4.0 vs 3.4 hours), imaged disproportionately (18.0% vs 6.9% undergoing computed tomography or magnetic resonance imaging), and admitted more often (18.8% vs 14.8%) (all P<.001). CONCLUSION Dizziness is not attributed to a vestibular disorder in most ED cases and often is associated with cardiovascular or other medical causes, including dangerous ones. Resource use is substantial, yet many patients remain undiagnosed.

National study of Emergency Department visits for burn injuries, 1993 to 2004.

Headache is a common complaint in the emergency department (ED). In order to examine headache work-ups and diagnoses across the USA, we queried a representative sample of adult ED visits (the National Hospital Ambulatory Medical Care Survey) for the years 1992–2001. Headache accounted for 2.1 million ED visits per year (2.2% of visits). Of the 14% of patients who underwent neuroimaging, 5.5% received a pathological diagnosis. Of the 2% of patients who underwent lumbar puncture, 11% received a pathological diagnosis. On multivariable analysis, a decreased rate of imaging was noted for patients without private insurance [odds ratio (OR) 0.61, confidence interval (CI) 0.44, 0.86] and for those presenting off-hours (OR 0.55, CI 0.39, 0.77). Patients over 50 were more likely to receive a pathological diagnosis (OR 3.3, CI 1.2, 9.3). In conclusion, clinicians should ensure that appropriate work-ups are performed regardless of presentation time or insurance status, and be vigilant in the evaluation of older patients.

Inappropriate Use of Antibiotics for Acute Asthma in United States Emergency Departments

BACKGROUND The clinical epidemiology of acute allergic reactions in the emergency department (ED) is uncertain. OBJECTIVES To characterize ED visits for acute allergic reactions and to evaluate national trends in ED management. METHODS The National Hospital Ambulatory Medical Care Survey was used to identify a nationally representative sample of ED visits between 1993 and 2004. Cases with a diagnosis of acute allergic reaction were identified by International Classification of Diseases, Ninth Revision (ICD-9) codes (9950, 9951, 9952, 9953, 9956). RESULTS A total of 12.4 million allergy-related ED visits occurred from 1993 to 2004, representing 1.0% (95% confidence interval, 0.93%-1.10%) of all ED visits or 1.03 million ED visits per year. The number of allergy-related ED visits remained relatively stable, averaging 3.8 per 1,000 US population per year (95% confidence interval, 3.4-4.1; P for trend = .39). Although 63% of all visits were coded as urgent, only 4% required hospitalization. Anaphylaxis coding was rare (1%). ED staff prescribed medications in 87% of visits, especially histamine, blockers (62%; P for trend = .29). Increases were noted from 1993 to 2004 for corticosteroids (22% to 50%; P < .001), histamine2 blockers (7% to 18%; P < .001), and inhaled beta-agonists (2% to 6%; P = .008). Epinephrine use was infrequent and declining (19% to 7%; P = .04). CONCLUSION Between 1993 and 2004, significant variability has occurred in ED management of acute allergic reactions.

National study of ambulance transports to United States emergency departments: importance of mental health problems

IntroductionWhile epilepsy is a well-characterized disease, the majority of emergency department (ED) visits for “seizure” involve patients without known epilepsy. The epidemiology of seizure presentations and national patterns of management are unclear. The aim of this investigation was to characterize ED visits for seizure in a large representative US sample and investigate any potential impact of race or ethnicity on management.MethodsSeizure visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1993 to 2003 were analysed. Demographic factors associated with presentation, neuroimaging and hospital admission in the USA were analysed using controlled multivariate logistic regression.ResultsSeizure accounts for 1 million ED visits annually [95% confidence interval (CI): 926,000–1,040,000], or 1% of all ED visits in the USA. Visits were most common among infants, at 8.0 per 1,000 population (95% CI: 6.0–10.0), and children aged 1–5 years (7.4; 95% CI: 6.4–8.4). Seizure was more likely among those with alcohol-related visits [odds ratio (OR): 3.2; 95% CI: 2.7–3.9], males (OR: 1.4; 95% CI: 1.3–1.5) and Blacks (OR: 1.4; 95% CI: 1.3–1.6). Neuroimaging was used less in Blacks than Whites (OR: 0.6; 95% CI: 0.4–0.8) and less in Hispanics than non-Hispanics (OR: 0.6; 95% CI: 0.4–0.9). Neuroimaging was used less among patients with Medicare (OR: 0.4; 95% CI: 0.2–0.6) or Medicaid (OR: 0.5; 95% CI: 0.4–0.7) vs private insurance and less in proprietary hospitals. Hospital admission was less likely for Blacks vs Whites (OR: 0.6; 95% CI: 0.4–0.8).ConclusionSeizures account for 1% of ED visits (1 million annually). Seizure accounts for higher proportions of ED visits among infants and toddlers, males and Blacks. Racial/ethnic disparities in neuroimaging and hospital admission merit further investigation.