Ralph Gonzales

Trends and Characteristics of US Emergency Department Visits, 1997-2007

CONTEXT The potential effects of increasing numbers of uninsured and underinsured persons on US emergency departments (EDs) is a concern for the health care safety net. OBJECTIVE To describe the changes in ED visits that occurred from 1997 through 2007 in the adult and pediatric US populations by sociodemographic group, designation of safety-net ED, and trends in ambulatory care-sensitive conditions. DESIGN, SETTING, AND PARTICIPANTS Publicly available ED visit data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1997 through 2007 were stratified by age, sex, race, ethnicity, insurance status, safety-net hospital classification, triage category, and disposition. Codes from the International Classification of Diseases, Ninth Revision (ICD-9), were used to extract visits related to ambulatory care-sensitive conditions. Visit rates were calculated using annual US Census estimates. MAIN OUTCOME MEASURES Total annual visits to US EDs and ED visit rates for population subgroups. RESULTS Between 1997 and 2007, ED visit rates increased from 352.8 to 390.5 per 1000 persons (rate difference, 37.7; 95% confidence interval [CI], -51.1 to 126.5; P = .001 for trend); the increase in total annual ED visits was almost double of what would be expected from population growth. Adults with Medicaid accounted for most of the increase in ED visits; the visit rate increased from 693.9 to 947.2 visits per 1000 enrollees between 1999 and 2007 (rate difference, 253.3; 95% CI, 41.1 to 465.5; P = .001 for trend). Although ED visit rates for adults with ambulatory care-sensitive conditions remained stable, ED visit rates among adults with Medicaid increased from 66.4 in 1999 to 83.9 in 2007 (rate difference, 17.5; 95% CI, -5.8 to 40.8; P = .007 for trend). The number of facilities qualifying as safety-net EDs increased from 1770 in 2000 to 2489 in 2007. CONCLUSION These findings indicate that ED visit rates have increased from 1997 to 2007 and that EDs are increasingly serving as the safety net for medically underserved patients, particularly adults with Medicaid.

Excessive Antibiotic Use for Acute Respiratory Infections in the United States

Estimating the amount and cost of excess antibiotic use in ambulatory practice and identifying the conditions that account for most excess use are necessary to guide intervention and policy decisions. Data from the 1998 National Ambulatory Medical Care Survey, a sample survey of United States ambulatory physician practices, was used to estimate primary care office visits and antibiotic prescription rates for acute respiratory infections. Weight-averaged antibiotic costs were calculated with use of 1996 prescription marketing data and adjusted for inflation. In 1998, an estimated 76 million primary care office visits for acute respiratory infections resulted in 41 million antibiotic prescriptions. Antibiotic prescriptions in excess of the number expected to treat bacterial infections amounted to 55% (22.6 million) of all antibiotics prescribed for acute respiratory infections, at a cost of approximately

Trends in Opioid Prescribing by Race/Ethnicity for Patients Seeking Care in US Emergency Departments

726 million. Upper respiratory tract infections (not otherwise specified), pharyngitis, and bronchitis were the conditions associated with the greatest amount of excess use. This study documents that the amount and cost of excessive antibiotic use for acute respiratory infections by primary care physicians are substantial and establishes potential target rates for antibiotic treatment of selected conditions.

National trends in ambulatory visits and antibiotic prescribing for skin and soft-tissue infections.

CONTEXT National quality improvement initiatives implemented in the late 1990s were followed by substantial increases in opioid prescribing in the United States, but it is unknown whether opioid prescribing for treatment of pain in the emergency department has increased and whether differences in opioid prescribing by race/ethnicity have decreased. OBJECTIVES To determine whether opioid prescribing in emergency departments has increased, whether non-Hispanic white patients are more likely to receive an opioid than other racial/ethnic groups, and whether differential prescribing by race/ethnicity has diminished since 2000. DESIGN AND SETTING Pain-related visits to US emergency departments were identified using reason-for-visit and physician diagnosis codes from 13 years (1993-2005) of the National Hospital Ambulatory Medical Care Survey. MAIN OUTCOME MEASURE Prescription of an opioid analgesic. RESULTS Pain-related visits accounted for 156 729 of 374 891 (42%) emergency department visits. Opioid prescribing for pain-related visits increased from 23% (95% confidence interval [CI], 21%-24%) in 1993 to 37% (95% CI, 34%-39%) in 2005 (P < .001 for trend), and this trend was more pronounced in 2001-2005 (P = .02). Over all years, white patients with pain were more likely to receive an opioid (31%) than black (23%), Hispanic (24%), or Asian/other patients (28%) (P < .001 for trend), and differences did not diminish over time (P = .44), with opioid prescribing rates of 40% for white patients and 32% for all other patients in 2005. Differential prescribing by race/ethnicity was evident for all types of pain visits, was more pronounced with increasing pain severity, and was detectable for long-bone fracture and nephrolithiasis as well as among children. Statistical adjustment for pain severity and other factors did not substantially attenuate these differences, with white patients remaining significantly more likely to receive an opioid prescription than black patients (adjusted odds ratio, 0.66; 95% CI, 0.62-0.70), Hispanic patients (0.67; 95% CI, 0.63-0.72), and Asian/other patients (0.79; 95% CI, 0.67-0.93). CONCLUSION Opioid prescribing for patients making a pain-related visit to the emergency department increased after national quality improvement initiatives in the late 1990s, but differences in opioid prescribing by race/ethnicity have not diminished.

Changing Use of Antibiotics in Community-Based Outpatient Practice, 1991-1999

BACKGROUND Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has emerged as a common cause of skin and soft-tissue infections (SSTIs) in the United States. It is unknown whether this development has affected the national rate of visits to primary care practices and emergency departments (EDs) and whether changes in antibiotic prescribing have occurred. METHODS We examined visits by patients with SSTIs to physician offices, hospital outpatient departments, and EDs using the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 1997 to 2005. We estimated annual visit rates for all SSTIs and a subset classified as abscess/cellulitis. For abscess/cellulitis visits, we examined trends in characteristics of patients and clinical settings and in antibiotic prescribing. RESULTS Overall rate of visits for SSTIs increased from 32.1 to 48.1 visits per 1000 population (50%; P = .003 for trend), reaching 14.2 million by 2005. More than 95% of this change was attributable to visits for abscess/cellulitis, which increased from 17.3 to 32.5 visits per 1000 population (88% increase; P < .001 for trend). The largest relative increases occurred in EDs (especially in high safety-net-status EDs and in the South), among black patients, and among patients younger than 18 years. Use of antibiotics recommended for CA-MRSA increased from 7% to 28% of visits (P < .001) during the study period. Independent predictors of treatment with these antibiotics included being younger than 45 years, living in the South, and an ED setting. CONCLUSIONS The incidence of SSTIs has rapidly increased nationwide in the CA-MRSA era and appears to disproportionately affect certain populations. Although physicians are beginning to modify antibiotic prescribing practices, opportunities for improvement exist, targeting physicians caring for patients who are at high risk.

Interventions to reduce unnecessary antibiotic prescribing: a systematic review and quantitative analysis.

Context Indiscriminate use of antibiotics promotes the development of antibiotic-resistant strains of bacteria. Contribution This survey of patient visits to community-based clinics shows that antibiotic use for ambulatory infections, especially upper respiratory tract infections, decreased from 19911992 to 19981999. However, the use of broad-spectrum antibiotics rose over this period. Implications Efforts to encourage rational use of antibiotics should focus on which antibiotic to use as well as whether or not to use antibiotics. The Editors Over the past decade, antibiotic resistance has increased substantially in the United States (1-3). In response, many experts have advocated a judicious approach to antibiotic use in both inpatient and outpatient settings (4-6). Such an approach may decrease community rates of antibiotic resistance, even to older drugs with long-standing histories of resistance (7, 8). Similarly, judicious use of potent newer agents may preserve their utility in the treatment of severe or complicated infections, forestalling the emergence of widespread resistance (9, 10). In a landmark study, McCaig and Hughes (11) documented increasing outpatient use of amoxicillin and the cephalosporins between 1980 and 1992 in the United States. Over the past decade, several studies and interventions have focused on the excess use of antibiotics. However, only recently has increasing attention been paid to the type of agents being prescribed (12-14). As a result, relatively little is known about the impact of antibiotic prescribing choices on quality of care, health care costs, and antibiotic resistance. In this study, we used a large, nationally representative sample of community-based physicians to evaluate outpatient antibiotic prescribing during the 1990s. First, we examined the ways in which patterns of antibiotic use have changed over the past decade, particularly among broad-spectrum agents such as azithromycin and clarithromycin, quinolones, amoxicillinclavulanate, and second- and third-generation cephalosporins. Next, we determined the association between these patterns of use and clinical factors related to the need for broad-spectrum therapy. Methods National Ambulatory Medical Care Survey We used the National Ambulatory Medical Care Survey (NAMCS) to collect data on outpatient antibiotic use. We collapsed 6 survey years into three study periods (19911992, 19941995, and 19981999), combining data from consecutive years to add power to our analyses. The NAMCS is an annual sample of outpatient visits to office-based community physicians who are principally engaged in patient care. Patient care encounters in emergency departments or hospital-based clinics and visits outside the office (for example, house calls or nursing home visits) were not recorded. Visits were sampled by using a multistage clustered probability sample design based on geographic location, provider specialty, and visits within individual physician practices. When patient weights are used, these data can be extrapolated to the approximately 650 million community-based outpatient visits that occur in the United States each year (15). Participation in the survey ranged from 63% to 73% of invited practices, with different physicians and patients being surveyed each year (15, 16). The NAMCS collected information on up to five (19911994) or six (19951999) medications prescribed for each patient at the conclusion of his or her visit, including both new and ongoing prescriptions. The NAMCS also collected data on up to three physician diagnoses related to the visit, including new diagnoses and ongoing medical conditions. All data, including demographic char acteristics, were recorded by the physician or by office staff completing the visit encounter form. Design and Classification We were interested in the use of oral and intramuscular antibiotics, but the NAMCS does not provide information on the route of drug administration. We therefore excluded patient visits to dermatologists and ophthalmologists because these specialists frequently prescribe topical antibiotics, which we could not distinguish from systemic forms of the same drugs. Visits to these specialists made up approximately 10% of patient encounters in each study period. Among the remaining sample, 60 252 visits were recorded in 19911992, 62 169 visits were recorded in 19941995, and 37 467 visits were recorded in 19981999. The smaller sample size in the last study period reflects a smaller number of visits surveyed by the NAMCS in those years. We divided the remaining sample into patient visits that did and did not involve an antibiotic. Antimicrobial medications used by outpatients almost exclusively in topical or intravenous form, such as polymyxins and aminoglycosides, were not counted as antibiotics. We also did not count antimycobacterial medications as antibiotics because they are infrequently used for typical bacterial infections. Antibiotic use, according to these criteria, was recorded in 8208 sampled visits in 19911992, 7944 visits in 19941995, and 4200 visits in 19981999. In each study period, 3% to 4% of these visits involved the use of more than one antibiotic. In total, there were 8514 antibiotic prescriptions in 19911992, 8308 antibiotic prescriptions in 19941995, and 4406 antibiotic prescriptions in 19981999. For the purposes of this study, we defined broad-spectrum agents as azithromycin and clarithromycin, quinolones, amoxicillinclavulanate, and second- and third-generation cephalosporins (17). Many of the broad-spectrum agents we studied were introduced more recently than narrow-spectrum ones. All nine narrow-spectrum agents that made up at least 2% of total antibiotic prescriptions in any study period received U.S. Food and Drug Administration approval before 1979. Among broad-spectrum agents that made up at least 2% of total antibiotic prescriptions, Food and Drug Administration approval was granted between 1979 and 1984 for amoxicillinclavulanate, cefaclor, and cefuroxime; in 1987 for ciprofloxacin; in 1991 for azithromycin, cefprozil, and clarithromycin; and in 1996 for levofloxacin (Bergman E. Personal communication. Publically available data from the Tufts Center for the Study of Drug Developments approved products database). Patients were considered to have a common infectious condition if the corresponding International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code appeared as the first, second, or third diagnosis for that visit (18). Diagnoses included nasopharyngitis (the common cold) or upper respiratory tract infection not otherwise specified (ICD-9-CM codes 460, 465); acute or chronic sinusitis (ICD-9-CM codes 461, 473); pharyngitis and streptococcal sore throat (ICD-9-CM codes 462, 34.0); suppurative or nonsuppurative otitis media (ICD-9-CM codes 381.0381.4, 382); acute or acute-on-chronic bronchitis and bronchiolitis (ICD-9-CM codes 466, 490, 491.21); acute tonsillitis, laryngitis, and tracheitis (ICD-9-CM codes 463464); bacterial or unspecified pneumonia (ICD-9-CM codes 481483, 485486); urinary tract infection or acute or unspecified cystitis (ICD-9-CM codes 599.0, 595.0, 595.9); cellulitis, carbuncle, or furuncle (ICD-9-CM codes 680682); prostatitis or pelvic inflammatory disease (ICD-9-CM codes 601, 614); and sexually transmitted diseases, including syphilis, gonococcal infections, and other venereal infections (ICD-9-CM codes 9099, 647.0647.2). In each study period, 11% to 13% of patients who were prescribed antibiotics received a diagnosis of more than one of these infectious conditions. To prevent confusion over which disease was treated by the listed antibiotics, we excluded these patients from the diagnosis-specific analyses. Among adults with a single diagnosis of an infectious disease, there were 1657 visits for the common cold and unspecified upper respiratory tract infections, 2652 visits for sinusitis, 963 visits for pharyngitis, 908 visits for otitis media, 1674 visits for acute bronchitis, and 1636 visits for urinary tract infection over the entire study period. Among children, there were 1976 visits for the common cold and unspecified upper respiratory tract infections, 651 visits for sinusitis, 1120 visits for pharyngitis, 3107 visits for otitis media, and 625 visits for acute bronchitis. Statistical Analysis We analyzed overall antibiotic use for a given patient at the level of the patient visit. Individual prescriptions were analyzed at the level of the antibiotic prescription. For example, a patient visit involving amoxicillin and ciprofloxacin would be counted twice, once for each medication. We did not account for clustering of more than one antibiotic in a single visit because only 3% to 4% of visits at which an antibiotic was prescribed in each period involved more than one antibiotic. To make our point estimates nationally representative, we used patient weights, which weight each visits contribution in inverse proportion to the likelihood of that visit being sampled from all community-based visits (15, 19). Patient weight can be interpreted as the number of visits in the population that the sampled visit represents. To adjust for the effects of survey design on standard errors, we clustered our analyses at the level of the physician. This accounts for correlation among outcomes sampled from the same physician and increases the standard errors to account for weighting and clustering within physicians. Identifiers of the true primary sampling unit (county or county equivalent) were not available to the public at the time this study was performed and therefore could not be used in our analyses. As a result, the calculated variances and point estimates in our analyses may differ slightly from those in analyses that incorporate both the primary and secondary sampling units. We conducted all analyses using the design-based F test, comparing the first study period (19911992) with the

Radiological Imaging of Patients with Suspected Urinary Tract Stones: National Trends, Diagnoses, and Predictors

Background:Overuse of antibiotics in ambulatory care persists despite many efforts to address this problem. We performed a systematic review and quantitative analysis to assess the effectiveness of quality improvement (QI) strategies to reduce antibiotic prescribing for acute outpatient illnesses for which antibiotics are often inappropriately prescribed. Research Design and Methods:We searched the Cochrane Collaborations Effective Practice and Organisation of Care database, supplemented by MEDLINE and manual review of article bibliographies. We included randomized trials, controlled before-after studies, and interrupted time series. Two independent reviewers abstracted all data, and disagreements were resolved by consensus and discussion with a third reviewer. The primary outcome was the absolute reduction in the proportion of patients receiving antibiotics. Results:Forty-three studies reporting 55 separate trials met inclusion criteria. Most studies (N = 38) addressed prescribing for acute respiratory infections (ARIs). Among the 30 trials eligible for quantitative analysis, the median reduction in the proportion of subjects receiving antibiotics was 9.7% [interquartile range (IQR), 6.6–13.7%] over 6 months median follow-up. No single QI strategy or combination of strategies was clearly superior. However, active clinician education strategies trended toward greater effectiveness than passive strategies (P = 0.096). Compared with studies targeting specific conditions or patient populations, broad-based interventions extrapolated to larger community-level impacts on total antibiotic use, with savings of 17–117 prescriptions per 1000 person-years. Study methodologic quality was fair. Conclusions:QI efforts are effective at reducing antibiotic use in ambulatory settings, although much room for improvement remains. Strategies using active clinician education and targeting management of all ARIs (rather than single conditions in single age groups) may yield larger reductions in community-level antibiotic use.

A Cluster Randomized Trial of Decision Support Strategies for Reducing Antibiotic Use in Acute Bronchitis

OBJECTIVES Overutilization of computed tomography (CT) is a growing public health concern due to increasing health care costs and exposure to radiation; these must be weighed against the potential benefits of CT for improving diagnoses and treatment plans. The objective of this study was to determine the national trends of CT and ultrasound (US) utilization for assessment of suspected urolithiasis in emergency departments (EDs) and if these trends are accompanied by changes in diagnosis rates for urolithiasis or other significant disorders and hospitalization rates. METHODS This was a retrospective cross-sectional analysis of ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS) between 1996 and 2007. The authors determined the proportion of patient visits for flank or kidney pain receiving CT or US testing and calculated the diagnosis and hospitalization rates for urolithiasis and other significant disorders. Patient-specific and hospital-level variables associated with the use of CT were examined. RESULTS Utilization of CT to assess patients with suspected urolithiasis increased from 4.0% to 42.5% over the study period (p < 0.001). In contrast, the use of US remained low, at about 5%, until it decreased beginning in 2005 to 2007 to 2.4% (p = 0.01). The proportion of patients diagnosed with urolithiasis (approximately 18%, p = 0.55), with other significant diagnoses (p > 0.05), and admitted to the hospital (approximately 11%, p = 0.49) did not change significantly. The following characteristics were associated with a higher likelihood of receiving a CT scan: male sex (odd ratio [OR] = 1.83, 95% confidence interval [CI] = 1.22 to 2.77), patients presenting with severe pain (OR = 2.96, 95% CI = 1.14 to 7.65), and those triaged in 15 minutes or less (OR = 2.41, 95% CI = 1.08 to 5.37). CT utilization was lower for patients presenting to rural hospitals (vs. urban areas; OR = 0.34, 95% CI = 0.19 to 0.61) and those managed by a nonphysician health care provider (OR = 0.19, 95% CI = 0.07 to 0.53). CONCLUSIONS From 1996 to 2007, there was a 10-fold increase in the utilization of CT scan for patients with suspected kidney stone without an associated change in the proportion of diagnosis of kidney stone, diagnosis of significant alternate diagnoses, or admission to the hospital.

Characterization of Viral Agents Causing Acute Respiratory Infection in a San Francisco University Medical Center Clinic during the Influenza Season

BACKGROUND National quality indicators show little change in the overuse of antibiotics for uncomplicated acute bronchitis. We compared the effect of 2 decision support strategies on antibiotic treatment of uncomplicated acute bronchitis. METHODS We conducted a 3-arm cluster randomized trial among 33 primary care practices belonging to an integrated health care system in central Pennsylvania. The printed decision support intervention sites (11 practices) received decision support for acute cough illness through a print-based strategy, the computer-assisted decision support intervention sites (11 practices) received decision support through an electronic medical record-based strategy, and the control sites (11 practices) served as a control arm. Both intervention sites also received clinician education and feedback on prescribing practices, as well as patient education brochures at check-in. Antibiotic prescription rates for uncomplicated acute bronchitis in the winter period (October 1, 2009, through March 31, 2010) following introduction of the intervention were compared with the previous 3 winter periods in an intent-to-treat analysis. RESULTS Compared with the baseline period, the percentage of adolescents and adults prescribed antibiotics during the intervention period decreased at the printed decision support intervention sites (from 80.0% to 68.3%) and at the computer-assisted decision support intervention sites (from 74.0% to 60.7%) but increased slightly at the control sites (from 72.5% to 74.3%). After controlling for patient and clinician characteristics, as well as clustering of observations by clinician and practice site, the differences for the intervention sites were statistically significant from the control sites (P = .003 for control sites vs printed decision support intervention sites and P = .01 for control sites vs computer-assisted decision support intervention sites) but not between themselves (P = .67 for printed decision support intervention sites vs computer-assisted decision support intervention sites). Changes in total visits, 30-day return visit rates, and proportion diagnosed as having uncomplicated acute bronchitis were similar among the study sites. CONCLUSIONS Implementation of a decision support strategy for acute bronchitis can help reduce the overuse of antibiotics in primary care settings. The effect of printed vs computer-assisted decision support strategies for providing decision support was equivalent. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00981994.

Production of Hyperalgesic Prostaglandins by Sympathetic Postganglionic Neurons

Abstract Background. With use of polymerase chain reaction (PCR) and a centrifugation-enhanced viral culture method, we characterized the viruses causing acute respiratory infection in adults during an influenza season. Methods. During January-March 2002, nasopharyngeal wash specimens from previously healthy adults presenting with respiratory symptoms were evaluated for viral pathogens with centrifugation-enhanced viral culture and PCR. Results The diagnoses in 266 cases included unspecified upper respiratory infection (in 142 [54%] of the cases), acute bronchitis (42 [16%]), sinusitis (23 [9%]), pharyngitis (22 [8%]), and pneumonia (17 [6%]). The use of a shell vial assay and PCR identified a pathogen in 103 (39%) of the patients, including influenza A or B in 54, picornavirus in 28 (including rhinovirus in 24), respiratory syncytial virus (RSV) in 12, human metapneumovirus in 4, human coronavirus OC43 in 2, adenovirus in 2, parainfluenza virus type 1 in 1, and coinfection with influenza and parainfluenza virus type 1 in 2. Conclusion. Our findings demonstrate that, even during the influenza season, rhinovirus and RSV are prevalent and must be considered in the differential diagnosis of adult acute respiratory infection before prescribing antiviral medication. Human coronavirus and human metapneumovirus did not play a substantial role. PCR was an especially useful tool in the identification of influenza and other viral pathogens not easily detected by traditional testing methods.