RESUMO
BACKGROUND AND PURPOSE: There has been no systematic analysis of emergency department (ED) utilization in the multiple sclerosis (MS) population. We investigated the acute-care needs of MS patients using ED as a route for entry into healthcare services. METHODS: ED visits made by MS patients were identified. Data extracted included demographics, medical/neurological history, and workup/management in the ED. RESULTS: The Mount Sinai ED received 569 visits from 224 MS patients during a 3-year period, of whom 33.5% were covered by Medicaid and 12.9% were uninsured. Patients with an Expanded Disability Status Scale score of ≥6 accounted for 54%, 50.5% of relapsing remitting MS patients were being treated with disease-modifying therapies, and 74.5% of the ED visits were non-neurological. Patients with mild-to-moderate MS were more likely to present to the ED for issues directly related to MS such as acute exacerbations, while those with severe MS presented more often due to medical issues indirectly related to MS, such as urinary tract infections (p<0.0001). CONCLUSIONS: Most MS patients seeking ED care suffer from acute non-neurological problems. The MS patients presenting to the ED tended to be underinsured, had high levels of disability, and were undertreated with disease-modifying therapies. The acute-care needs of MS patients evolve over the disease course, as do the resources that must be utilized in providing emergency care across the spectrum of MS severity. Understanding the characteristics, problems, and needs of MS patients utilizing the ED is an important step in improving care in this population from both clinical and public health perspectives.
RESUMO
IMPORTANCE: Prompt diagnosis and early initiation of disease-modifying treatment improves long-term outcomes in MS patients. This study looks at the path to MS diagnosis from the Emergency Department (ED), a frequent point of access for healthcare. OBJECTIVE: To evaluate how patients presenting to the Mount Sinai ED with initial manifestations of MS are ultimately diagnosed with demyelinating disease. DESIGN: Retrospective, observational analysis of all patients diagnosed with MS from 2005 to 2009. Part of the Resource Utilization in MS (RESUMS) Study. SETTING: Urban, tertiary care center Emergency Department PARTICIPANTS: Forty-nine patients were diagnosed with MS during the study period and made a total of 98 ED visits prior to that diagnosis. MAIN OUTCOME MEASURES: Outcome measures included percentage of ED visits for neurologic symptoms, percentage that were likely initial manifestations of MS, percentage of visits admitted, mean length of hospital stay of those patients admitted, time until MS diagnosis, and time until initiation of disease modifying agent. Demographic and presentation-specific features correlating with time until MS diagnosis were evaluated. RESULTS: 69.4% of patients were female. Mean age was 32.9 years (range 16-56). Hispanics comprised 40.8%, African Americans 28.6%, and Caucasians 18.2%. 59.2% of patients had private insurance, 26.5% Medicaid, and 6.1% Medicare. 50% of ED visits (49) were for neurologic symptoms (sensory symptoms 44.9%, vision changes 26.5%, weakness 24.5%, imbalance 16%, diplopia and vertigo 10.2%). 75.5% of the ED visits for neurologic symptoms were admitted; mean length of stay was 5.7 days (range 1-18). MS or demyelinating disease was diagnosed at the time of the ED visit or admission in 30/49 (61.2%) of neurologic presentations, with 73.5% diagnosed within a week. In the remaining 26.6%, MS diagnosis was delayed. 18.4% were diagnosed within a year of their neurologic ED visit and 8.2% remained undiagnosed at 1 year. Disease modifying agents were started in 71.4% of patients, 77.1% within 6 months. CONCLUSIONS AND RELEVANCE: ED presentations for acute neurologic symptoms are an important opportunity to diagnose and treat early MS, and while the majority of the patients studied were appropriately triaged, diagnosed and treated in a timely manner, there exists room for improvement.
