Associations between chronic pain, anxiety, and depression among adults in the United States.

OBJECTIVE: The objective of the study was to determine the associations of depression and anxiety with chronic pain among U.S. adults. SETTING: Nationally representative cross-sectional survey analysis. METHODS: The National Health Interview Survey for 2019 was analyzed with respect to the chronic pain module and embedded depression and anxiety scales (PHQ-8 and GAD-7). Univariate associations between the presence of chronic pain and depression and anxiety scores were determined. Similarly, associations between the presence of chronic pain and the adults' treating with medications for depression and anxiety were also determined. Odds ratios, adjusted for age and sex, were computed for these associations. RESULTS: Among 244.6 million sampled U.S. adults, 50.2 million (95% confidence interval, 48.2-52.2 million) reported chronic pain (20.5%, [19.9%-21.2%] of the population). Adults with chronic pain had elevated severity of depressive symptoms (PHQ-8 categories: none/minimal: 57.6%, mild: 22.3%, moderate: 11.4%, and severe: 8.7%) versus those without chronic pain (87.6%, 8.8%, 2.3%, and 1.2%; p < 0.001). Adults with chronic pain had elevated severity of anxiety symptoms (GAD-7 categories: none/minimal: 66.4%, mild: 17.1%, moderate: 8.5%, severe: 8.0%) versus those without chronic pain (89.0%, 7.5%, 2.1%, and 1.4%; p < 0.001). 22.4% and 24.5% of chronic pain sufferers were taking medication for depression and anxiety versus 6.6% and 8.5% of those without chronic pain, respectively (both p < 0.001). Adjusted odds ratios for the association of chronic pain with increasing severity of depression or anxiety and taking a depression or anxiety medication were 6.32 (5.82-6.85), 5.63 (5.15-6.15), 3.98 (3.63-4.37), and 3.42 (3.12-3.75), respectively. CONCLUSIONS: The presence of chronic pain in adults associated with significantly higher severity scores for both anxiety and depression as measured by validated surveys in a nationally representative sample. The same is true for the association between chronic pain and an adult taking medication for depression and/or anxiety. These data highlight the impact of chronic pain has on psychological well-being within the general population.

ReActiv8 Stimulation Therapy vs. Optimal Medical Management: A Randomized Controlled Trial for the Treatment of Intractable Mechanical Chronic Low Back Pain (RESTORE Trial Protocol).

INTRODUCTION: Chronic low back pain (CLBP) is the leading cause of years lived with disability globally. The role of restorative neurostimulation in the treatment of patients with refractory mechanical CLBP and multifidus muscle dysfunction has been established in one randomized controlled trial (RCT) and several clinical studies that demonstrated both safety and clinical benefit. This post-market trial provides a direct comparison to optimized medical management to test the hypothesis that the addition of restorative neurostimulation to current care paradigms results in significant improvements in back pain-related disability. METHODS AND ANALYSIS: This trial will include people who have reported significant levels of back pain and back pain-related disability with symptoms that have persisted for longer than 6 months prior to enrollment and resulted in pain on most days in the 12 months prior to enrollment. Eligible patients will be randomized to either optimal medical management or optimal medical management plus ReActiv8® restorative neurostimulation therapy. Patient-reported outcomes will be collected at regular intervals out to the 1-year primary endpoint, at which time the patients in the control arm will be offered implantation with the ReActiv8 system. Assessment of each group will continue for an additional year. ETHICS AND DISSEMINATION: The RESTORE trial follows the principles of the Declaration of Helsinki. The WCG IRB acts as the Central Institutional Review Board (IRB) for most sites and some sites will receive local IRB approval prior to enrollment of patients. Each IRB assessed the protocol and related documentation. The protocol complies with Good Clinical Practice (GCP). All patients provide written informed consent to participate in the trial. PROTOCOL VERSION: Version C, 07 Sep 2022. CLINICALTRIALS: gov registration number. NCT04803214 registered March 17, 2021.

Restorative neurostimulation is a treatment for intractable CLBP associated with dysfunction of the multifidus muscle, which normally provides functional stability to the lumbar spine. To date, ReActiv8^® (Mainstay Medical) is the only neurostimulator specifically developed and approved for this indication. Electrical stimulation of the muscle's nerve overrides the dysfunction and reactivates it. Several prior studies demonstrated that the most of participants experienced clinically substantial and durable symptom relief compared to baseline. This protocol describes a second RCT in which all participants are on individualized optimal medical management and half of them are randomly selected to be implanted with a ReActiv8 system to receive restorative neurostimulation. The purpose of this design is to measure if there is any clinical benefit of restorative neurostimulation over individualized optimal medical management alone over the course of a full year.

The prevalence of opioid medication use among adults in the United States.

OBJECTIVE: More than one in five American adults experiences chronic pain, and numerous approaches can be used to treat chronic pain. Opioid analgesics are commonly used to treat pain though precise estimates of the prevalence of opi-oid analgesic use vary widely. This study sought to determine the prevalence of opioid use for pain among adults in the United States. METHODS: We performed a retrospective analysis of the National Health Interview Survey, a national-level house-hold-based annual survey of self-reported health status of US adults, using a chronic pain module introduced in the 2019 edition. We examined overall rates of opioid medication use for pain and correlates of opioid use using survey-weighted analyses. RESULTS: We found 30.8 million adults (95 percent CI: 29.3-32.3 million), or 12.3 percent (11.8-12.8) of the population, had used opioids for pain in the preceding 12 months, while 9.3 million (8.6-10.0 million), or 3.7 percent (3.5-4.0), had used opioids for chronic pain in the preceding 3 months. Individuals reporting pain every day were more likely to have used opi-oids than those experiencing pain less frequently. Individuals who had tried other methods such as physical therapy and self-management programs were more likely to have used opioids. Individuals who used opioids for pain were more likely to report poorly controlled pain, with 38.0 percent (31.5-45.0) reporting their pain management was "not at all effective." CONCLUSIONS: Opioid use for chronic pain is common and frequently part of a multimodal and multidisciplinary approach.

Tramadol Use in United States Emergency Departments 2007-2018.

BACKGROUND: Amidst the opioid epidemic, there has been an increasing focus on opioid utilization in U.S. emergency departments (EDs). Compared with other opioids, little is known about the use of tramadol over the past decade. Tramadol has uncertain efficacy and a concerning adverse effect profile compared with traditional opioids. OBJECTIVE: Our aim was to describe trends in tramadol use in U.S. EDs between 2007 and 2018. METHODS: We analyzed the National Hospital Ambulatory Medical Care Survey from 2007 to 2018 to examine ED visits by patients 18 years or older in which tramadol was administered or prescribed. We examined trends in demographics and resource utilization and compared these trends with those of traditional opioids. Survey-weighted analyses were conducted to provide national-level estimates. RESULTS: Between 2007 and 2018, ED visits in which tramadol was used increased 70.6%, from 1.7% of all ED visits in 2007 to 2.9% in 2018. The largest increases were noted among patients aged 55 through 64 years and 65 years and older. Diagnostic resource utilization increased across the study period. Overall opioid utilization during the study period decreased from 28.4% in 2007 to 17.9% in 2018 (p < 0.001). The use of other specific opioids declined or remained stable between 2007 and 2018. CONCLUSIONS: Although the use of traditional opioids decreased from 2007 to 2018, the use of tramadol increased. Increases were largest among older patients, who may be more susceptible to the adverse effects associated with this medication. Further research in the appropriate use of tramadol in the ED setting is warranted.

Prevalence of chronic pain among adults in the United States.

ABSTRACT: Chronic pain is associated with reduced quality of life, increased medical expenditures, and significant economic costs. Chronic pain is among the most common chronic conditions in the United States, although estimates vary widely regarding its precise prevalence. Understanding the scope of the problem using the most contemporaneous data is therefore an important goal. This study sought to determine the prevalence of chronic pain and its impacts among adults in the United States using the National Health Interview Survey, a household-based annual survey of self-reported health status of U.S. adults that can be used to generate national-level estimates. Using a chronic pain module introduced in the 2019 edition of National Health Interview Survey, we found that 50.2 million adults (20.5%) reported pain on most days or every day. The most common pain locations were back pain and hip, knee, or foot pain. The most commonly used management strategies for chronic pain were physical therapy and massage. Respondents with chronic pain reported limitations in daily functioning, including social activities and activities of daily living. Respondents with chronic pain reported significantly more workdays missed compared with those without chronic pain (10.3 vs 2.8, P < 0.001). Overall, these findings indicate that more than 1 in 5 adults in America experiences chronic pain; additional attention to managing the burden of this disease is warranted.

Impact of demographic factors on chronic pain among adults in the United States.

Introduction: Chronic pain affects more than 1 in 5 American adults, and its effects are not evenly distributed throughout the population. Methods: Using the National Health Interview Survey (NHIS), a household-based annual survey of self-reported health status of U.S. adults, this cross-sectional study describes differences in the prevalence of chronic pain and its effects across socioeconomic groups. Results: In univariate analyses, chronic pain was more prevalent among female respondents, persons with lower educational attainment, non-Hispanic White individuals, and those who were insured as well as those who were married. After accounting for all other demographic factors, age, female sex, and lower educational attainment were associated with higher odds of having chronic pain, whereas Hispanic and non-Hispanic Black race were associated with lower odds. Despite lower odds of having chronic pain, Hispanic and non-Hispanic Black race were associated with greater odds of reporting more severe pain than White race. There were no significant differences across race in the effects of pain on life, work, or family, although female sex and lower educational attainment were associated with greater effects of pain on these domains. Educational attainment was the only characteristic associated with greater odds of ineffective pain management after accounting for all other demographic factors. Conclusions: Implications for reducing disparities in the treatment of chronic pain are discussed.

Trends in the Evaluation and Management of Back Pain in Emergency Departments, United States, 2007-2016.

OBJECTIVE: Back pain is one of the most common pain syndromes in the United States, but there has been limited recent description of the role of emergency departments (EDs) in caring for patients with back pain. We investigated trends in the evaluation and management of back pain in U.S. EDs from 2007 to 2016. METHODS: We performed a retrospective analysis of the National Hospital Ambulatory Medical Care Survey, a nationally representative annual survey of ED visits, which includes data on patient-, hospital-, and visit-level characteristics. We evaluated trends among adult ED visits for back pain, including demographics, resource utilization, and disposition. Trends were assessed through the use of survey-weighted analyses. RESULTS: Visit rates as a proportion of overall ED visits were stable from 2007 to 2016 (9.1% [95% confidence interval (CI): 8.5-9.6] vs. 9.3% [95% CI: 8.6-10.0]; P = 0.44). Admission rates declined from 6.4% (95% CI: 5.1-8.0) to 5.0% (95% CI: 3.5-6.9; P < 0.001). Imaging utilization increased from 51.7% (95% CI: 49.3-54.1) to 57.6% (95% CI: 53.3-61.7; P = 0.023), with an increase of 58.3% in computed tomography. Overall opioid utilization declined from 53.5% (95% CI: 49.4-57.5) to 46.5% (95% CI: 43.2-49.8; P < 0.001). Tramadol use increased over the study period (4.1% [95% CI: 3.0-5.8] vs. 8.4% [95% CI: 6.6-10.7]; P < 0.001). CONCLUSIONS: Opioid utilization during ED visits for back pain decreased from 2007 to 2016, whereas tramadol use more than doubled. Care intensity increased significantly despite declining admission rates. Further research into optimal strategies for back pain management in the ED is needed.

National trends in U.S. emergency department visits for chief complaint of hypertension (2006-15).

OBJECTIVES: Hypertension is one of the most common chronic illnesses among adults in the United States. While poor hypertension control is a risk factor for many emergent conditions, asymptomatic hypertension is rarely an emergency. Despite this, patients may present to the emergency department (ED) with a chief complaint of hypertension, and there may be significant variability in the management of these patients. Our objective was to characterize national trends in ED visits for chief complaint of hypertension between 2006 and 2015. METHODS: We used the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2006 to 2015 to examine ED visits for chief complaint of hypertension. We examined trends in demographics, diagnostic resource utilization, and clinical management of these patients. RESULTS: Between 2006 and 2015, visits with hypertension as the primary chief complaint represented 0.6% of all ED visits, or 6,215,787 national-level ED visits. Of these, 63.9% received a primary diagnosis of hypertension. While there was no significant growth in these visits over the study period, 79.3% of visits received any form of diagnostic testing, with 35.5% of patients receiving an antihypertensive medication. Increasing blood pressure and non-white race were associated with increased odds of receiving antihypertensive medications. CONCLUSIONS: Despite clinical policies and guidelines recommending against routine diagnostic testing for asymptomatic hypertension, roughly 4 out of 5 ED visits received diagnostic testing, and more than 1 out of 3 received medications. These visits may represent an opportunity for improvement to reduce overutilization, as well as for innovative approaches as EDs expand their role in care coordination across settings.

Electrocardiogram and cardiac testing among patients in the emergency department with seizure versus syncope.

OBJECTIVE: Cardiogenic syncope can present as a seizure. The distinction between seizure disorder and cardiogenic syncope can only be made if one considers the diagnosis. Our main objective was to identify whether patients presenting with a chief complaint (reason for visit) as seizure or syncope received an electrocardiogram in the emergency department across all age groups. METHODS: We conducted a secondary analysis of data collected in the 2010 to 2014 National Hospital Ambulatory Medical Care Survey comparing patients presenting with a chief complaint of syncope versus seizure to determine likelihood of getting an evaluation for possible life threatening cardiovascular disease. The primary endpoint was receiving an electrocardiogram in the emergency department; secondary endpoint was receiving cardiac biomarkers. RESULTS: There was a total of 144,094 patient encounters. Of these visits, 1,553 had syncope and 1,470 had seizure (60.3% vs. 44.2% female, 19.9% vs. 29.0% non-white). After adjusting for age, sex, mode of arrival and insurance, patients with syncope were more likely to receive an electrocardiogram compared to patients with seizure (odds ratio, 10.86; 95% confidence interval [CI], 8.52 to 13.84). This was true across all age groups (0 to 18 years, 56% vs. 7.5%; 18 to 44 years, 60% vs. 27%; 45 to 64 years, 82% vs. 41%; ≥65 years, 85% vs. 68%; P<0.01 for all). Car- diac biomarkers were also obtained more frequently in adult patients with syncope patients (18 to 44 years, 17.5% vs. 10.5%; 45 to 64 years, 33.8% vs. 21.4%; ≥65 years, 47.1% vs. 32.3%; P<0.01 for all). CONCLUSION: Patients evaluated in the emergency department for syncope received an electrocar- diogram and cardiac biomarkers more frequently than those that had seizure.

Trends in and predictors of hydromorphone administration in US emergency departments (2007-2014).

OBJECTIVE: To examine recent trends in and predictors of hydromorphone administration in US emergency departments (EDs) compared with other opioids. DESIGN: Retrospective review of data from the National Hospital Ambulatory Medical Care Survey from 2007 to 2014. PARTICIPANTS: All adult ED visits where an opioid analgesic was administered were included. MAIN OUTCOME MEASURES: Trends in and predictors of hydromorphone administration were assessed using survey-weighted logistic regression, comparing hydromorphone visits with ED visits where other opioids were administered. RESULTS: From 2007 to 2014, in an estimated 128.9 million US ED visits where opioids were administered, hydromorphone use increased significantly from 30.2 percent in 2007 to 36.8 percent of visits in 2014 (p = 0.027). Hydromorphone accounted for a greater proportion of opioids administered by the end of the study period, compared to other opioids. Patient characteristics associated with hydromorphone were age <65 years, white race, private insurance or Medicare, and severe pain. Patients who received hydromorphone also had indicators of higher severity illness, including more laboratory testing, procedures, and higher admission rates. Common conditions where hydromorphone was administered were headache, back pain, musculoskeletal pain, and abdominal pain. CONCLUSION: From 2007 to 2014, hydromorphone was administered to more than one in three US ED patients who were administered opioids, and several factors predicted its use. High use was found in some conditions where opioid use is inappropriate, suggesting a need for additional initiatives to promote rational prescribing of high-potency opioids.

Alcohol-Related Visits to US Emergency Departments, 2001-2011.

AIMS: Alcohol intoxication is a source of significant illness and injury commonly resulting in emergency department (ED) visits. We characterize recent trends in alcohol-related visits to US EDs using nationally representative data. METHODS: We conducted a retrospective review of data on national ED visits among patients aged 18 years or older with alcohol intoxication between 2001 and 2011 using the National Hospital Ambulatory Medical Care Survey (NHAMCS). Demographic and resource utilization trends in alcohol-related visits were examined. We also assessed ED length of stay (LOS) across the study period, as well as the total hours spent on ED care for alcohol-related complaints. RESULTS: Between 2001-2002 and 2010-2011, alcohol-related visits increased from 2,459,748 to 3,856,346 (P = 0.049). Utilization of resources such as laboratory tests, medications and radiography increased, with the use of advanced imaging (i.e. computed tomography and magnetic resonance imaging) increasing 232.2% (P < 0.001) from 2001-2002 to 2010-2011. Overall LOS increased 16.1% (P = 0.028), while LOS among patients admitted to the hospital increased 24.9% (P = 0.076). Total alcohol-related hours spent in EDs nationwide increased from 5.6 million in 2001 to 11.6 million in 2011, an increase of 108.5% (P < 0.001) compared with an increase in overall ED hours of 54.0% (P < 0.001). CONCLUSION: Alcohol-related ED visits are increasing at a greater rate than overall ED visits and represent a growing burden on hospital resources.

Trends in Opioid Analgesic Use in Encounters Involving Physician Trainees in U.S. Emergency Departments.

BACKGROUND: Opioid analgesic use has increased dramatically in emergency departments (EDs), but the relative contribution of physician trainees has not been explored. We assessed trends in opioid utilization focusing on ED encounters where a physician trainee was involved. METHODS: We studied ED visits from the National Hospital Ambulatory Medical Care Survey, 2001-2011. Adult ED visits in which an opioid was administered in the ED or prescribed at discharge were stratified by whether or not there was trainee involvement. Trends in use over time for five common opioids (codeine, hydrocodone, hydromorphone, morphine, oxycodone) were tested using survey-weighted logistic regression. RESULTS: From 2001-02 to 2009-11, the proportion of ED visits where an opioid analgesic was used increased 31.5% from 21.9% (95% CI: 20.3-23.6) of visits to 28.8% (95% CI: 27.5-30.1). Trainee involvement in ED visits was stable, with 9.3% (95% CI: 7.7-11.3) seen by a trainee in 2001-02 vs. 10.2% (95% CI: 8.1-12.7) in 2010-11. Opioid use in visits with trainee involvement did not change significantly over time relative to visits without a trainee (increase of 36.8% compared to 31.2% without trainees, P = 0.652). Trends in opioid utilization for trainee visits paralleled non-trainee visits. Hydromorphone had the greatest relative increase in use for all providers. Adjusted for patient- and hospital-level factors, the probability of receiving opioids when a trainee was involved increased to a greater extent than among non-trainee visits (30.9% vs. 24.0%). CONCLUSION: Opioid utilization patterns for visits involving trainees reflect similar trends in attending practice, and highlights the more liberal opioid prescribing climate over time.

A retrospective cross-sectional study of patients treated in US EDs and ambulatory care clinics with sexually transmitted infections from 2001 to 2010.

INTRODUCTION: Sexually transmitted infections (STIs) are commonly seen in the ambulatory health care settings such as emergency departments (EDs) and outpatient clinics. Our objective was to assess trends over time in the incidence and demographics of STIs seen in the ED and outpatient clinics compared with office-based clinics using the National Hospital Ambulatory Medical Care Survey and National Ambulatory Medical Care Survey. METHODS: This study was conducted using 10 years of National Hospital Ambulatory Medical Care Survey and National Ambulatory Medical Care Survey data (2001-2010). We compared data from 2001-2005 to data from 2006-2010. Patients were included in analyses if they were 15 years and older and had an International Classification of Diseases, Ninth Revision code consistent with cervicitis, urethritis, chlamydia, gonorrhea, or trichomonas. RESULTS: We analyzed 82.4 million visits for STIs, with 16.5% seen in hospital-based EDs and 83.5% seen in office-based clinics between 2001 and 2010. Compared with patients seen in office-based clinics, ED patients were younger (P< .05), more likely to be male (P< .001) and nonwhite (P< .001), and less likely to have private insurance (P< .05). We found a significant increase in adolescent (15-18 years) ED visits (P< .05) from 2001-2015 to 2006-2010 and a decrease in adolescent and male STI visits in office-based settings (P< .05). CONCLUSION: Although patients with STI are most commonly seen in office-based clinics, EDs represent an important site of care. In particular, ED patients are relatively younger, male, and nonwhite, and less likely to be private insured.

Trends in advanced computed tomography use for injured patients in United States emergency departments: 2007-2010.

OBJECTIVES: Studies have documented increased advanced radiography use in U.S. emergency departments (EDs) for injured patients over the past decade. The authors explored trends in recent years (2007 through 2010) in advanced radiography use, specifically head computed tomography (CT) and nonhead CT scans. METHODS: This was a retrospective analysis of ED visits conducted using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), a representative sample of the U.S. ED visits from 2007 through 2010. All patients designated by the NHAMCS as "related to injury" were included in analyses. CT use was examined by head and nonhead use. Trends, predictors of utilization, and diagnostic yield for head and nonhead CT scans in injured ED patients were analyzed using survey-weighted logistic regression. Diagnostic yield was defined as the proportion of injury-related visits where patients imaged with CT received International Classification of Diseases, 9th Revision (ICD-9), code diagnoses of a severe head or nonhead injury. RESULTS: Among injured ED patients, head CT use increased from 9.6% in 2007 to 11.6%, a relative increase of 20.8% (p < 0.001), and nonhead CT from 5.5% to 7.3%, a relative increase of 47.3% (p < 0.001). Diagnostic yield for head CT was unchanged (4.9% in 2007 vs. 3.4% in 2010, p = 0.093), but fell for nonhead CT from 6.4% in 2007 to 3.3% in 2010 (p = 0.04. CONCLUSIONS: Advanced radiography use has continued to increase since 2007 in injured patients, and diagnostic yield for nonhead CT has continued to fall. Head CT is more common than CTs of other body areas and may represent an opportunity for reduction given validated clinical decision rules.

Predictors of hospital admission after ED observation unit care.

BACKGROUND: Emergency department observation units (EDOUs) represent an opportunity to efficiently manage patients with common conditions requiring short-term hospital care. Understanding which patients are ultimately admitted to the hospital after care in an EDOU may enhance patient selection for EDOU care. METHODS: We conducted a retrospective analysis of US emergency department visits resulting in admission to observation status using the National Hospital Ambulatory Care Survey (NHAMCS) from 2009 to 2010, a nationally representative sample. We used survey-weighted logistic regression to identify predictors at the patient level, visit level, and hospital level for inpatient hospital admission after EDOU care. RESULTS: Between 2009 and 2010, there were 4.65 million patient visits (95% confidence interval [CI], 3.68-5.63) to EDOUs in the United States. Of those evaluated in an EDOU, 40.4% (95% CI, 34.5%-46.6%) were admitted to the hospital after EDOU care. Progressively older patient age was a strong predictor of hospital admission: patients age older than 65 years were more than 5 times more likely to be admitted than patients age younger than 18 years (odds ratio, 5.36; 95% CI, 2.26-12.73). The only other visit-level factor associated with admission was a reason for visit of chest pain; this was associated with a lower rate of hospital admission (odds ratio, 0.61; 95% CI, 0.41-0.91). CONCLUSION: Across the United States in 2009 to 2010, older patient age was a strong predictor of admission after EDOU care, suggesting that older patients are more likely to require inpatient hospital services after EDOU care than younger patients.

Trends in opioid analgesic use for headaches in US emergency departments.

OBJECTIVE: Although not recommended as first line therapy by consensus guidelines, opioid analgesics are commonly used to treat headaches. This study evaluates trends in opioid use for headaches in US emergency departments (EDs). METHODS: We performed a retrospective review of the National Hospital Ambulatory Medical Care Survey, 2001 through 2010. Adult headache-related visits were identified. Medications (opioid and nonopioid) used for the treatment of headache were categorized based on medication class. Trends in ED use of the most common opioids (codeine, hydrocodone, hydromorphone, morphine, and oxycodone) were explored. The proportion of visits for which each medication was used was tabulated, and trends were analyzed using survey-weighted logistic regression. RESULTS: Headache visits during which any opioid was used increased between 2001 (20.6%; 95% confidence interval [CI], 18.1-23.4) and 2010 (35.0%; 95% CI, 31.8-38.4; P < .001). Prescribing of hydromorphone, morphine, and oxycodone increased, with the largest relative increase (461.1%) in hydromorphone (2001, 1.8% [95% CI, 1.2-2.6]; 2010, 10.1% [95% CI, 8.2-12.4]). Codeine use declined, and hydrocodone use remained stable. Use of opioid alternatives, including acetaminophen, butalbital, and triptans did not change over the study period, whereas use of nonsteroidal anti-inflammatory drugs increased from 26.2% (95% CI, 23.0-29.7) to 31.4% (95% CI, 28.6-34.3). Prescribing of antiemetic agents decreased from 24.1% (95% CI, 19.6-29.2) to 23.5% (95% CI, 21.1-26.0). Intravenous fluid use increased from 20.0% (95% CI, 17.0-23.4) to 34.5% (95% CI, 31.0-38.2) of visits. CONCLUSIONS: Despite limited endorsement by consensus guidelines, there was increased use of opioid analgesics to treat headaches in US EDs over the past decade.

US emergency department use by children, 2001-2010.

OBJECTIVE: Children commonly use emergency departments (EDs) for a variety of health care needs. We describe recent trends in US ED use by children. METHODS: This is a cross-sectional analysis of the National Hospital Ambulatory Medical Care Survey, a nationally representative sample of ED visits, and US Census data between 2001 and 2010. We examined demographic trends, visit characteristics, insurance status, disposition, hospital variables, diagnoses, reason for visit, and resource use among patients younger than 19 years. Linear regression was used to evaluate significance of trends. RESULTS: Approximately one quarter of all ED visits was made by patients younger than 19 years. Emergency department visits by children increased 14.4% between 2001 and 2010 (P = 0.04); the rate of visits increased from 36.4 to 40.6 per 100 population. Trauma is the most common reason for pediatric ED visits. Black children had the highest rate of ED use (61.9 per 100 in 2010). Visit rates by Hispanic children were relatively low but increased by 82.7% since 2001 (P = 0.00). The proportion of ED visits by Medicaid beneficiaries rose from 32.0% to 51.9% (P = 0.00). The volume and frequency of diagnostic testing, administration of intravenous fluids, medication administration, and discharge prescriptions increased. Visits with computed tomography or magnetic resonance imaging almost doubled from 3.1% of the visits in 2001 to 6.6% of the visits in 2010 (P = 0.00). CONCLUSIONS: The use of ED by children is growing faster than population growth, and the intensity of ED care has risen sharply. Hispanic children and Medicaid beneficiaries represent the fastest growing populations of children using the ED.

The impact of race on analgesia use among pediatric emergency department patients.

We studied the effect of race on analgesia use in potentially pain-related pediatric emergency department visits using the National Hospital Ambulatory Medical Care Survey (2005-2010). There were independent patient- and hospital-level racial disparities when it came to the type of analgesia used, suggesting black children are treated differently even within hospitals with high numbers of black patients.

Rising rates of proton pump inhibitor prescribing in US emergency departments.

OBJECTIVE: There have been mounting safety concerns over increasing prescription rates for proton pump inhibitors (PPIs). Trends in PPI use have not been studied in emergency departments (EDs). We characterize trends in PPI use in US EDs. METHODS: We used data from the National Hospital Ambulatory Care Survey, from 2001 to 2010, focusing on encounters with a reason for visit with a potential indication for a PPI, histamine receptor (H2) blocker, or antacid. Patient, provider, visit, and hospital-level factors associated with increases in PPI use were evaluated. RESULTS: Among included visits, ED PPI prescribing more than doubled from 3.0 (95% confidence interval [CI]: 2.4-3.8) to 7.2% (95% CI: 6.3-8.3) from 2001 to 2010. Histamine receptor blocker use decreased from 6.8% (95% CI: 6.0-7.7) to 5.7% (95% CI: 4.9-6.7) and antacids from 7.2% (95% CI: 6.3-8.2) to 5.5% (95% CI: 4.8-6.3). Proton pump inhibitor prescribing was higher in males and whites yet increased across all demographics, including in adults aged 65 years and older. Proton pump inhibitor prescribing increased significantly in all US regions and across all hospital and payer types. Pantoprazole was the agent with the largest increase in use. CONCLUSIONS: Over the past decade, there have been considerable increases in PPI prescribing in US EDs. This trend occurred despite rising safety concerns, even in populations at higher risk for adverse events such as older adults. More education may be needed to ensure that ED providers are familiar with indications for PPIs.