A brief educational intervention may increase public acceptance of emergency research without consent.

OBJECTIVES: We hypothesized that knowing the regulations regarding emergency research without consent would increase public support for this type of research. METHODS: Randomized controlled trial. Consecutive patients presenting during eight 24-h periods received one of two interviews; the intervention interview included an educational paragraph. RESULTS: There were 473 (74% of eligible) patients who participated: 51% (95% confidence interval [CI] 46-55) were willing to be enrolled in a study using exception to informed consent; 84% (95% CI 80-87) believed that current therapy for cardiac arrest offers ≥ 50% chance of full recovery, and these patients were less willing to enroll (odds ratio [OR] 0.5, 95% CI 0.3-0.9). The educational intervention increased willingness to enroll (OR 1.3, 95% CI 1.0-1.6, p = 0.03). CONCLUSIONS: A brief educational intervention had only a modest effect on willingness to participate in emergency research without consent. It may be more important to educate patients on the shortcomings of current therapy than on the ethical and regulatory justifications for such research.

Disconnect between charted vestibular diagnoses and emergency department management decisions: a cross-sectional analysis from a nationally representative sample.

OBJECTIVES: The most common vestibular disorders seen in the emergency department (ED) are benign paroxysmal positional vertigo (BPPV) and acute peripheral vestibulopathy (APV; i.e., vestibular neuritis or labyrinthitis). BPPV and APV are two very distinct disorders that have different clinical presentations that require different diagnostic and treatment strategies. BPPV can be diagnosed without imaging and is treated with canalith-repositioning maneuvers. APV sometimes requires neuroimaging by magnetic resonance imaging (MRI) to exclude posterior fossa stroke mimics and should be treated with vestibular sedatives and corticosteroids. We sought to determine if emergency physicians (EPs) apply best practices to diagnose and treat these common vestibular disorders. METHODS: This was a cross-sectional study of ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS). A weighted sample of U.S. ED visits (1993-2005) was used. Patients at least 16 years of age who were given a final ED diagnosis of BPPV (International Classification of Diseases, 9th Revision [ICD-9], 386.11) or APV (ICD-9 386.12 or 386.3x) comprised the study population. The frequency of imaging and drug therapy in those diagnosed as BPPV or APV versus controls was the main outcome measure. RESULTS: A total of 9,472 dizzy patient visits were sampled over 13 years (weighted estimate 33.6 million U.S. ED visits over that period). A weighted estimate of 2.5 million patients (7.4%) were given a vestibular diagnosis, mostly BPPV (weighted 0.2 million) or APV (weighted 1.9 million). Patients given BPPV (19%) and APV (19%) diagnoses were more likely to undergo imaging (all by computed tomography [CT]) than controls (7%; p < 0.001). Patients given BPPV (58%) and APV (70%) diagnoses were more likely to receive meclizine than controls (0.1%; p < 0.001). Corticosteroid administration was rarely documented (2% BPPV, 1% APV). CONCLUSIONS: Patients given a vestibular diagnosis in the ED may not be managed optimally. Patients given BPPV and APV diagnoses undergo imaging (predominantly CT) with equal frequency, suggesting overuse of CT (BPPV) and probably underuse of MRI (APV). Most patients diagnosed with BPPV are given meclizine, which is not indicated. Specific therapy for APV (corticosteroids) is probably underutilized. Educational initiatives and clinical guidelines merit consideration.

Spectrum of dizziness visits to US emergency departments: 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.

Inappropriate use of antibiotics for acute asthma in United States emergency departments.

OBJECTIVES: The aim was to examine the use of antibiotics to treat asthma patients in U.S. emergency departments (EDs). The authors sought to investigate inappropriate antibiotic prescriptions by identifying the frequency and predictors of antibiotics prescribed for asthma exacerbations using data from two sources, the National Hospital Ambulatory Medical Care Survey (NHAMCS) and the National Emergency Department Safety Study (NEDSS). METHODS: The authors used data from NHAMCS and NEDSS to identify the proportion of ED visits for asthma exacerbations that resulted in the prescription of an antibiotic. NHAMCS provided national data from 1993 through 2004, while NEDSS provided data from 63 primarily academic EDs from 2003 through 2006. Univariate analysis and multivariate logistic regression modeling were used to identify variables associated with antibiotic administration. RESULTS: Analysis of NHAMCS data revealed that 22% (95% confidence interval [CI] = 20% to 24%) of acute asthma visits resulted in an antibiotic prescription from 1993 through 2004, with no significant change in prescribing frequency over the 12-year period. NEDSS data from 2003 through 2006 showed that 18% (95% CI = 17% to 19%) of acute asthma cases in academic EDs received an antibiotic. Multivariate modeling of NHAMCS data revealed that African American patients (odds ratio [OR] = 0.8; 95% CI = 0.6 to 0.97) and patients in urban EDs (OR = 0.5; 95% CI = 0.4 to 0.7) were less likely to receive antibiotics for asthma exacerbations than white patients and patients in nonurban EDs, respectively. NHAMCS analysis also found that patients in the South were more likely to receive antibiotics than those in the Northeast (OR = 1.4; 95% CI = 1.1 to 1.9). A NEDSS multivariate model found a similar difference, with African Americans (OR = 0.6; 95% CI = 0.4 to 0.8) and Hispanics (OR = 0.6; 95% CI = 0.4 to 0.8) being less likely than whites to receive an antibiotic. CONCLUSIONS: ED treatment of acute asthma with unnecessary antibiotics is likely to contribute to bacterial antibiotic resistance. Interventions are needed to reduce inappropriate antibiotic prescriptions and to address disparities in asthma care.

United States emergency department visits for vaginal bleeding during early pregnancy, 1993-2003.

OBJECTIVE: The purpose of this study was to describe the epidemiology of emergency department (ED) visits for vaginal bleeding during early pregnancy (VBEP). STUDY DESIGN: We analyzed data from the National Hospital Ambulatory Medical Care Survey, 1993-2003. Cases presented with a complaint of vaginal bleeding and had diagnoses consistent with presentation during early pregnancy. RESULTS: Over the 11-year period, there were 5.4 million visits for VBEP, which represents 1.6% of all ED visits or almost 500,000 visits/year. ED visits for VBEP increased from 5.6-7.8 visits per 1000 US population (P for trend < .01). The population rates were highest in the 20-29 year age group. ED patients with VBEP were more likely to be black, Hispanic, and uninsured, as compared to women presenting for other reasons. CONCLUSION: ED visits for VBEP are rising, particularly among younger and Hispanic women. Programs that ensure primary obstetric care would help decrease reliance on the ED for this important condition.

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.

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

INTRODUCTION: While 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. METHODS: Seizure 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. RESULTS: Seizure 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). CONCLUSION: Seizures 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.

Increasing US emergency department visit rates and subsequent hospital admissions for atrial fibrillation from 1993 to 2004.

STUDY OBJECTIVE: Atrial fibrillation is a significant public health problem that is becoming increasingly prevalent. The clinical epidemiology of US emergency department (ED) visits for atrial fibrillation is uncertain. This study seeks to describe recent trends in ED visits for atrial fibrillation. METHODS: ED visits with a primary diagnosis of atrial fibrillation were analyzed using data from the US National Hospital Ambulatory Medical Care Survey, 1993 to 2004. RESULTS: During the 12-year period, there were approximately 2.7 million (95% confidence interval [CI] 2.4 to 3.0 million) ED visits for atrial fibrillation in the United States, and the population-adjusted visit rate increased from 0.6 to 1.2 per 1,000 US population (P for trend=.02). Similarly, the absolute number of visits increased 88%, from 300,000 (95% CI 209,000 to 392,000) in 1993 to 1994 to 564,000 (95% CI 423,000 to 705,000) in 2003 to 2004. Approximately 64% (95% CI 59% to 69%) of these patients were admitted to the hospital, a rate that remained constant throughout the 12-year period (P for trend=.73). Admission rates were significantly lower in the western region of the United States (48%; 95% CI 36% to 60% versus 76%; in the Northeast, 95% CI 68% to 84%). Patient characteristics and ED management did not materially differ by admission status. In a multivariate model, congestive heart failure was the only predictor of admission but accounted for only 14% of admissions. CONCLUSION: From 1993 to 2004, the population-adjusted rate of ED visits for atrial fibrillation increased, whereas the proportion admitted to the hospital remained stable. Patient characteristics and ED management were similar regardless of admission status, and there were relatively few predictors of admission.

Direct medical costs of acute pancreatitis hospitalizations in the United States.

OBJECTIVES: To determine the direct medical costs of hospitalizations for acute pancreatitis in the United States and analyze the demographic characteristics of hospitalized patients. METHODS: We searched the 2003 Healthcare Cost and Utilization Project-National Inpatient Sample for hospitalizations with a primary discharge diagnosis of acute pancreatitis. These were analyzed with respect to patient demographics, hospitalization rates, and total hospital charges and costs. RESULTS: The estimated total cost for acute pancreatitis admissions was $2.2 billion (95% confidence interval [CI], 2.0 billion-2.3 billion) at a mean cost per hospitalization of $9870 (95% CI, 9300-10,400), and a mean cost per hospital day of $1670 (95% CI, 1620-1720). Costs per hospitalization were higher in urban hospitals, teaching hospitals, and for patients older than 65 years, based on a longer length of stay (LOS). The hospitalization rate was 0.52 per 1000 US population (95% CI, 0.48-0.56) for whites versus 0.76 per 1000 (95% CI, 0.65-0.87) for blacks. CONCLUSIONS: Acute pancreatitis hospitalizations cost more than $2 billion annually, and certain population groups (blacks and older patients) have disproportionately high hospitalization rates. This study highlights the need for prevention efforts, particularly targeting high-risk groups, and for further studies to identify cost effective treatment strategies for acute pancreatitis.

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

No studies have examined U.S. burn epidemiology from the perspective of the Emergency Department. We sought to describe patient characteristics, injury types, and Emergency Department practice patterns. Data were collected from the National Hospital Ambulatory Medical Care Survey between 1993 and 2004. Emergency Department visit rates for burn injury decreased from 1993 to 2004 with a peak of 2.8 (95% confidence interval [CI] 2.1-3.4) per 1000 U.S. population in 1995 and a nadir of 1.6 (95% CI 1.2-2.0) per 1000 in 2004. The Emergency Department visit rate for burn injuries was greater for men than women (2.7 [95% CI 2.4-3.0] vs 1.8 [95% CI 1.6-2.0] per 1000) and for black than white subjects (3.4 [95% CI 2.8-3.9] vs 2.1 [95%CI 1.9-2.3] per 1000), though all these groups showed decreases. Emergency Department visit rates for burns were greatest in the first and third decades (3.3 [95% CI 2.8-3.7] and 3.5 [95% CI 3.0-4.0] per 1000, respectively) and decreased thereafter. The upper extremity was the most commonly burned part of the body (37% of total) and most burns of specified depth were partial thickness (48% of total). Less than half of patients received analgesics (47%) or topical antibiotics (38%). Emergency Department visits for burns are declining, but rates remain high in men, black individuals, and children. Burn-prevention efforts should target these groups. Upper-extremity and partial-thickness injuries are common, and less than half of patients receive analgesics or topical antibiotics. Collaboration between burn specialists and Emergency Department personnel should focus on the care of these types of injuries.

US outpatient office visits for bronchiolitis, 1993-2004.

OBJECTIVE: To describe the clinical epidemiology of US outpatient visits for children younger than 2 years with bronchiolitis. METHODS: Data were obtained from the 1993-2004 National Ambulatory Medical Care Survey. Visits had ICD-9 code 466 and were restricted to patients younger than 2 years. National estimates were obtained by using assigned patient visit weights and reported with 95% confidence intervals (95% CIs) calculated by the relative standard error of the estimate; analysis included the chi2 test. RESULTS: From 1993 to 2004, bronchiolitis accounted for approximately 198 outpatient visits representing 8.75 million visits for children younger than 2 years. Among this same age group, the overall rate was 103 (95% CI, 83, 124) per 1000 US children and 17 (95% CI, 13, 20) per 1000 visits. When we compared bronchiolitis visits to all nonbronchiolitis visits, we found that those with bronchiolitis were less likely to be from the Northeast (12% vs 22%; P < .05) and more likely to be admitted to the hospital (2% vs 0.4%; P < .05). Fifty-two percent were prescribed albuterol; diagnostic tests were uncommon. CONCLUSIONS: The annual number of outpatient office visits for bronchiolitis among children younger than 2 years has remained stable over the last decade but has averaged almost 750,000 visits per year. More than half of primary care providers are prescribing medications to children with bronchiolitis.

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

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.

Increasing United States hospital admissions for acute pancreatitis, 1988-2003.

PURPOSE: To examine the epidemiology of hospital admissions for acute pancreatitis in the United States. METHODS: We compiled data from the 1988-2003 National Hospital Discharge Survey and analyzed it with respect to patient demographics, hospital type and region, procedures performed, length of hospital stay, and inpatient mortality. RESULTS: Hospital admissions for acute pancreatitis increased from a 1988 low of 101,000 (95% confidence interval [CI]: 87,000-116,000) to a 2002 peak of 210,000 (95% CI: 186,000-234,000). The corresponding admission rate increased from 0.4 to 0.7 hospitalizations per 1000 U.S. population (p = 0.001). The patients' average age was 53 years, 51% were male, and 23% were black. The hospitalization rate was higher among blacks (0.9; 95% CI, 0.6-1.1) than among whites (0.4; 95% CI, 0.3-0.5). The mean length of stay was 6.9 days and decreased over the study period. Overall mortality was 2%, with increasing age and male gender comprising independent risk factors for death. CONCLUSIONS: The hospitalization rate for acute pancreatitis in the United States is rising and is higher in blacks than in whites. Further research is necessary to identify the cause(s) of increasing pancreatitis admissions, the observed racial disparity, and the cost of these admissions.

U.S. emergency department visits for supraventricular tachycardia, 1993-2003.

BACKGROUND: Supraventricular tachycardia (SVT) is often described as a recurrent condition that leads to emergency department (ED) visits. However, the epidemiology of ED visits for SVT is unknown. OBJECTIVES: To define the frequency of SVT in U.S. EDs and to analyze patient characteristics, ED management, and disposition for such visits. METHODS: The authors analyzed data from the National Hospital Ambulatory Medical Care Survey, 1993-2003. SVT cases were identified by using the International Classification of Diseases, Ninth Revision, Clinical Modification codes 426.7 or 427.0 in any of the three diagnostic fields. RESULTS: Of the 1.1 billion ED visits over the 11-year study period, an estimated 555,000 (0.05%; 95% confidence interval [CI] = 0.04% to 0.06%) were related to SVT. The annual frequency and population rate appear stable between 1993 and 2003 (p for trend = 0.35). Compared with non-SVT visits, those with SVT were more likely to be older than 65 years of age (26% vs. 15%, p < 0.01) and female (70% vs. 53%, p < 0.01). Electrocardiograms were documented for most visits (91%; 95% CI = 85% to 96%). Approximately half of the patients (51%; 95% CI = 40% to 61%) received an atrioventricular nodal blocking medication, most frequently adenosine (26%; 95% CI = 17% to 36%). SVT visits ended in hospital admission for 24% (95% CI = 15% to 34%). At the other extreme, 44% (95% CI = 32% to 56%) were discharged without planned follow-up. CONCLUSIONS: Supraventricular tachycardia accounts for approximately 50,000 ED visits each year. Higher visit rates in older adults and female patients are consistent with prior studies of SVT in the general population. This study provides an epidemiologic foundation that will enable future research to assess and improve clinical management strategies of SVT in the ED.

Declining antibiotic prescriptions for upper respiratory infections, 1993-2004.

OBJECTIVES: To examine antibiotic prescribing trends for U.S. emergency department (ED) visits with upper respiratory tract infections (URIs) between 1993 and 2004. METHODS: Data were compiled from the National Hospital Ambulatory Medical Care Survey (NHAMCS). URI visits were identified by using ICD-9-CM code 465.9, whereas antibiotics were identified using the National Drug Code Directory class Antimicrobials. A multivariate logistic regression model revealed sociodemographic and geographic factors that were independently associated with receipt of an antibiotic prescription for URIs. RESULTS: There were approximately 23.4 million ED visits diagnosed as URIs between 1993 and 2004. Although the proportion of URI diagnoses remained relatively stable (ptrend = 0.26), a significant decrease in provision of antibiotic prescriptions for URIs occurred during this 12-year period, from a maximum of 55% in 1993, to a minimum of 35% in 2004. Patients who were prescribed antibiotics were more likely to be white than African American and to have been treated in EDs located in the southern United States. CONCLUSIONS: Antibiotic prescribing for URIs continues to decrease, a favorable trend that suggests that national efforts to reduce inappropriate antibiotic usage are having some success. Nevertheless, the frequency of antibiotic treatment for URI in the ED remains high (35%). Future efforts to reduce inappropriate antibiotic prescribing may focus on patients and physicians in southern U.S. EDs. Additional work is needed to address continued evidence of race-related disparities in care.

National study of United States emergency department visits for acute pancreatitis, 1993-2003.

BACKGROUND: The epidemiology of acute pancreatitis in the United States is largely unknown, particularly episodes that lead to an emergency department (ED) visit. We sought to address this gap and describe ED practice patterns. METHODS: Data were collected from the National Hospital Ambulatory Medical Care Survey between 1993 and 2003. We examined demographic factors and ED management including medication administration, diagnostic imaging, and disposition. RESULTS: ED visits for acute pancreatitis increased over the study period from the 1994 low of 128,000 visits to a 2003 peak of 318,000 visits (p = 0.01). The corresponding ED visit rate per 10,000 U.S. population also increased from 4.9 visits (95%CI, 3.1-6.7) to 10.9 (95%CI, 7.6-14.3) (p = 0.01). The average age for patients making ED visits for acute pancreatitis during the study period was 49.7 years, 54% were male, and 27% were black. The ED visit rate was higher among blacks (14.7; 95%CI, 11.9-17.5) than whites (5.8; 95%CI, 5.0-6.6). At 42% of ED visits, patients did not receive analgesics. At 10% of ED visits patients underwent CT or MRI imaging, and at 13% of visits they underwent ultrasound testing. Two-thirds of ED visits resulted in hospitalization. Risk factors for hospitalization were older age (multivariate odds ratio for each increasing decade 1.5; 95%CI, 1.3-1.8) and white race (multivariate odds ratio 2.3; 95%CI, 1.2-4.6). CONCLUSION: ED visits for acute pancreatitis are rising in the U.S., and ED visit rates are higher among blacks than whites. At many visits analgesics are not administered, and diagnostic imaging is rare. There was greater likelihood of admission among whites than blacks. The observed race disparities in ED visit and admission rates merit further study.

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 149,000 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 543 million dollars, with a mean cost of 3799 dollars per hospitalization. Mean cost of bronchiolitis with a codiagnosis of pneumonia was 6191 dollars. In a multivariate analysis controlling for 3 confounding factors (including length of stay), cost per hospitalization was higher for children > or = 1 year and lower for those in the South versus Northeast. CONCLUSIONS: Bronchiolitis admissions cost more than 500 million dollars 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.

National study of emergency department visits for sepsis, 1992 to 2001.

STUDY OBJECTIVE: Epidemiologic data on emergency department (ED) patients with sepsis are limited. Inpatient discharge records from 1979 to 2000 show that hospitalizations for sepsis are increasing. We examine the epidemiology of sepsis in US EDs and the hypothesis that sepsis visits are increasing. METHODS: The National Hospital Ambulatory Medical Care Survey data (1992 to 2001) provided nationally representative estimates of frequency and disposition in adult ED visits for sepsis. Sepsis visits were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes; severe sepsis was defined as sepsis in conjunction with organ failure. RESULTS: Of 712 million adult visits during the 10-year period, approximately 2.8 million (0.40%, 95% confidence interval [CI] 0.33% to 0.46%) were related to sepsis. We found no significant increase in overall ED visits for sepsis from 1992 to 2001 (P for trend=.09). ED patients with sepsis were more likely to be elderly, non-Hispanic, and publicly insured and to arrive by ambulance compared with nonsepsis patients (all P<.01). The overall admission rate was 87% (95% CI 82% to 92%), with only 12% (95% CI 8% to 16%) of patients admitted to the ICU. The most frequent codiagnoses were pneumonia (13%), urinary tract infection (13%), and dehydration (11%). Severe sepsis accounted for 8% (95% CI 5% to 11%) of sepsis visits, for an annual incidence of 0.01%; 98% of patients with severe sepsis were admitted. CONCLUSION: In contrast to data from hospital discharges, ED visits for sepsis demonstrated no increase. Most ED visits for sepsis resulted in admission to non-critical care units.

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

INTRODUCTION: Understanding ambulance utilization patterns is essential to assessing prehospital system capacity and preparedness at the national level. OBJECTIVE: To describe the characteristics of patients transported to U.S. emergency departments (EDs) by ambulance and to determine predictors of ambulance utilization. METHODS: Data were obtained from the National Hospital Ambulatory Medical Care Survey using mode of arrival, demographic and visit information, ICD-9-CM E and V-codes, and classified reasons for the visit. RESULTS: The rates for ED visits of persons conveyed by ambulence were stable between 1997 and 2003, consisting of approximately one in every seven ED visits (14%). In 2003, there were 16.2 million ED visits for which an ambulance was used in the U.S. However, for patients with mental health visits, nearly one in three ED presentations (31%) arrived by ambulance. Significantly higher rates of ambulance use were associated with: (1) mental health visits; (2) older age; (3) African-Americans; (4) Medicare or self-pay insurance status; (5) urban ED location; (6) U.S. regions outside of the South; (7) presentation between 12 midnight to 0800 hours; (8) injury-related visits; (9) urgent visit status; and/or (10) those resulting in hospital admission. Among mental health patients, older age, self-pay insurance status, urban ED location, regions outside the southern US, and urgent visit classification predicted ambulance use. Ambulance usage within the mental health group was highest for suicide and lowest for mood and anxiety disorder-related visits. CONCLUSION: Reliance on ambulance services varies by age, insurance status, geographic factors, time of day, urgency of visit, subsequent admission status, and type of mental health disorder. Even after controlling for many confounding factors, mental health problems remain an important predictor of ambulance use.