Emergency department patient payer status after implementation of the Affordable Care Act: A nationwide analysis using NHAMCS data.

OBJECTIVE: To evaluate changes in insurance status among emergency department (ED) patients presenting in the two years immediately before and after full implementation of the Affordable Care Act (ACA). METHODS: We evaluated National Hospital Ambulatory Medical Care Survey (NHAMCS) Emergency Department public use data for 2012-2015, categorizing patients as having any insurance (private; Medicare; Medicaid; workers' compensation) or no insurance. We compared the pre- and post-ACA frequency of insurance coverage-overall and within the older (≥65), working-age (18-64) and pediatric (<18) subpopulations-using unadjusted odds ratios with 95% confidence intervals. We also conducted a difference-in-differences analysis comparing the change in insurance coverage among working-age patients with that observed for older Medicare-eligible patients, while controlling for sex, race and underlying temporal trends. RESULTS: Overall, the proportion of ED patients with any insurance did not significantly change from 2012 to 2013 to 2014-2015 (74.2% vs 77.7%) but the proportion of working-age adult patients with at least one form of insurance increased significantly, from 66.0% to 71.8% (OR 1.31, CI: 1.13-1.52). The difference-in-differences analysis confirmed the change in insurance coverage among working-age adults was greater than that seen in the reference population of Medicare-eligible adults (AOR 1.70, CI: 1.29-2.23). The increase was almost entirely attributable to increased Medicaid coverage. CONCLUSION: In the first two years following full implementation of the ACA, there was a significant increase in the proportion of working-age adult ED patients who had at least one form of health insurance. The increase appeared primarily associated with expansion of Medicaid.

A review of oral anticoagulants, old and new, in major bleeding and the need for urgent surgery.

Oral anticoagulants, old and new, are effective therapies for prevention and treatment of venous thromboembolism and reduction of stroke risk in patients with atrial fibrillation. However, blocking elements of the clotting cascade carries an inherent risk of bleeding. Also, anticoagulated patients sometimes require urgent surgery or invasive procedures. This has led to the emergence of a body of scientific literature on the reversal of anticoagulation in these two settings. Traditionally, vitamin K antagonists (VKAs), which indirectly inactivate clotting factors II, VII, IX and X (and natural anticoagulant proteins C and S), had been the mainstay of oral anticoagulation for half a century. Only a few years ago, the US Food and Drug Administration (FDA) approved a specific VKA reversal agent, 4-Factor Prothrombin Complex Concentrate (4F-PCC). The last decade has seen the rise of non-Vitamin K oral anticoagulants (NOACs), which target specific factors, i.e. Factors IIa and Xa. Investigators have rapidly developed reversal agents for these agents as well, idarucizumab for the Factor IIa inhibitor dabigatran (Pradaxa) and andexanet alfa for the entire class of Factor Xa inhibitors (FXaIs), currently four drugs: rivaroxaban (Xarelto), apixaban (Eliquis), edoxaban (Savaysa) and betrixaban (Bevyxxa). Clinicians still use off-label PCC for reversing FXaIs in some settings, and a universal reversal agent, ciraparantag, remains in development. This review summarizes the safety and efficacy of these reversal agents in the setting of anticoagulant-associated major bleeding and the need for urgent surgery.

The characteristics of dockless electric rental scooter-related injuries in a large U.S. city.

OBJECTIVE: To describe the characteristics of dockless electric rental scooter ("e-scooter")-related injuries presenting to two emergency departments in one large U.S. city. METHODS: This observational cohort study utilized the city's public health syndromic surveillance system to prospectively identify patients with e-scooter-related injuries presenting between September and November 2018. The medical records for all adult patients treated at the two participating emergency departments were manually reviewed to extract demographic and clinical data. Cases involving mobility scooters or non-electric scooters were excluded. RESULTS: For the 124 included adult patients with e-scooter-related injuries, the median age was 30 years (IQR: 22-43), they were predominantly male (59.7%), and approximately half (51.6%) arrived by ambulance. Falling from the scooter (84.7%) was the most common mechanism; twelve patients (9.7%) had collided with a motor vehicle. Head and face injuries (45.5%) were common; only 2 patients (1.6%) were documented as wearing a helmet at the time of injury. Most patients (n = 112, 90.3%) required imaging, more than half (n = 78, 62.9%) required an emergency department procedure, and 26 (21.0%) required surgical intervention. Most patients were discharged home, but 35 (28.2%) were admitted to hospital. Two patients (1.6%) were admitted to the intensive care unit. CONCLUSIONS: E-scooters are an emerging transportation technology associated with a wide range of potentially serious injuries that consume substantial emergency department and hospital resources. Head injuries are a particular concern, as few e-scooter riders are wearing helmets at the time of injury.