Diagnostic testing and treatment of low back pain in United States emergency departments: a national perspective.

STUDY DESIGN: This study is an analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS), a large sample representative of all emergency department (ED) visits throughout the United States. OBJECTIVE: To use NHAMCS to describe the frequency of ED visits for the treatment of low back pain, and the diagnostic and therapeutic strategies employed by emergency clinicians. SUMMARY OF BACKGROUND DATA: Low back pain is common in the general population. While it accounts for 2.5% of all outpatient office visits, the role of the ED has yet to be described. METHODS: We included cases if they had both a reason for visit related to back pain and a primary ED discharge ICD9 code consistent with low back pain. The outcomes included frequency of ED use, and frequency of various diagnostic and therapeutic strategies. Individual patient visits are weighted so that data can be extrapolated to all ED visits throughout the United States. RESULTS: Low back pain related disorders caused 2.63 million (95% CI: 2.32, 2.93 million) annual ED visits in the US. Of all patients with low back pain, 30.5% (28.1, 32.9) had a plain radiograph; 9.6% (95% CI: 7.2, 12.6) had a CT or MRI in 2006 compared with 3.2% (95% CI: 2.0, 5.1) in 2002 (P for trend <0.01). Age and type of insurance were associated with advanced imaging, though geographic region was not. Of medications either administered in the ED or prescribed at discharge, the most frequently used classes were opioids (61.0%, 95% CI: 58.4, 63.5), followed by nonsteroidal anti-inflammatory drugs (49.9%, 95% CI: 47.2, 52.7) and muscle relaxants (43.1%, 95% CI: 40.4, 45.8). CONCLUSION: Low back pain related disorders are a frequent cause of ED visit. Diagnostic imaging is performed in one-third of all patients. There was a strong secular trend in use of advanced imaging; patients were nearly 3 times as likely to receive a CT or MRI in 2006 as they were 4 years earlier. Although opioids were administered or prescribed to two-thirds of patients, use of therapeutic agents was generally in keeping with guideline recommendations.

Applying the International Classification of Headache Disorders to the emergency department: an assessment of reproducibility and the frequency with which a unique diagnosis can be assigned to every acute headache presentation.

STUDY OBJECTIVE: Although almost 2 decades have passed since the International Headache Society first introduced its International Classification of Headache Disorders (ICHD), the applicability of this classification scheme in the emergency department (ED) has not been assessed. As a first step toward identifying the role the ICHD should play in the ED, we address 2 questions: Can a structured interview and adherence to the ICHD allow ED headache patients to be classified in a reproducible manner? With the ICHD, how often can one specific diagnosis be assigned to each ED headache presentation? METHODS: This was a structured interview and medical record review of patients with nontraumatic headache, performed in an urban ED from March 2004 through August 2005. Using the data from the interview and the subject's ED record, 2 emergency medicine investigators independently classified each of the headaches twice: first, to determine presence or absence of a primary headache disorder, and then to determine presence or absence of a secondary headache disorder. If a primary headache was present, it was further classified as migraine, tension-type headache, trigeminal autonomic cephalalgia, chronic daily headache, or primary headache unclassifiable. Interobserver discordance was adjudicated by an experienced headache specialist. RESULTS: Four hundred eighty patients were enrolled in the study. The emergency medicine investigators had a high level of interobserver agreement on secondary headaches (agreement 94% [95% confidence interval (CI) 92% to 96%]) and primary headaches (agreement 91% [95% CI 88% to 93%]). Among the 480 subjects, 122 (25%) had a secondary headache disorder, 309 (64%) had a primary headache disorder, 49 (10%) had a coexisting primary and secondary headache, and for 95 (20%) subjects, neither a primary nor a secondary headache could be diagnosed. Of 309 subjects with a primary headache, 186 (60%) had migraine, 34 (11%) had tension-type headache, 2 (1%) had trigeminal autonomic cephalalgia, and 77 (26%) had an unclassifiable primary headache. Overall, a specific ICHD headache diagnosis could not be assigned to 36% of subjects either because a specific primary headache disorder could not be identified or because neither a primary nor a secondary headache disorder could be diagnosed. CONCLUSION: Although a detailed structured interview in the ED and adherence to the ICHD resulted in reproducible classification of headache patients, more than one third of acute headache patients could not readily be given a specific ICHD diagnosis in the ED.

Status report: Development of emergency medicine research since the Macy Report.

In Williamsburg, VA, April 17 to 20, 1994, the Josiah Macy, Jr. Foundation sponsored a conference entitled "The Role of Emergency Medicine in the Future of American Medical Care," a report on which was published in Annals in 1995. This report promulgated recommendations for the development and enhancement of academic departments of emergency medicine and a conference to develop an agenda for research in emergency medicine. The American College of Emergency Physicians' Research Committee, along with several ad hoc members, presents updates in several of the areas addressed by the Macy Report and subsequent conferences, as a status report for the development of emergency medicine research as a whole, as of late 2002.

Report of the task force on residency training information (2002-2003), American Board of Emergency Medicine.

The American Board of Emergency Medicine gathers extensive background information on emergency medicine residents and the programs in which they train. We present the sixth annual report on the status of US emergency medicine residency programs.

Report of the task force on residency training information (2001-2002), American Board of Emergency Medicine.

The American Board of Emergency Medicine gathers extensive background information on emergency medicine residents and the programs in which they train. We present the fifth annual report on the status of US emergency medicine residency programs