Pregnancy and Emergency Department Utilization in North Carolina, 2016-2021: A Population-Based Surveillance Study.

Introduction: Pregnancy-associated complaints are a common reason for emergency department visits for women of reproductive age. Emergency department utilization during pregnancy is associated with worse birth outcomes for both mothers and infants. We used statewide North Carolina emergency department surveillance data between 2016 and 2021 to describe the sociodemographic factors associated with the use of emergency department for pregnancy-associated problems and subsequent hospital admission. Methods: North Carolina Disease Event Tracking and Epidemiologic Collection Tool is a syndromic surveillance system that includes all emergency department encounters at civilian acute-care facilities in North Carolina. We analyzed all emergency department visits between January 1, 2016 and December 31, 2021 for female patients aged 15-44 years residing in North Carolina with at least 1 ICD-10-CM code (analysis occurred in July 2021-October 2022). Each emergency department visit was categorized as pregnancy-associated if assigned ICD-10-CM code(s) indicated pregnancy. We stratified visits by age, race, ethnicity, county of residence, and insurance and compared them with estimated pregnant population proportions using 1-sample t-tests. We used multivariable logistic regression to determine whether pregnancy-associated visits were more likely to be associated with hospital admission and then to determine sociodemographic predictors of admission among pregnancy-associated emergency department visits. Results: More than 6.4 million emergency department visits were included (N=6,471,197); 10.1% (n=655,476) were pregnancy-associated, significantly higher than the proportion of women estimated to be pregnant at any given time in North Carolina (4.6%, p<0.0001) and increased over time (8.6% in 2016 vs 11.1% in 2021, p<0.0001). Pregnancy-associated visits were lower than expected for ages 25-44 years and higher than expected for those aged 15-24 years, for those of Black race, and for patients residing in rural or suburban areas. The proportion admitted was higher for pregnancy-associated emergency department visits than for nonpregnancy associated (15.6% vs 7.0%, AOR=3.06 [95% CI=3.03, 3.09]). Pregnancy-associated emergency department visits for patients of Black race had 0.58 times (95% CI=0.57, 0.59) the odds of admission compared with White patients. Conclusions: Emergency department utilization during pregnancy is common. The proportion of pregnancy-associated emergency department visits among reproductive-age women is increasing, as are inpatient admissions from the emergency department for pregnancy-associated diagnoses. Use of public health surveillance databases such as the North Carolina Disease Event Tracking and Epidemiologic Collection Tool may help identify opportunities for improving disparities in maternal health care, especially related to access to care.

Informing COVID-19 Response and Health Equity Agenda: Collection of Public Health Reports Articles on Emerging Viral Epidemics in the United States, 1878-2021.

OBJECTIVE: Public Health Reports (PHR) is the oldest public health journal in the United States and has reported on viral epidemics since the 19th century. We describe the creation and analysis of a collection of historic PHR articles on emerging viral epidemics in the United States to inform public health response to COVID-19 and future epidemics. METHODS: We searched databases from 1878 through 2021 using custom search strings and conducted a manual search for articles published under previously used names for PHR. We evaluated all articles based on inclusion/exclusion criteria and coded the final list for virus/disease, article type, public health emergency preparedness and response capabilities from the Centers for Disease Control and Prevention (CDC), and PubMed citation count. RESULTS: We identified 349 relevant articles including 130 commentaries/reviews/editorials, 79 epidemiologic reports, 75 research articles, and 65 case study/practice articles. The collection focused on influenza (n = 244), COVID-19 (n = 75), dengue (n = 14), and other emerging viruses, such as Zika and Ebola (n = 25). The collection included 48 articles on health disparities/health of various disadvantaged populations, highlighting such disparities as race and ethnicity (n = 22), socioeconomic status (n = 17), and age (n = 15). When we categorized articles by CDC public health emergency preparedness and response capabilities, we found that 207 addressed surveillance and epidemiologic investigation, 36 addressed community preparedness, and 28 addressed medical countermeasure dispensing and administration. The articles addressing surveillance and epidemiologic investigation, nonpharmaceutical interventions, and community preparedness had the most PubMed citations (799, 334, and 308, respectively). CONCLUSIONS: PHR's historic articles on US emerging viral epidemics covered a range of virus/disease types, emergency preparedness and response capabilities, and contribution types and were widely cited in the scholarly literature. This publicly available and continuously updated collection is a valuable resource for pandemic planning and response.

Linking Emergency Medical Services and Emergency Department Data to Improve Overdose Surveillance in North Carolina.

INTRODUCTION: Linking emergency medical services (EMS) data to emergency department (ED) data enables assessing the continuum of care and evaluating patient outcomes. We developed novel methods to enhance linkage performance and analysis of EMS and ED data for opioid overdose surveillance in North Carolina. METHODS: We identified data on all EMS encounters in North Carolina during January 1-November 30, 2017, with documented naloxone administration and transportation to the ED. We linked these data with ED visit data in the North Carolina Disease Event Tracking and Epidemiologic Collection Tool. We manually reviewed a subset of data from 12 counties to create a gold standard that informed developing iterative linkage methods using demographic, time, and destination variables. We calculated the proportion of suspected opioid overdose EMS cases that received International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes for opioid overdose in the ED. RESULTS: We identified 12 088 EMS encounters of patients treated with naloxone and transported to the ED. The 12-county subset included 1781 linkage-eligible EMS encounters, with historical linkage of 65.4% (1165 of 1781) and 1.6% false linkages. Through iterative linkage methods, performance improved to 91.0% (1620 of 1781) with 0.1% false linkages. Among statewide EMS encounters with naloxone administration, the linkage improved from 47.1% to 91.1%. We found diagnosis codes for opioid overdose in the ED among 27.2% of statewide linked records. PRACTICE IMPLICATIONS: Through an iterative linkage approach, EMS-ED data linkage performance improved greatly while reducing the number of false linkages. Improved EMS-ED data linkage quality can enhance surveillance activities, inform emergency response practices, and improve quality of care through evaluating initial patient presentations, field interventions, and ultimate diagnoses.

A Mixed-Methods Comparison of a National and State Opioid Overdose Surveillance Definition.

OBJECTIVES: We assessed the differences between the first version of the Centers for Disease Control and Prevention (CDC) opioid surveillance definition for suspected nonfatal opioid overdoses (hereinafter, CDC definition) and the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT) surveillance definition to determine whether the North Carolina definition should include additional International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes and/or chief complaint keywords. METHODS: Two independent reviewers retrospectively reviewed data on North Carolina emergency department (ED) visits generated by components of the CDC definition not included in the NC DETECT definition from January 1 through July 31, 2018. Clinical reviewers identified false positives as any ED visit in which available evidence supported an alternative explanation for patient presentation deemed more likely than an opioid overdose. After individual assessment, reviewers reconciled disagreements. RESULTS: We identified 2296 ED visits under the CDC definition that were not identified under the NC DETECT definition during the study period. False-positive rates ranged from 2.6% to 41.4% for codes and keywords uniquely identifying ≥10 ED visits. Based on uniquely identifying ≥10 ED visits and a false-positive rate ≤10.0%, 4 of 16 ICD-10-CM codes evaluated were identified for NC DETECT definition inclusion. Only 2 of 25 keywords evaluated, "OD" and "overdose," met inclusion criteria to be considered a meaningful addition to the NC DETECT definition. PRACTICE IMPLICATIONS: Quantitative and qualitative trends in coding and keyword use identified in this analysis may prove helpful for future evaluations of surveillance definitions.

Use of statewide emergency department surveillance data to assess incidence of animal bite injuries among humans in North Carolina.

OBJECTIVE--To determine incidence of animal bite injuries among humans in North Carolina by use of statewide emergency department visit data; to evaluate incidence rates on the basis of age, sex, urbanicity, biting species, and month for selected species; and to characterize bite-related emergency department visits. DESIGN--Retrospective cohort and cross-sectional study. SAMPLE--Records of 38,971 incident animal bite-related emergency department visits in North Carolina from 2008 to 2010. PROCEDURES--Emergency department visits were selected for inclusion by means of external-cause-of-injury codes assigned with an international coding system and keyword searches of chief complaint and triage notes. Rates were calculated with denominators obtained from census data. Cross-sectional analysis of incident emergency department visits was performed. RESULTS--By the age of 10, a child in North Carolina had a 1 in 50 risk of dog bite injury requiring an emergency department visit. Incidence rates for dog bites were highest for children ≤ 14 years of age, whereas the incidence rate for cat bites and scratches was highest among individuals > 79 years of age. Lifetime risk of cat bite or scratch injury requiring an emergency department visit was 1 in 60 for the population studied. Rabies postexposure prophylaxis was administered during 1,664 of 38,971 (4.3%) incident visits. CONCLUSIONS AND CLINICAL RELEVANCE--Emergency department visit surveillance data were used to monitor species-specific bite incidence statewide and in various subpopulations. Emergency department surveillance data may be particularly useful to public health veterinarians. Results may inform and renew interest in targeted animal bite prevention efforts.

North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT) and the National Hospital Ambulatory Medical Care Survey (NHAMCS): comparison of emergency department data.

The North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT) is a near-real-time database of emergency department (ED) visits automatically extracted from hospital information system(s) in the state of North Carolina. The National Hospital Ambulatory Medical Care Survey (NHAMCS) is a retrospective probability sample survey of visits to U.S. hospital EDs. This report compares data from NC DETECT (2006) with NHAMCS (2005) ED visit data to determine if the two data sets are consistent. Proportions, rates, and confidence intervals (CIs) were calculated for ED visits by age and gender; arrival method and age; expected source of payment; disposition; hospital admissions; NHAMCS top 20 diagnosis groups and top five primary diagnoses by age group; International Classifications of Disease, 9th revision, Clinical Modification (ICD-9-CM) primary diagnosis codes; and cause of injury. North Carolina DETECT captured 79% of statewide ED visits. Twenty-eight persons for every 100 North Carolina residents visited a North Carolina ED that reports to NC DETECT at least once in 2006, compared to 20% nationally. Twenty-seven percent of ED visits in North Carolina had private insurance as the expected payment source, compared with 40% nationwide. The proportion of injury-related ED visits in North Carolina is 25%, compared to 36.4% nationally. Rates and proportions of disease groups are similar. Similarity of NC DETECT rates and proportions to NHAMCS provides support for the face and content validity of NC DETECT. The development of statewide near-real-time ED databases is an important step toward the collection, aggregation, and analysis of timely, population-based data by state, to better define the burden of illness and injury for vulnerable populations.