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1.
Artigo em Inglês | MEDLINE | ID: mdl-32001253

RESUMO

Anaphylaxis is an acute, potential life-threatening systemic allergic reaction that may have a wide range of clinical manifestations. Severe anaphylaxis and/or the need for repeated doses of epinephrine to treat anaphylaxis are risk factors for biphasic anaphylaxis. Antihistamines and/or glucocorticoids are not reliable interventions to prevent biphasic anaphylaxis, although evidence supports a role for antihistamine and/or glucocorticoid premedication in specific chemotherapy protocols and rush aeroallergen immunotherapy. Evidence is lacking to support the role of antihistamines and/or glucocorticoid routine premedication in patients receiving low- or iso-osmolar contrast material to prevent recurrent radiocontrast media anaphylaxis. Epinephrine is the first-line pharmacotherapy for uniphasic and/or biphasic anaphylaxis. After diagnosis and treatment of anaphylaxis, all patients should be kept under observation until symptoms have fully resolved. All patients with anaphylaxis should receive education on anaphylaxis and risk of recurrence, trigger avoidance, self-injectable epinephrine education, referral to an allergist, and be educated about thresholds for further care.

2.
Am J Emerg Med ; 2019 Dec 09.
Artigo em Inglês | MEDLINE | ID: mdl-31839521

RESUMO

OBJECTIVES: The Elderly Risk Assessment (ERA) score is a validated index for primary care patients that predict hospitalizations, mortality, and Emergency Department (ED) visits. The score incorporates age, prior hospital days, marital status, and comorbidities. Our aim was to validate the ERA score in ED patients. METHODS: Observational cohort study of patients age ≥ 60 presenting to an academic ED over a 1-year period. Regression analyses were performed for associations with outcomes (hospitalization, return visits and death). Medians, interquartile range (IQR), odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS: The cohort included 27,397 visits among 18,607 patients. Median age 74 years (66-82), 48% were female and 59% were married. Patients from 54% of visits were admitted to the hospital, 16% returned to the ED within 30 days, and 18% died within one year. Higher ERA scores were associated with: hospital admission (score 10 [4-16] vs 5 [1-11], p < 0.0001), return visits (11 [5-17] vs 7 [2-13], p < 0.0001); and death within one year (14 [7-20] vs 6 [2-13], p < 0.0001). Patients with ERA score ≥ 16 were more likely to be admitted to the hospital, OR 2.14 (2.02-2.28, p < 0.0001), return within 30 days OR 1.99 (1.85-2.14), and to die within a year, OR 2.69 (2.54-2.85). CONCLUSION: The ERA score can be automatically calculated within the electronic health record and helps identify patients at increased risk of death, hospitalization and return ED visits. The ERA score can be applied to ED patients, and may help prognosticate the need for advanced care planning.

3.
Artigo em Inglês | MEDLINE | ID: mdl-31786255

RESUMO

The true global scale of anaphylaxis remains elusive, because many episodes occur in the community without presentation to health care facilities, and most regions have not yet developed reliable systems with which to monitor severe allergic events. The most robust data sets currently available are based largely on hospital admissions, which are limited by inherent issues of misdiagnosis, misclassification, and generalizability. Despite this, there is convincing evidence of a global increase in rates of all-cause anaphylaxis, driven largely by medication- and food-related anaphylaxis. There is no evidence of parallel increases in global all-cause anaphylaxis mortality, with surprisingly similar estimates for case-fatality rates at approximately 0.5% to 1% of fatal outcomes for hospitalizations due to anaphylaxis across several regions. Studying regional patterns of anaphylaxis to certain triggers have provided valuable insights into susceptibility and sensitizing events: for example, the link between the mAb cetuximab and allergy to mammalian meat. Likewise, data from published fatality registers can identify potentially modifiable risk factors that can be used to inform clinical practice, such as prevention of delayed epinephrine administration, correct posturing during anaphylaxis, special attention to populations at risk (such as the elderly on multiple medications), and use of venom immunotherapy in individuals at risk of insect-related anaphylaxis.

4.
Artigo em Inglês | MEDLINE | ID: mdl-31704438

RESUMO

BACKGROUND: Biphasic reaction rates and potential associated risk factors are not well understood. OBJECTIVE: To evaluate biphasic reaction rates and associated risk factors. METHODS: We prospectively enrolled patients with anaphylaxis at 2 Midwestern academic emergency departments (EDs). We gathered data using patient and ED provider surveys and a structured health record review. Biphasic reaction rates and clinically significant biphasic reaction rates, defined as recurrent reactions that met anaphylaxis diagnostic criteria or were treated with epinephrine, were calculated. Characteristics associated with biphasic reactions were assessed with logistic regression and reported with odds ratios (ORs) and 95% CIs. RESULTS: Of 430 ED anaphylaxis visits, 31 (7.2%) patients had biphasic reactions; 22 (5.1%) had clinically significant biphasic reactions. The median time from anaphylaxis onset to first epinephrine dose was longer for patients with biphasic (78 minutes) than uniphasic courses (45 minutes) (P = .005). A biphasic course was associated with an ED setting of first epinephrine dose (OR, 3.72; 95% CI, 1.36-10.14) and a delay of more than 30 minutes from symptom onset to first epinephrine dose (OR, 3.39; 95% CI, 1.13-10.18), and was inversely associated with arrival by ambulance (OR, 0.18; 95% CI, 0.05-0.61). A clinically significant biphasic reaction was associated with an ED setting of first epinephrine dose (OR, 3.32; 95% CI, 1.08-10.25) and inversely associated with arrival by ambulance (OR, 0.08; 95% CI, 0.01-0.61). CONCLUSIONS: Biphasic reactions and clinically significant biphasic reactions occurred in 7.2% and 5.1% of ED anaphylaxis patients, respectively. Delayed epinephrine administration was associated with biphasic reactions.

5.
West J Emerg Med ; 20(5): 760-769, 2019 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-31539333

RESUMO

INTRODUCTION: Angioedema represents self-limited, localized swelling of submucosal or subcutaneous tissues. While the underlying etiology may be undeterminable in the emergent setting, nonhistaminergic and histaminergic angioedema respond differently to therapeutic interventions, with implications for empiric treatment. Clinical features and outcome differences among nonhistaminergic vs histaminergic angioedema patients in the emergency department (ED) are poorly characterized. We aim to describe the clinical characteristics and outcomes among ED patients with angioedema by suspected etiology. METHODS: This was a 10-year retrospective study of adult ED patients with angioedema, using data abstracted from the electronic health record. We evaluated univariable associations of select clinical features with etiology and used them to develop a multivariable logistic regression model for nonhistaminergic vs histaminergic angioedema. RESULTS: Among 450 adult angioedema patients, the mean +/- standard deviation age was 57 +/- 18 years, and 264 (59%) were female. Among patients, 30% had suspected nonhistaminergic angioedema, 30% had suspected histaminergic angioedema, and 40% were of unknown etiology. As compared to histaminergic angioedema, nonhistaminergic angioedema was associated with angiotensin-converting enzyme inhibitors (ACEI) or use of angiotensin II receptor blockers (ARB) (odds ratio [OR] [60.9]; 95% confidence interval [CI], 23.16-160.14) and time of onset one hour or more prior to ED arrival (OR [5.91]; 95% CI,1.87-18.70) and was inversely associated with urticaria (OR [0.05]; 95% CI, 0.02-0.15), dyspnea (OR [0.23]; 95% CI, 0.08-0.67), and periorbital or lip edema (OR [0.25]; 95% CI, 0.08-0.79 and OR [0.32]; 95% CI, 0.13-0.79, respectively). CONCLUSION: As compared to histaminergic angioedema, patients with nonhistaminergic angioedema were more likely to present one hour or more after symptom onset and take ACEI or ARB medications, and were less likely to have urticaria, dyspnea, or periorbital or lip angioedema. Identification of characteristics associated with the etiology of angioedema may assist providers in more rapidly initiating targeted therapies.


Assuntos
Angioedema/terapia , Gerenciamento Clínico , Serviço Hospitalar de Emergência , Previsões , Angioedema/diagnóstico , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Registros Eletrônicos de Saúde , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
6.
Am J Emerg Med ; 37(8): 1409-1415, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30361150

RESUMO

OBJECTIVE: To characterize pediatric Emergency Medicine Service (EMS) transports to the Emergency Department (ED) using a national claims database. METHODS: We included children, 18 years and younger, transported by EMS to an ED, from 2007 to 2016 in the OptumLabs Data Warehouse. ICD-9 and ICD-10 diagnosis codes were used to categorize disease system involvement. Interventions performed were extracted using procedure codes. ED visit severity was measured by the Minnesota Algorithm. RESULTS: Over a 10-year period, 239,243 children were transported. Trauma was the most frequent diagnosis category for transport for children ≥5 years of age, 35.1% (age 6-13) and 32.7% (age 14-18). The most common diagnosis category in children <6 years of age was neurologic (29.3%), followed by respiratory (23.1%). Over 10 years, transports for mental disorders represented 15.3% in children age 14 to 18, and had the greatest absolute increase (rate difference + 10.4 per 10,000) across all diagnoses categories. Neurologic transports also significantly increased in children age 14 to 18 (rate difference + 6.9 per 10,000). Trauma rates decreased across all age groups and had its greatest reduction among children age 14 to 18 (rate difference - 6.8 per 10,000). Across all age groups, an intervention was performed in 15.6%. Most children (83.3%) were deemed to have ED care needed type of visit, and 15.8% of the transports resulted in a hospital admission. CONCLUSION: Trauma is the most frequent diagnosis for transport in children older than 5 years of age. Mental health and neurologic transports have markedly increased, while trauma transports have decreased. Most children arriving by ambulance were classified as requiring ED level of care. These changes might have significant implication for EMS personnel and policy makers.


Assuntos
Serviços Médicos de Emergência/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Setor Privado/estatística & dados numéricos , Transporte de Pacientes/estatística & dados numéricos , Adolescente , Distribuição por Idade , Ambulâncias/estatística & dados numéricos , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Revisão da Utilização de Seguros , Masculino , Doenças do Sistema Nervoso/epidemiologia , Doenças do Sistema Nervoso/terapia , Transtornos do Neurodesenvolvimento/epidemiologia , Transtornos do Neurodesenvolvimento/terapia , Doenças Respiratórias/epidemiologia , Doenças Respiratórias/terapia , Distribuição por Sexo , Estados Unidos/epidemiologia , Ferimentos e Lesões/etiologia , Ferimentos e Lesões/terapia
7.
Ann Allergy Asthma Immunol ; 121(6): 717-721.e1, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30189249

RESUMO

BACKGROUND: Anaphylaxis is a potentially life-threatening allergic reaction with a strong risk of recurrence. OBJECTIVE: To assess risk factors associated with recurrent anaphylaxis-related emergency department (ED) visits within 1 year of an ED visit for anaphylaxis in a large observational cohort study. METHODS: We used an administrative claims database to identify patients seen from 2008 through 2012 in the ED for anaphylaxis based on an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code algorithm. Patients with at least 2 years of continuous enrollment in a health plan were included. Multivariable logistic regression analysis was used to determine associations with recurrence of anaphylaxis within 1 year. RESULTS: During the 5-year study period, 7,367 patients (median age, 42 years; <18 years old, 23.3%) met the inclusion criteria. The most common anaphylaxis trigger was unspecified (56.2%), followed by food (25.3%), medication (14.6%), and venom (3.9%). Overall, 3.0% of patients had an additional anaphylaxis-related ED visit within 1 year (3.61 episodes per 100 patient-years). On multivariable analysis, risk factors associated with anaphylaxis recurrence were food trigger (odds ratio [OR], 2.31; 95% confidence interval [CI], 1.34-3.99), history of asthma (OR, 1.30; 95% CI, 1.13-1.51), and intensive care unit admission at the index anaphylaxis event (OR, 1.95; 95% CI, 1.41-2.69). CONCLUSION: In this contemporary cohort study, history of asthma, food trigger, and greater index anaphylaxis severity, as measured by intensive care unit admission, were associated with a higher likelihood of a recurrent anaphylaxis-related ED visit within 1 year.


Assuntos
Anafilaxia/epidemiologia , Hipersensibilidade a Drogas/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Hipersensibilidade Alimentar/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anafilaxia/diagnóstico , Criança , Pré-Escolar , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologia , Peçonhas/toxicidade , Adulto Jovem
8.
West J Emerg Med ; 19(4): 693-700, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30013706

RESUMO

Introduction: Anaphylaxis continues to cause significant morbidity and mortality. Healthcare providers struggle to promptly recognize and appropriately treat anaphylaxis patients. The goal of this study was to characterize anaphylaxis-related malpractice lawsuits. Methods: We collected jury verdicts, settlements, and court opinions regarding alleged medical malpractice involving anaphylaxis from May 2011 through May 2016 from an online legal database (Thomson Reuters Westlaw). Data were abstracted onto a standardized data form. Results: We identified 30 anaphylaxis-related malpractice lawsuits. In 80% of cases, the trigger was iatrogenic (40% intravenous [IV] contrast, 33% medications, 7% latex). Sixteen (53%) cases resulted in death, 7 (23%) in permanent cardiac and/or neurologic damage, and 7 (23%) in less severe outcomes. Fourteen (47%) of the lawsuits were related to exposure to a known trigger. Delayed recognition or treatment was cited in 12 (40%) cases and inappropriate IV epinephrine dosing was reported in 5 (17%) cases. Defendants were most commonly physicians (n=15, 50%) and nurses (n=5, 17%). The most common physician specialties named were radiology and primary care (n=3, 10% each), followed by emergency medicine, anesthesiology, and cardiology (n=2, 7% each). Among the 30 cases, 14 (47%) favored the defendant, 8 (37%) resulted in findings of negligence, 3 (10%) cases settled, and 5 (17%) had an unknown legal outcome. Conclusion: Additional anaphylaxis education, provision of epinephrine autoinjectors or other alternatives to reduce dosing errors, and stronger safeguards to prevent administration of known allergens would all likely reduce anaphylaxis-related patient morbidity and mortality and providers' legal vulnerability to anaphylaxis-related lawsuits.


Assuntos
Anafilaxia/diagnóstico , Anafilaxia/terapia , Imperícia/legislação & jurisprudência , Erros Médicos/estatística & dados numéricos , Adulto , Anafilaxia/mortalidade , Criança , Medicina de Emergência , Epinefrina/administração & dosagem , Feminino , Humanos , Masculino , Médicos/legislação & jurisprudência , Atenção Primária à Saúde , Radiologia
9.
Pediatr Allergy Immunol ; 29(5): 538-544, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29663520

RESUMO

BACKGROUND: Food is the leading cause of anaphylaxis in children seen in emergency departments in the United States, yet data on emergency department visits and hospitalizations related to food-induced anaphylaxis are limited. The objective of our study was to examine national time trends of pediatric food-induced anaphylaxis-related emergency department visits and hospitalizations. METHODS: We conducted an observational study using a national administrative claims database from 2005 through 2014. Participants were younger than 18 years with an emergency department visit or hospitalization for food-induced anaphylaxis. Outcome measures of our study included time trends of pediatric food-induced anaphylaxis-related emergency department visits and hospitalizations, including observations (in an emergency department or a hospital unit), inpatient admissions, and intensive care unit admissions. RESULTS: During the study period, participants had 7310 food-induced anaphylaxis-related emergency department visits. Emergency department visits for food-induced anaphylaxis increased by 214% (P < .001); the highest rates were in infants and toddlers (age 0-2 years). Rates of emergency department visits significantly increased in all age-groups, with the highest increase in adolescents (age 13-17 years: 413%; P < .001). Peanuts accounted for the highest rates (5.85 per 100 000 in 2014) followed by tree nuts/seeds (4.62 per 100 000 in 2014). The greatest increase in rates of emergency department visits for food-induced anaphylaxis occurred with tree nuts/seeds (373.0% increase during the study period). CONCLUSIONS: The incidence of food-induced anaphylaxis has significantly increased over time in children of all ages. Food-induced anaphylaxis in children is an important national public health concern.


Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Anafilaxia/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Hipersensibilidade Alimentar/epidemiologia , Hospitalização/estatística & dados numéricos , Adolescente , Alérgenos/imunologia , Criança , Feminino , Alimentos , Humanos , Lactente , Recém-Nascido , Masculino , Estados Unidos
10.
Am J Emerg Med ; 36(11): 2029-2034, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-29631923

RESUMO

OBJECTIVE: Psychiatric patient boarding in emergency department (ED) is a severe and growing problem. In July 2013, Minnesota implemented a law requiring jailed persons committed to state psychiatric facilities be transferred within 48-h of commitment. This study aims to quantify the effect of this law on a large ED's psychiatric patient flow. METHODS: A pre- and post- comparison of 2011-2015 ED length of stay (LOS) for adult psychiatric patients was performed using electronic medical record data. Comparisons of the median LOS were assessed using a segmented regression model with time series error, and risk differences (RD) were used to determine changes in the proportion of patients with LOS ≥3 and ≥5days. Changes in patient disposition proportions were assessed using risk ratios. RESULTS: The median ED LOS for patients admitted for psychiatric care increased by 5.22h from 2011 to 2015 (95% CI: (4.33, 7.15)), while the frequency of patient encounters remained constant. Although no significant difference in the rate of ED LOS increase was found pre- and post- implementation, the proportion of adults with LOS ≥3days and ≥15days increased (RD 0.017 (95% CI: (0.013, 0.021)); 0.002 (95% CI: (0.001,0.004)), respectively). CONCLUSIONS: The proportion of ED adult psychiatric patients experiencing prolonged LOS increased following the implementation of a statewide law requiring patients committed through the criminal justice system be transferred to a state psychiatric hospital within 48h. Identifying characteristics of subsets of psychiatric patients disproportionally affected could suggest focused healthcare system improvements to improve ED psychiatric care.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Transtornos Mentais/terapia , Adulto , Humanos , Minnesota , Estudos Retrospectivos , Fatores de Tempo
11.
BMC Health Serv Res ; 18(1): 154, 2018 03 02.
Artigo em Inglês | MEDLINE | ID: mdl-29499700

RESUMO

BACKGROUND: The decision to obtain a computed tomography CT scan in the emergency department (ED) is complex, including a consideration of the risk posed by the test itself weighed against the importance of obtaining the result. In patients with limited access to primary care follow up the consequences of not making a diagnosis may be greater than for patients with ready access to primary care, impacting diagnostic reasoning. We set out to determine if there is an association between CT utilization in the ED and patient access to primary care. METHODS: We performed a cross-sectional study of all ED visits in which a CT scan was obtained between 2003 and 2012 at an academic, tertiary-care center. Data were abstracted from the electronic medical record and administrative databases and included type of CT obtained, demographics, comorbidities, and access to a local primary care provider (PCP). CT utilization rates were determined per 1000 patients. RESULTS: A total of 595,895 ED visits, including 98,001 visits in which a CT was obtained (16.4%) were included. Patients with an assigned PCP accounted for 55% of all visits. Overall, CT use per 1000 ED visits increased from 142.0 in 2003 to 169.2 in 2012 (p < 0.001), while the number of annual ED visits remained stable. CT use per 1000 ED visits increased from 169.4 to 205.8 over the 10-year period for patients without a PCP and from 118.9 to 142.0 for patients with a PCP. Patients without a PCP were more likely to have a CT performed compared to those with a PCP (OR 1.57, 95%CI 1.54 to 1.58; p < 0.001). After adjusting for age, gender, year of visit and number of comorbidities, patients without a PCP were more likely to have a CT performed (OR 1.20, 95% CI 1.18 to 1.21, p < 0.001). CONCLUSIONS: The overall rate of CT utilization in the ED increased over the past 10 years. CT utilization was significantly higher among patients without a PCP. Increased availability of primary care, particularly for follow-up from the ED, could reduce CT utilization and therefore decrease costs, ED lengths of stay, and radiation exposure.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Acesso aos Serviços de Saúde/estatística & dados numéricos , Atenção Primária à Saúde , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Registros Eletrônicos de Saúde , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem
12.
J Allergy Clin Immunol Pract ; 6(5): 1553-1558.e1, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29449164

RESUMO

BACKGROUND: ß-Blocker use has been associated with increased anaphylaxis severity. OBJECTIVE: We aimed to assess for an association between ß-blocker use and requirement for more than 1 dose of epinephrine for anaphylaxis management. METHODS: We conducted a retrospective observational study of patients seen in our emergency department for anaphylaxis between April 2008 and January 2015. The primary outcome measure was the number of doses of epinephrine. Associations with repeat epinephrine administration (>1 vs ≤1 dose of epinephrine) and associations with any epinephrine administration (>0 vs 0 dose) were evaluated using logistic regression models and summarized as odds ratio (OR) and 95% CIs. The study was powered to detect a 10% or greater difference in need for repeat epinephrine administration between patients who were and were not taking ß-blocker medications. RESULTS: Of 789 patient visits with a documented medication history included in the study, 63 (8%) required more than 1 epinephrine dose and 83 (11%) were on ß-blocker therapy. Among patients who required more than 1 epinephrine dose, 8 (13%) were taking a ß-blocker, compared with 75 patients (10%) who received 0 or 1 dose of epinephrine (OR, 1.26; 95% CI, 0.58-2.75). Among patients who required at least 1 epinephrine dose, 41 (9%) were taking a ß-blocker, compared with 42 patients (12%) who received no epinephrine (OR, 0.73; 95% CI, 0.46-1.14). CONCLUSIONS: ß-Blocker use may not be clinically significant with regard to the need for epinephrine dosing among emergency department patients with anaphylaxis.


Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Anafilaxia/tratamento farmacológico , Broncodilatadores/uso terapêutico , Uso de Medicamentos/estatística & dados numéricos , Epinefrina/uso terapêutico , Adolescente , Adulto , Anafilaxia/epidemiologia , Cálculos da Dosagem de Medicamento , Serviço Hospitalar de Emergência , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos/epidemiologia , Adulto Jovem
13.
Popul Health Manag ; 21(3): 172-179, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28486061

RESUMO

The objective was to examine the impact of a multipayer patient-centered medical home (PCMH) on health care utilization for behavioral health patients seen at a tertiary care emergency department (ED). A retrospective health records review was performed for PCMH and non-PCMH patients who presented and received a psychiatric consultation during a 2-year period in the ED of the Mayo Clinic Hospital in Rochester, Minnesota. Univariable and multivariable associations with the outcomes of admission and return visits within 72 hours were evaluated using logistic regression models and summarized with odds ratios (ORs) and 95% confidence intervals (CIs). There were 5398 visits among 3815 patients during the study period. Among these, there were 2440 (45%) PCMH patient visits. There were 2983 (55%) total patient visits resulting in an admission. In a univariable model, PCMH patients (53%) were less likely to be admitted from the ED compared with non-PCMH patients (57%) (OR 0.84; 95% CI 0.76-0.94; P = 0.002) and this remained statistically significant (OR 0.83; 95% CI 0.74-0.93; P = 0.001) after multivariable adjustment. Among the 2415 non-admitted patients, there was no significant difference in returns within 72 hours between PCMH patients (13%) and non-PCMH patients (12%) (OR 1.12; 95% CI 0.83-1.43; P = 0.36). PCMH membership was associated with a lower probability of inpatient hospitalization from the ED. PCMH interventions may be associated with a reduction in health care utilization.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Transtornos Mentais/terapia , Assistência Centrada no Paciente/estatística & dados numéricos , Adolescente , Adulto , Feminino , Humanos , Masculino , Transtornos Mentais/epidemiologia , Minnesota , Estudos Retrospectivos , Adulto Jovem
14.
J Allergy Clin Immunol Pract ; 6(3): 1002-1009.e2, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-28941671

RESUMO

BACKGROUND: Although the incidence of anaphylaxis appears to be increasing, trends in anaphylaxis-related health care utilization are not well understood. OBJECTIVE: To better understand the potential increasing health care burden, we analyzed the changes in anaphylaxis-related health care utilization, including emergency department (ED) discharges, observation stays, inpatient admissions, intensive care unit admissions, and endotracheal intubations. METHODS: We conducted an observational study examining outcomes of anaphylaxis-related ED visits between January 1, 2005, and December 31, 2014. We analyzed administrative claims data from OptumLabs Data Warehouse, which includes more than 100 million Medicare Advantage and privately insured enrollees in the United States. We studied trends in the proportions of ED-related anaphylaxis visits based on demographic characteristics, triggers, and ED disposition for our study population. RESULTS: Among 56,212 anaphylaxis-related ED visits during a 10-year period, the proportion of patient observation/inpatient admissions increased by 37.6% (P = .02), from 13.2% of anaphylaxis-related ED visits in 2005 to 18.2% in 2014. The proportion of patients admitted to the intensive care unit increased by 27.4% (P = .001), from 4.5% in 2005 to 5.8% in 2014. Proportions of endotracheal intubation increased by 145.2% (P < .001). CONCLUSIONS: The increasing proportions of observation/inpatient admissions, intensive care unit admissions, and endotracheal intubations suggest an increase in anaphylaxis severity. Enhanced awareness of these trends among patients, practitioners, and the community is necessary to create effective strategies to prevent anaphylaxis and decrease associated adverse consequences.


Assuntos
Anafilaxia/epidemiologia , Serviço Hospitalar de Emergência , Hospitalização/estatística & dados numéricos , Hipersensibilidade/epidemiologia , Intubação Intratraqueal/estatística & dados numéricos , Adolescente , Adulto , Feminino , Humanos , Incidência , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Estados Unidos/epidemiologia , Adulto Jovem
15.
West J Emerg Med ; 18(5): 835-845, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28874935

RESUMO

INTRODUCTION: Our goal was to investigate trends in computed tomography (CT) utilization in emergency departments (EDs) and its association with hospitalization. METHODS: We conducted an analysis of an administrative claims database of U.S. privately insured and Medicare Advantage enrollees. We identified ED visits from 2005 through 2013 and assessed for CT use, associated factors, and hospitalization after CT, along with patient demographics. We used both descriptive methods and regression models adjusted for year, age, sex, race, geographic region, and Hwang comorbidity score to explore associations among CT use, year, demographic characteristics, and hospitalization. RESULTS: We identified 33,144,233 ED visits; 5,901,603 (17.8%) involved CT. Over time, CT use during ED visits increased 59.9%. CT use increased in all age groups but decreased in children since 2010. In propensity-matching analysis, odds of hospitalization increased with age, comorbidities, male sex, and CT use (odds ratio, 2.38). Odds of hospitalization over time decreased more quickly for patients with CT. CONCLUSION: CT utilization in the ED has increased significantly from 2005 through 2013. For children, CT use after 2010 decreased, indicating caution about CT use. Male sex, older age, and higher number of comorbidities were predictors of CT in the ED. Over time, odds of hospitalization decreased more quickly for patients with CT.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Hospitalização/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Tomografia Computadorizada por Raios X/tendências , Estados Unidos/epidemiologia , Adulto Jovem
16.
West J Emerg Med ; 18(5): 884-893, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28874941

RESUMO

INTRODUCTION: Our goal was to describe the pattern and identify risk factors of early-return ED visits or inpatient admissions following an index mental health and substance abuse (MHSA)-related ED visit in the United States. METHODS: We performed a retrospective cohort study using Optum Labs Data Warehouse, a nationally representative database containing administrative claims data on privately insured and Medicare Advantage enrollees. Authors identified patients presenting to an ED with a primary diagnosis of MHSA between 2005 and 2013 who were discharged home. Study inclusion required continuous insurance enrollment for the 12 months preceding and the 31 days following the index ED visit. During the study period we included only the first ED visit for each patient. RESULTS: A total of 49,672 (14.2%) had a return visit to the ED or had a hospitalization within 30 days following discharge. Mean time to the next ED visit or inpatient admission was 11.7 days. An increased age (age 65+ vs. age <18 years; OR 1.65, 95% CI [1.57 to 1.74]), chronic medical comorbidities (Hwang comorbidity 5+ vs 0; OR 1.31, 95% CI [1.27 to 1.35]), prior ED and inpatient utilization (4+ visits vs 0 visits; OR 5.59, 95% CI [5.41 to 5.78]) were associated with return visits within 30 days following discharge. CONCLUSION: In an analysis of nearly 350,000 ED visits for MHSA, 14.2 % of patients returned to the ED or hospital within 30 days. This study identified a number of factors associated with return visits for acute care.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Transtornos Mentais/terapia , Transtornos Relacionados ao Uso de Substâncias/terapia , Adolescente , Adulto , Idoso , Bases de Dados Factuais , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Masculino , Transtornos Mentais/epidemiologia , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Estados Unidos/epidemiologia , Adulto Jovem
17.
Ann Allergy Asthma Immunol ; 119(5): 452-458.e1, 2017 11.
Artigo em Inglês | MEDLINE | ID: mdl-28916424

RESUMO

BACKGROUND: National guidelines recommend that patients with anaphylaxis be prescribed an epinephrine auto-injector (EAI) and referred to an allergy/immunology (A/I) specialist. OBJECTIVE: To evaluate guideline concordance and identify predictors of EAI dispensing and A/I follow-up in patients with anaphylaxis treated in the emergency department (ED). METHODS: We identified patients seen in the ED for anaphylaxis from 2010 through 2014 from an administrative claims database using an expanded International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code algorithm. RESULTS: Of 7,790 patients identified, 46.5% had an EAI dispensed and 28.8% had A/I follow-up within 1 year after discharge. On multivariable analysis, those 65 years or older (odds ratio [OR] 0.35, 95% confidence interval [CI] 0.30-0.41) and with a medication trigger (OR 0.24, 95% CI 0.21-0.28) had a lower likelihood of EAI dispensing. Those younger than 5 years (OR 2.67, 95% CI 2.15-3.32) and with food (OR 1.40, 95% CI 1.24-1.59) or venom (OR 4.48, 95% CI 3.51-5.72) triggers had a higher likelihood of EAI dispensing. Similarly, for A/I follow-up, the likelihood was lower for age 65 years or older (OR 0.46, 95% CI 0.39-0.54) and medication trigger (OR 0.66, 95% CI 0.56-0.78) and higher for age younger than 5 years (OR 3.15, 95% CI 2.63-3.77) and food trigger (OR 1.39, 95% CI 1.22-1.58). CONCLUSION: Overall, 46.5% of patients with anaphylaxis in the ED had EAI dispensing and 28.8% had A/I follow-up. Patient age and triggers were associated with likelihood of EAI dispensing and A/I follow-up. Post-ED visit anaphylaxis management can be improved, with the potential to decrease future morbidity and mortality risk.


Assuntos
Anafilaxia/epidemiologia , Uso de Medicamentos/estatística & dados numéricos , Serviços Médicos de Emergência/estatística & dados numéricos , Epinefrina/uso terapêutico , Hipersensibilidade/epidemiologia , Adolescente , Adulto , Idoso , Anafilaxia/tratamento farmacológico , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Hipersensibilidade/tratamento farmacológico , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
18.
J Allergy Clin Immunol Pract ; 5(5): 1295-1301, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28888253

RESUMO

BACKGROUND: Anaphylaxis is a systemic allergic reaction that is commonly treated in the emergency department (ED). The risk of a biphasic reaction is the rationale for observation. OBJECTIVE: To derive a prediction rule to stratify ED anaphylaxis patients at risk of a biphasic reaction. METHODS: We conducted an observational study of a cohort of patients presenting to an academic ED with signs and symptoms of anaphylaxis. We collected clinical data on biphasic reactions meeting National Institutes of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network diagnostic criteria. Logistic regression analyses were conducted to identify predictors of biphasic reactions, and odds ratios (ORs) with 95% CIs are reported. The predictive ability of the model features is summarized using the area under a receiver operating characteristics curve, or AUC. Internally validated AUCs were obtained using bootstrap resampling. RESULTS: We identified 872 anaphylaxis-related visits. Thirty-six (4.1%) visits resulted in biphasic reactions. Multivariable analysis showed that prior anaphylaxis (OR, 2.74; 95% CI, 1.33-5.63), unknown inciting trigger (OR, 2.40; 95% CI, 1.14-4.99), and first epinephrine administration more than 60 minutes after symptom onset (OR, 2.29; 95% CI, 1.09-4.79) were statistically significantly associated with biphasic reactions. The AUC of this model was 0.70 (95% CI, 0.61-0.79), with an internally validated AUC of 0.67 (95% CI, 0.59-0.76). The P value from the goodness-of-fit test was .91. CONCLUSIONS: Our study demonstrated a 4.1% rate of biphasic reactions and found that prior anaphylaxis, unknown inciting trigger, and delayed epinephrine use were risk factors for biphasic reactions.


Assuntos
Anafilaxia/diagnóstico , Serviço Hospitalar de Emergência , Hipersensibilidade Alimentar/diagnóstico , Adolescente , Adulto , Anafilaxia/tratamento farmacológico , Anafilaxia/epidemiologia , Estudos de Coortes , Epinefrina/uso terapêutico , Feminino , Hipersensibilidade Alimentar/tratamento farmacológico , Hipersensibilidade Alimentar/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Recidiva , Risco , Fatores de Risco , Estados Unidos/epidemiologia , Adulto Jovem
19.
Ann Allergy Asthma Immunol ; 119(4): 356-361.e2, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-28958375

RESUMO

BACKGROUND: Anaphylaxis is an acute systemic allergic reaction and may be life-threatening. OBJECTIVE: To assess risk factors associated with severe and near-fatal anaphylaxis in a large observational cohort study. METHODS: We analyzed administrative claims data from Medicare Advantage and privately insured enrollees in the United States from 2005 to 2014. Severe anaphylaxis was defined as anaphylaxis resulting in hospital or intensive care unit (ICU) admission, requiring endotracheal intubation, or meeting criteria for near-fatal anaphylaxis. RESULTS: Of 38,695 patients seen in the emergency department for anaphylaxis during the study period, 4,431 (11.5%) required hospitalization, 2,057 (5.3%) were admitted to the ICU, 567 (1.5%) required endotracheal intubation, and 174 (0.45%) were classified as having a near-fatal episode. Multivariable analysis revealed that medication-related anaphylaxis (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.38-1.63; P < .001), age of 65 years or older (OR, 3.15; 95% CI, 2.88-3.44; P < .001), and the presence of cardiac disease (OR, 1.56; 95% CI, 1.50-1.63; P < .001) or lung disease (OR, 1.23; 95% CI, 1.16-1.30; P < .001) were associated with increased odds of severe anaphylaxis requiring any hospital admission, ICU admission, or intubation or being a near-fatal reaction. CONCLUSION: In this large contemporary cohort study, 11.6% of patients had severe anaphylaxis. Age of 65 years or older, medication as a trigger, and presence of comorbid conditions (specifically cardiac and lung disease) were associated with significantly higher odds of severe anaphylaxis. Additional studies examining risk factors for severe anaphylaxis are needed to define risk assessment strategies and establish a framework for management.


Assuntos
Anafilaxia/diagnóstico , Hospitalização/estatística & dados numéricos , Revisão da Utilização de Seguros/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Fatores Etários , Idoso , Anafilaxia/fisiopatologia , Anafilaxia/terapia , Broncodilatadores/uso terapêutico , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/fisiopatologia , Estudos de Coortes , Epinefrina/uso terapêutico , Feminino , Humanos , Intubação Intratraqueal , Pneumopatias/diagnóstico , Pneumopatias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Índice de Gravidade de Doença , Estados Unidos
20.
J Allergy Clin Immunol Pract ; 5(5): 1272-1279.e1, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28756081

RESUMO

BACKGROUND: Anaphylaxis is a potentially life-threatening allergic reaction; measures including prescription of an epinephrine autoinjector (EAI) and allergy/immunology (A/I) follow-up may prevent future morbidity. OBJECTIVE: The objective of this study was to evaluate trends in outpatient management of anaphylaxis by studying EAI dispensing and A/I follow-up among patients seen in the emergency department (ED) for anaphylaxis from 2005 through 2014. METHODS: We analyzed administrative claims data from the OptumLabs Data Warehouse database using an expanded International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code algorithm. RESULTS: The study cohort comprised 18,279 patients with a mean age of 39 years; 58% were female, and 86% were discharged from an ED. Within 1 year after discharge, 46% had filled an EAI prescription and 29% had A/I follow-up. Overall, from 2005 to 2014, annual rates of filled EAI prescriptions and A/I follow-up did not change. Among children (aged <18 years), rates increased for filled EAI prescriptions (16.1% increase; P = .02 for trend) and A/I follow-up (18.8% increase; P = .048 for trend). Rates decreased for A/I follow-up among adults (15.4% decrease; P = .002 for trend). Overall rates of filled EAI prescriptions were highest in those with venom-induced (73.9 per 100 ED visits) and food-induced anaphylaxis (69.4 per 100 ED visits); the lowest rates were among those with medication-related anaphylaxis (18.2 per 100 ED visits). CONCLUSIONS: Over the past decade, rates of EAI dispensing and A/I follow-up after an ED visit for anaphylaxis have remained low, suggesting that patients may not be prepared to manage future episodes.


Assuntos
Anafilaxia/tratamento farmacológico , Uso de Medicamentos/estatística & dados numéricos , Epinefrina/uso terapêutico , Adolescente , Adulto , Idoso , Anafilaxia/epidemiologia , Criança , Pré-Escolar , Estudos de Coortes , Serviço Hospitalar de Emergência , Feminino , Seguimentos , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos/epidemiologia , Adulto Jovem
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