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Emergency Department Visit Rates by Selected Characteristics: United States, 2021

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• Series: NCHS data brief ; no. 478
• Personal Author: Cairns, Christopher ; Ashman, Jill J. ; King, J.M. Cairns, Christopher ; Ashman, Jill J. ; King, J.M. Less -
• Corporate Authors: National Center for Health Statistics (U.S.)
• Description: In 2021, 140 million emergency department (ED) visits occurred in the United States. During that year, about 4% of children had two or more ED visits in the past 12 months, and 18% of adults had visited the ED in the past 12 months. This report presents characteristics of ED visits by age group, sex, race and ethnicity, insurance, and mentions of COVID-19, using data from the 2021 National Hospital Ambulatory Medical Care Survey (NHAMCS). Key findings Data from the National Hospital Ambulatory Medical Care Survey ● The overall emergency department (ED) visit rate was 43 visits per 100 people in 2021. ● ED visit rates were highest for infants under age 1 year (103 visits per 100 infants) and adults aged 75 and over (66 per 100 people). ● The ED visit rate for Black or African-American non-Hispanic people (81) was the highest among the selected racial and ethnic groups. ● The ED visit rate for patients with private insurance was lowest compared with all other primary expected sources of payment, and the rate for patients with Medicaid was highest. ● In 2021, a COVID-19 diagnosis was confirmed for 3.8% of all ED patient visits. Suggested citation: Cairns C, Ashman JJ, King JM. Emergency department visit rates by selected characteristics: United States, 2021. NCHS Data Brief, no 478. Hyattsville, MD: National Center for Health Statistics. 2023. DOI: https://dx.doi.org/10.15620/ cdc:131757. CS342162 More ▼ -->
• Subjects: [+] Adult Child COVID-19 Emergency Service, Hospital Ethnicity Humans
• Document Type: Journal Issue
• Name as Subject: National Hospital Ambulatory Medical Care Survey (U.S.)
• Genre: Statistics
• Place as Subject: United States
• Collection(s): Stephen B. Thacker CDC Library collection
• Main Document Checksum: [+] urn:sha256:48f953beb5671199f4c089d7d3f69336edb92ab2e59da77096b13feb56ea5fb3
• Download URL: https://stacks.cdc.gov/view/cdc/131757/cdc_131757_DS1.pdf

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From the dataset abstract

The National Hospital Ambulatory Medical Care Survey (NHAMCS), conducted by the National Center for Health Statistics (NCHS), collects annual data on visits to emergency departments to...

Source: Estimates of Emergency Department Visits in the United States from 2016-2021

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Drug Abuse Warning Network (DAWN)

The Drug Abuse Warning Network (DAWN) is a nationwide public health surveillance system that captures data on emergency department visits related to recent substance use and misuse directly from the electronic health records of participating hospitals. SAMHSA administered DAWN from 1992 through 2011 (legacy DAWN) and reestablished the current version of DAWN in 2018.

Data Source

The Drug Abuse Warning Network (DAWN) is a nationwide public health surveillance system that captures data on emergency department (ED) visits related to recent substance use and misuse directly from the electronic health records of participating hospitals. The key objectives of DAWN are to:

• Monitor demographic and geographic distribution, and identify trends in substance-related ED visits;
• Provide timely data and serve as an early warning system that identifies emerging and novel psychoactive substances and/or combinations of substances; and
• Provide national estimates of substance-related ED visits to key stakeholders and the public.

Where Do the Data Come From?

DAWN data are collected from a selection of non-federal, short-stay, general surgical, and medical hospitals with at least one ED open 24 hours a day, 7 days a week and more than 100 visits per month. The recruitment of 53 hospitals was completed in 2021.

Frequently Asked Questions

1. what is dawn.

• The Drug Abuse Warning Network (DAWN) is a nationwide public health surveillance system administered by the U.S. Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Center for Behavioral Health Statistics and Quality (CBHSQ). DAWN captures data on emergency department (ED) visits related to recent substance use and misuse directly from the electronic health records of participating hospitals. SAMHSA administered DAWN from 1992 through 2011 (legacy DAWN), and re-established the current DAWN in 2018.

2. Who is responsible for DAWN?

• Authorized by the 21st Century Cures Act in December 2016, DAWN is a data collection program of CBHSQ. SAMHSA is required and authorized, under section 42 U.S.C. §290aa-4(d)(1)(A), to collect the number of individuals admitted to the emergency rooms of hospitals as a result of the abuse of alcohol or other drugs. SAMHSA is authorized to receive protected health information from hospital ED’s for the purpose of public health surveillance under the HIPAA Privacy Rule (45 C.F.R. 164.512(b)(1)). Such disclosures are permitted and do not require the authorization of the patient.

3. Can I compare data from legacy DAWN (1992-2011) to data from the DAWN launched in 2018?

• Data should not be compared between legacy DAWN and the current DAWN version. The sample designs are different with the current iteration’s design established to provide surveillance.

4. How does DAWN define a drug-related emergency department (ED) visit?

• In DAWN, a drug-related ED visit is a visit in which the patient was treated in the ED for a condition that was induced by or related to recent drug and/or alcohol use.

5. How does DAWN define a drug?

• DAWN defines a drug as any substance and/or combination that falls under the following categories: alcohol, illicit drugs, prescription medications, over-the-counter medications (OTCs), dietary supplements, non-pharmaceutical inhalants, and substances that are vaped. DAWN classifies drugs using DAWN’s Drug Reference Vocabulary (DRV).

6. What is the DAWN Drug Reference Vocabulary (DRV)?

• The DAWN DRV is a comprehensive drug vocabulary and classification system for all the substances collected by DAWN. The DAWN DRV is derived from the Multum Lexicon©, 2020 Cerner Multum, Inc. The classification was modified to meet DAWN's unique requirements.

7. How are DAWN data abstracted?

• DAWN medical record abstractors review ED records to identify drug-related visits. They access hospital’s electronic health record systems to review records and abstract data when an ED visit meets the DAWN case definition.

8. How does DAWN ensure patient confidentiality?

• DAWN data elements do not include direct identifiers. All DAWN project staff are trained on protections and procedures to ensure the privacy and confidentiality of all health information. Additionally, suppression rules are applied to minimize disclosure risk.

9. What is a sentinel hospital? Why does DAWN include sentinel hospitals?

• In DAWN, a sentinel hospital is defined as a large urban hospital selected from a high-priority sentinel area. A high priority sentinel area is defined as counties with high mortality and morbidity associated with opioid, cocaine, and psychostimulant overdose.
• Sentinel hospitals are expected to yield cases of concern, allowing for the collection and analysis of data quickly so a plan of action for addressing key and emerging problems can be developed. Therefore, DAWN includes 10 sentinel hospitals selected by SAMHSA across the nation.

10. How is the quality of DAWN data assessed?

• DAWN uses a multi-step process to ensure data quality. Automated checks are embedded in the web-based abstraction system at initial entry to minimize errors, and machine learning algorithms are applied to each drug-related visit once submitted. Cases flagged by the machine learning model are subject to human review for accuracy. Quality audits are performed on each abstractor’s data bi-annually to focus training needs and assess quality.

Short Reports and Spotlights

Drug Abuse Warning Network (DAWN): ED Visits Involving Alcohol Short Report presents the following data from January 2021-September 2023 (1) national...

Annual Report

Public use files, dataset documentation, dataset downloads.

Hospitals seeing rise in pediatric, young adult mental health cases

New data  shows how severely U.S. kids' and young adults' mental health is suffering. 

The number of ER visits for suicide-related events is up five-fold over the past decade in children, teens and young adults. Youth ER visits for mental health conditions have about doubled, according to a new study in the Journal of the American Medical Association.

Researchers looked at data from the National Hospital Ambulatory Medical Care Survey, specifically emergency department visits for 6-to-24-year-olds from 2011 to 2020.

Giving kids 'mental health days' could help their emotional well-being

A National Alliance on Mental Illness poll found 1 in 6 teens report feeling negative emotions often or always. Some parents are taking action.

According to the findings, mental health–related visits rose from 4.8 million to 7.5 million. Mental health–related emergency department visits increased the most among 10-to-14-year olds. Males were more likely to go to the ER for mental health in the younger child and young adult age ranges. Mental health visits were more likely among females in the adolescent years.

Suicide-related visits saw the largest increase across all age groups, as well as across sex, race and ethnicity, insurance type and location.

Clinical psychologist Dr. Earl Turner, founder of  Therapy for Black Kids , was not an author on the study. He says it's important to not only look at the number of visits being up, but that this also highlights the urgent need for more mental health providers.

More kids are showing up to ERs with mental health crises

WARNING: You're going to hear doctors and a family talk about suicidal thoughts, suicide attempts, and about children who've killed themselves.

"I get this — in terms of referral requests from parents — oftentimes, if they have a son, they're looking for a male therapist. And  we know that  is also something that is really challenging in the field, and that only about a third of child psychologists identify as male. And so, when we want someone to meet that need, it can be a challenge. And if you add an additional layer when we talk about race/ethnicity, that number is even smaller," he said.

The research looks at visits, so it doesn't account for the number of patients. The doctors and researchers who worked on this study say these trends show where health care is really lacking, and mental health providers in the emergency department are needed.

The study did not include visits at psychiatric hospitals with crisis or urgent care centers, meaning the actual number of emergency visits for mental health and suicide could be even higher.

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• Management and outcome of oncological patients under immune checkpoint inhibitors presenting at the emergency department
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• http://orcid.org/0009-0004-2545-3062 Francesco Pini ,
• Bogdan Grigoriu ,
• Ameye Lieveke ,
• Anne-Pascale Meert
• Jules Bordet Institute , Brussels , Belgium
• Correspondence to Dr Francesco Pini, Jules Bordet Institute, Brussels, Belgium; francesco.pini{at}hotmail.com

Introduction With the rising use of immune checkpoint inhibitors ( ICIs ) in oncology, emergency physicians are increasingly confronted with their immune-related adverse events ( irAEs ). We described the types of irAEs presenting to the ED of a Belgian cancer centre and determined associations with the development of an irAE and other patient’s characteristics. Secondary objectives describe the therapeutic management and determine 7 and 30-day mortality.

Methods A retrospective chart review of ED visits of patients on ICI from 15 December 2016 to 6 December 2020 was performed. Clinical presentation, cancer characteristics and type of ICI were extracted by a single abstractor. We recorded any suspicion of irAE in the ED and confirmation of an irAE was based on the patient’s oncologist report. Outcome was based on mortality at date of last follow-up.

Results 227 patients on ICI presented to the ED, with a total of 451 visits. 54 (12%) of the visits resulted in a diagnosis of irAE. Four clinical features were associated with an irAE: gastrointestinal complaints (p=0.01), skin rashes (p=0.02), acute renal failure (p=0.002) and abnormal liver function (p=0.04). An irAE was also associated with three different factors: a cancer status in remission (OR=5.33, 95% CI 2.57 to 11.04), a combination of two ICIs (OR=4.43, 95% CI 2.09 to 9.42) and a medical history of irAE (OR=2.44, 95% CI 1.27 to 4.68). 30-day mortality was lower in the irAE group (0%) than in the non-irAE group (13%, 95% CI 9% to 19%).

Conclusions Oncological patients under ICI presenting in the ED are more likely to have an irAE if they present with gastrointestinal and dermatological complaints, acute renal failure and abnormal liver function. This is also true for patients with any history of irAE, a concomitant use of two ICIs and with a cancer status in remission.

• Medical Oncology

Data availability statement

Data are available upon reasonable request. Data are available on reasonable request.

https://doi.org/10.1136/emermed-2023-213605

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Immune checkpoint inhibitors (ICI) are increasingly used in oncology and managing them in an emergency setting can be challenging. A few studies evaluated their acute management, but little is known on how to distinguish patients presenting to the ED with side effects from other conditions.

WHAT THIS STUDY ADDS

In this observational study of oncological patients on ICI presenting to an ED, an immune-related adverse event was more likely if they had gastrointestinal and dermatological complaints, acute renal failure or abnormal liver function, as well as history of adverse reaction to ICI, a concomitant use of two ICIs and a cancer status in remission.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

Our findings may allow emergency physicians to more quickly recognise an immune-related side effect and initiate treatment sooner.

Introduction

The human immune system is balanced between its action of destroying foreign antigens on the one hand, and the controlling of the development of autoimmune phenomena on the other hand. This complex balance is maintained, among other means, by cellular signalling pathways that inhibit or stimulate the immune system. Some inhibitory pathways, such as the programmed cell death protein 1 / programmed cell death ligand 1 pathway and the cytotoxic T-lymphocyte-associated protein 4 / protein B7 pathway, can be overexpressed by cancer cells to prevent their destruction. 1 Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that can overcome this immune inhibition, thereby potentially inducing cancer cell destruction.

The efficacy of ICI has been initially demonstrated in the advanced stages of melanoma 2 and certain non-small cell lung cancers. 3 4 Their indications have progressively been extended to many other cancers in combination with or as an alternative to chemotherapy, and they have now become a therapeutic standard in oncology. Patients on ICI are at risk of developing side effects that mimic autoimmune reactions, which may be challenging to differentiate from other manifestations such as cancer progression or infections. Some of these immune-related adverse events ( irAEs ) may be severe enough to require intensive care management. 5 Virtually, all organs can be affected, with variable timing and frequency depending on the type and number of ICIs used. 6–8 Prognosis is largely dependent on the nature of the irAE, with pulmonary involvement having a poor prognosis. 7 A recent British study 9 showed that among 300 ED visits of patients on ICI, 2% resulted in death associated with irAE.

Rapid identification of an irAE is essential and lack of knowledge about these toxicities may delay management and aggravate patient’s outcome. 10 This is especially important considering the specificity of the treatment, which may require high doses of corticosteroids or other immunosuppressive agents. 11 12 A 2019 French single-centre retrospective study based on 409 patients treated with ICI 13 found only 50% of irAE diagnoses are made in the ED. This study also identified potential factors favouring the development of irAE such as cancer in remission, concomitant use of multiple ICIs, as well as a higher number of ICI doses.

Previous investigations have shed some light on the acute presentation and management of oncological patients on ICI. 7 9 13 14 Unfortunately, there is insufficient evidence to guide physicians in how to differentiate irAEs from other diseases. Our study aimed to evaluate the frequency of irAE and determine which factors might be associated with the development of an adverse effect. The secondary objectives were to identify the therapeutic management as well as to determine mortality at 7 and 30 days after ED presentation.

This retrospective monocentric study was carried out at the Jules Bordet Institute in Brussels, Belgium. It is a specialised centre in oncology and onco-haematology, which possesses an ED managing the patients of the institute only.

Patients were selected by matching those who received therapy with at least one ICI (avelumab/Bavencio, durvalumab/Imfinzi, pembrolizumab/Keytruda, nivolumab/Opdivo, atezolizumab/Tecentriq or ipilimumab/Yervoy), with those who visited the ED over a 4-year period from 15 December 2016 to 6 December 2020. Of these, patients who received their last dose more than 6 months previously and those under the age of 18 years were excluded.

Data collection

Data for the study were extracted from the electronic medical records of visits documented by emergency physicians during the study period. Extraction of the data was performed by a single investigator, and then the validity of the data was crosschecked by an independent researcher. All information was then encoded and anonymised with the REDCap computer software.

Among the general data, we collected the chief complaint at the ED visit. If the patient was sent to the ED following an abnormal routine laboratory result, the laboratory result was considered as a chief complaint. Chief complaints were then categorised into seven main clinical presentations. Those categories were arbitrarily decided by the authors, based on main system involvement. We also collected the primary cancer location, a history of autoimmune diseases and irAE, as well as cancer status. A cancer in remission was considered when cancer has responded partially/completely to a treatment and is not actively progressing, based on the last oncology consultation/imagery preceding the emergency visit. Immunotherapy was assessed according to the ICI used, the time from the first dose to the ED visit, the time from the last dose to the ED visit and the total number of doses already received. The final diagnosis of the emergency physician, internist and/or oncologist was recorded. An adverse event was categorised as an irAE if the oncologist/internist in the inpatient or outpatient setting considered the irAE probable or definite; the grade of the irAE was also recorded and classified using the Common Terminology Criteria for Adverse Events from the National Cancer Institute. 15 We recorded a suspicion of irAE if the emergency doctor considered an irAE in the differential diagnosis. Therapeutic management of irAE described the necessity of discontinuation of immunotherapy, temporary or permanently. Patient prognosis was measured by mortality 7 and 30 days after consultation. Mortality was determined based on death certificates last checked on 12 June 2021, which are automatically updated every 2 weeks with the national database of Belgium.

Statistical analysis

The sample size for this study was pragmatic: a 4-year period was chosen based on limiting factors, mostly time available for data collection. Statistical analysis included a descriptive analysis, a comparison between the irAE and the non-irAE group and an assessment of mortality at 7 and 30 days after ED presentation. Categorical data were compared using χ 2 or Fisher’s exact test when appropriate. Wilcoxon test was used for continuous data comparisons. For descriptive analysis and comparison between the irAE and non-irAE groups, when the same patient visited the ED more than once, each visit was considered. If a patient presented the same irAE twice in less than 30 days, the second visit was excluded. Logistic regression was used to assess which explanatory variables are independently associated to irAE. For demographic analyses, and the assessment of mortality, only the first ED visit was considered. Mortality was assessed using the Kaplan-Meier and Cox proportional hazards model. For all statistical analyses, the significance threshold was set at p<0.05.

Patient and public involvement

Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.

During the 4-year study period, the Institute recorded a total of 9355 ED visits. Of these, 227 patients receiving ICI therapy made 451 ED visits. The population was mostly male (63.4%), with a median age of 64 (55–69) years. Bronchopulmonary cancers accounted for more than half of the cases (53.7%), followed by melanoma (21.6%) and bladder cancers (15.9%). Pembrolizumab was the most commonly used checkpoint inhibitor (43.6%), followed by nivolumab (34.8%) and atezolizumab (10.6%). The characteristics of the patients are summarised in table 1 .

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Patient characteristics on first ED visit

The chief complaints at the ED were classified into seven categories ( table 2 ). Among the 451 ED visits, the most frequent clinical presentations were 70 (15.5%) fever, 69 (15.3%) dyspnoea, 37 (8.2%) musculoskeletal pain, 36 (8%) asthenia, 30 (6.7%) abdominal pain and 28 (6.2%) diarrhoea ( table 2 ).

Clinical variables for irAE and non-irAE on all ED visits

Out of the 451 ED visits, there were 54 (12%) that resulted in a diagnosis of an irAE. 43 (79.6%) of irAEs had been suspected by the emergency doctor. Visits for gastrointestinal symptoms (p=0.01), acute renal failure (p=0.002), abnormal liver function (elevation of aspartate aminotransferase and/or alanine aminotransferase) (p=0.04) and skin rashes (p=0.02) were more frequently associated with an irAE. Within the gastrointestinal symptoms group, diarrhoea was associated with developing an irAE (p<0.001).

The most frequent irAEs were colitis/diarrhoea (24.1%), pneumonia (24.1%), hepatitis (9.3%) and dermatitis (9.3%). Most patients had severe irAEs of grades III–IV (n=36; 66.6%). Only two patients had (3.6%) grade I events. Five patients had multiple simultaneous irAEs. The characteristics of the irAE are summarised in table 3 .

Characteristics of irAE on all ED visits

The development of irAE was associated with a cancer status in remission (OR=5.33, 95% CI 2.57 to 11.04), any history of irAE (OR = 2.44, 95% CI 1.27 to 4.68) and the use of two ICIs (OR=4.43, 95% CI 2.09 to 9.42) . When added to the logistic regression model, a history of autoimmune disease, timing between the first dose of ICI and the ED visit or number of doses of immunotherapy before presenting to the ED were not retained as independently associated to irAE: respective p values of 0.21, 0.27 and 0.41 ( table 4 ). ICI treatment had to be stopped in 40 (72.7%) of patients with irAEs. This interruption was permanent in 37 (92.5%) cases.

Logistic regression model for predictive factors associated with an irAE

We assessed mortality in the 6 months after the first ED visit ( figure 1 ). Patients diagnosed with irAE had a lower mortality rate: HR 0.31 (95% CI 0.12 to 0.86; p=0.02). The 30-day mortality after ED presentation was 0% in the irAE group versus 13% (95% CI 9% to 19%) in the non-irAE group.

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Mortality rate after first ED visit. irAE, immune-related adverse event.

In this single-centre study of the ED of an oncology referral centre, 5% of visits involved patients treated with ICI. Out of those visits, 12% ultimately resulted in the diagnosis of irAE. We found that patients with gastrointestinal and dermatological chief complaints, and those diagnoses with renal failure and abnormal liver function, were more likely to have an irAE, although the last two of these were rare. Cancer in remission, history of an irAE and simultaneous treatment with two ICIs were also associated with an irAE.

The frequency of irAEs in our retrospective study is lower than in the literature. Indeed, different studies have found values of <10%, 14 14.4%, 13 25% 7 and 32.7%. 9 This low frequency is likely because our hospital is specialised in oncology, and less severe irAEs are caught earlier in consultation by the oncologist. The same is true for the high percentage of irAE suspected in the ED (79.6%), as our emergency staff only manages oncological patients and receives continuous information about new cancer drugs. Still, it is important to note that some rare and particularly severe adverse events were missed in the ED such as myocarditis, Guillain-Barré syndrome and a cytokine-releasing syndrome. It seems essential to stay aware of the high variability that these adverse events can present.

The association of an irAE with cancer status in remission has been previously shown. A recent meta-analysis of 51 studies 16 found progression-free survival (clinical endpoint measuring the time during or after treatment when the cancer does not progress) in the irAE group was 17.61 months (95% CI 10.1 to 25.1) compared with 2.23 months in the non-irAE group (95% CI 1.77 to 2.68) for melanomas, and similar figures were found for other metastatic neoplasms. The author explains this association by a potential cross-reactivity of the immune system between antigens from healthy cells and antigens from cancer cells. We hypothesised that patients with a positive therapeutic response would benefit from prolonged treatment, thus raising the probability of developing an irAE. However, in our cohort, the time between ICI therapy initiation and emergency visit was similar in both groups. Therefore, a high degree of suspicion for toxicity should remain when facing patients under immunotherapy, regardless of the time from initiation of the treatment.

We also found a significant association between a history of irAE (regardless of the grade) and the development of another irAE. Ongoing research 17 is attempting to identify markers that predispose or facilitate the development of irAEs. However, much more research is needed in this area.

The development of an irAE was three times more likely in patients treated with two ICIs than those with a single ICI. The only combination used in our population was nivolumab with ipilimumab used in the treatment of melanoma. This combination has also been linked to the development of a higher grade side effect in patients with melanoma. 18

Although a history of autoimmune disease has been associated with an almost twofold increase in hospitalisations resulting in a diagnosis of irAE by Kehl et al , 19 we did not find this to be true of our population. However, Kehl’s study excluded autoimmune hypothyroidism, which accounts for the majority of the history of autoimmune disease in our population. As the number of our patients with other autoimmune diseases is statistically insufficient, we cannot draw a clear conclusion on this subject.

ICI treatment had to be stopped in more almost three-quarters of the patients with irAEs, resulting in a permanent interruption in almost all cases. Our high frequency of permanent discontinuation of ICI may be explained by the fact that our study includes only ED presentations, which are usually severe. Indeed, two-thirds of the irAEs in our population were grade ≥III. Discontinuation may raise concerns about a possible neoplastic progression after ICI discontinuation, but this may not be a significant issue in practice. One study from Schadendorf et al evaluated patient prognosis after discontinuation of a nivolumab-ipilimumab combination due to irAE and showed no significant decrease in progression-free survival at 18 months when the development of irAE required discontinuation of ICI (p=0.97). 20 Nevertheless, we cannot confirm whether this trend is maintained in the long run. A study 21 analysed reintroduction of ICI in a population with a grade ≥II irAE, and over half of patients did not redevelop a grade ≥II irAE. Given the apparent association between the development of an irAE and a positive therapeutic response, it seems essential to assess for each patient the benefit-risk balance of reintroducing ICI after the occurrence of an irAE.

The 30-day mortality after ED presentation after the first visit only was significantly lower in the irAE group. This was also found by Grangeon et al in patients with non-small cell lung cancer (HR 0.42; 95% CI 0.32 to 0.57; p<0.001). 22 This reduction in mortality is likely related to the positive therapeutic response to the immunotherapy, as Zaorsky et al found >40% of deaths in oncological patients are related to their cancer. 23 This high difference in mortality could be explained because most irAEs are rapidly reversible if appropriately treated. This favourable outcome appears to be maintained in the long term, but further investigation is warranted to confirm this trend.

Limitations

This study suffers the inherent biases from retrospective data collection. It is important to note that our study only evaluated urgent presentations, we cannot apply these results to all patients undergoing ICI treatment. Also, as our centre is specialised in oncology, the acute management of irAE is not generalisable to non-oncological hospitals. Finally, we decided to consider multiple visits in the descriptive analysis, which may skew the data.

Conclusions

More than 1 in 10 patients under ICI presenting to the ED have an irAE. Certain presentations, the history of an irAE and cancer in remission increase the likelihood of an irAE. Early recognition is helpful as patients with irAE often need to discontinue the medication.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and was approved by the ethics committee of Jules Bordet Institute, Brussels, Belgium on 5 January 2021 (Reference No OM011). It was a retrospective study.

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• Zaorsky NG ,
• Churilla TM ,
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Emergency Department Visit Rates by Adults With Diabetes: United States, 2020–2021

NCHS Data Brief No. 487, December 2023

PDF Version (427 KB)

Loredana Santo, M.D., M.P.H., Susan M. Schappert, M.A., and Jill J. Ashman, Ph.D.

• Key findings

What was the ED visit rate by adults with diabetes in 2020–2021 and did it differ by sex and age?

Did the ed visit rate by adults with diabetes differ by race and ethnicity and age, did the ed visit rate by adults with diabetes differ by number of other chronic conditions and age, did ed visit rates by adults with diabetes change over the past decade, definitions, data source and methods, about the authors, suggested citation.

Data from the National Hospital Ambulatory Medical Care Survey

In 2020–2021, the emergency department visit rate by adults with diabetes was 72.2 visits per 1,000 adults, and the rate increased with age.

Emergency department visit rates by adults with diabetes were highest among Black non-Hispanic people (136.6 visits per 1,000 adults per year) and higher among White non-Hispanic people (69.9) compared with Hispanic people (52.3).

In 2020–2021, the emergency department visit rate by adults with diabetes and two to four other chronic conditions was 541.4 per 1,000 adults per year and increased with age.

Emergency department visit rates by adults with diabetes increased from 48.6 visits per 1,000 adults in 2012 to 74.9 visits per 1,000 adults in 2021.

In 2021, diabetes was the eighth leading cause of death in the United States ( 1 ). Over 37 million Americans have diabetes ( 2 ). While it most often develops in people older than age 45 ( 3 ), its frequency is increasing in young adults ( 4 ). Among people with diabetes, increasing age is a risk factor for hospitalization ( 5 ). Emergency department (ED) visits by people with diabetes have been used to monitor access to care and healthcare use ( 6 ). This report describes ED visits made by adults with diabetes, and presents selected characteristics by age.

Keywords : emergency care, National Hospital Ambulatory Medical Care Survey

• In 2020–2021, the annual ED visit rate by adults with diabetes was 72.2 visits per 1,000 adults ( Figure 1 ).
• ED visit rates by adults with diabetes did not differ significantly by sex, with 75.1 visits per 1,000 women and 69.1 visits per 1,000 men.
• Among adults ages 18–44 with diabetes, ED visit rates were higher among women (32.2) than men (19.5). Among adults ages 45–64 with diabetes, ED rates were similar for women (86.2) and men (84.4). Among adults age 65 and older with diabetes, the observed difference in ED rates between men (159.9) and women (142.8) was not significant.
• ED visit rates by adults with diabetes increased with age for both women and men.

Figure 1. Emergency department visit rate among adults with diabetes, by sex and age group: United States, 2020–2021

• In 2020–2021, ED visit rates by adults with diabetes were highest among Black non-Hispanic people (subsequently, Black) (136.6 visits per 1,000 adults), followed by White non-Hispanic (subsequently, White) (69.9) and Hispanic (52.3) people ( Figure 2 ).
• For each age group, ED rates by adults with diabetes were highest among Black people. Differences between Hispanic and White people were not significant.
• ED visit rates by adults with diabetes increased with age among Black, White, and Hispanic people.

Figure 2. Emergency department visit rate among adults with diabetes, by race and ethnicity and age group: United States, 2020–2021

• Most ED visits by adults with diabetes were made by patients with two to four other reported chronic conditions (541.4 visits per 1,000 visits) ( Figure 3 ). Rates by patients with no other chronic conditions were lowest (90.2).
• Among adults with diabetes ages 18–44, ED visit rates were highest among those with two to four other chronic conditions (402.0) and lowest among those with five or more other conditions (93.8).
• Among adults with diabetes ages 45–64, ED visit rates were highest among those with two to four other chronic conditions (526.4) and lowest among those with no other conditions (87.7).
• Among adults with diabetes age 65 and older, ED visit rates were highest among those with two to four other conditions (605.2), followed by those with five or more conditions (217.7), one other chronic condition (140.6), and no other conditions (36.5).
• The ED visit rate by adults with diabetes and two to four or five or more other chronic conditions increased by age, but the rates for those with no other chronic conditions or one other condition decreased with age.

Figure 3. Emergency department visit rate among adults with diabetes, by number of additional chronic conditions and age group: United States, 2020–2021

• ED visit rates by adults with diabetes increased from 48.6 visits per 1,000 adults in 2012 to 74.9 in 2021 ( Figure 4 ).
• ED visit rates by adults with diabetes age 65 and older were higher than all other age groups during 2012–2021, and increased from 113.4 in 2012 to 156.8 in 2021.
• ED visit rates by adults with diabetes ages 45–64 increased from 53.1 in 2012 to 89.2 in 2021.
• ED visit rates by adults with diabetes ages 18–44 increased from 20.9 in 2012 to 26.4 in 2016, but their rates remained stable for 2016–2021.

Figure 4. Emergency department visit rate among adults with diabetes, by age group: United States, 2012–2021

In 2020–2021, the annual ED visit rate by adults with diabetes was 72.2 visits per 1,000 adults. ED visit rates by adults with diabetes increased with age for both women and men. ED visit rates were highest among Black people, and higher among White people compared with Hispanic people. Among each race and ethnicity group, ED visit rates increased with age. Rates by adults with two or more other chronic conditions were higher than rates for adults with one or no other chronic conditions. From 2012 through 2021, ED visit rates among all adults with diabetes increased, as well as among adults age 45 and older. Among adults ages 18–44, ED visit rates increased during 2012–2016 and then remained stable during 2016–2021. This report includes the most recent estimates of ED visits by adults with diabetes from the National Hospital Ambulatory Medical Care Survey (NHAMCS) and shows an increasing trend in rates by adults with diabetes in the ED setting.

ED visits by adults with diabetes: In both 2020 and 2021, a checkbox item was included in NHAMCS that asked, “Does the patient have (mark all that apply).” The list included three checkboxes for diabetes: diabetes mellitus, type 1; diabetes mellitus, type 2; and diabetes mellitus, type unspecified. A separate item, provider’s diagnosis, collected information on up to five diagnoses related to the current visit, using verbatim text entries from the patient’s medical record, which were later coded by National Center for Health Statistics medical coders using the International Classification of Diseases , Ninth Revision , Clinical Modification (for survey years 2012–2015) and the International Classification of Diseases , 10th Revision, Clinical Modification (for 2016–2021) ( 7 , 8 ). To be sure that the chronic condition checkbox data were complete, a consistency check was performed during data editing to review responses to the provider’s diagnosis item. If any of the chronic conditions from the checkbox item were also listed in the diagnosis item, the relevant checkbox item was also checked. This report includes ED visits made by adults (age 18 and older) that had either a reported diagnosis of diabetes ( International Classification of Diseases , Ninth Revision , Clinical Modification codes 249–250 or International Classification of Diseases , 10th Revision, Clinical Modification codes E08–E13) or a checkbox category of diabetes. Adults that either had diabetes diagnosed at the ED visit or had pre-existing diabetes that was documented in the medical record were included in the analysis.

ED visits by adults with diabetes and additional chronic conditions reported : The number of chronic conditions, excluding diabetes, was grouped into none (referring to adults with only diabetes), one, two to four, and five or more of the conditions collected in NHAMCS. Beside the checkboxes for diabetes described above, checkboxes for alcohol misuse, abuse, or dependence; Alzheimer disease or dementia; asthma; cancer; cerebrovascular disease or history of stroke or transient ischemic attack; chronic kidney disease; chronic obstructive pulmonary disease; congestive heart failure; coronary artery disease, ischemic heart disease or history of myocardial infarction; depression; end-stage renal disease; history of pulmonary embolism or deep vein thrombosis; HIV; hyperlipidemia; hypertension; obesity; obstructive sleep apnea; osteoporosis; and substance use disorders were included in NHAMCS in 2020 and 2021. The consistency check described above was performed during data editing for each checkbox.

ED visit rate : Calculated by dividing the number of ED visits by adults with diabetes, by the July 1, 2012–2021, sets of estimates of the U.S. civilian noninstitutionalized population (obtained from the U.S. Census Bureau’s Population Division) for each demographic group. Visit rates for adults with chronic conditions are calculated by dividing the number of ED visits made by adults with diabetes and a specified number of other chronic conditions by the total number of ED visits made by adults with diabetes in 2020 and 2021. Visit rates are presented as annual average rates per year.

Race and ethnicity : Race and Hispanic ethnicity were collected separately and converted into a single combined variable that includes Hispanic, Black non-Hispanic, White non-Hispanic, and other races non-Hispanic. Other races includes American Indian and Alaska Native, Asian, and Native Hawaiian or Other Pacific Islander people, and people of two or more races, representing 4.5% of all ED visits by adults with diabetes. Data for other races are included in the denominator but not shown. For 2020–2021, 13.6% of weighted race data and 10.7% of weighted ethnicity data were missing for ED visits by adults with diabetes; race and ethnicity were imputed for these missing records ( 7 , 8 ).

This report analyzed data from NHAMCS, a nationally representative annual survey of nonfederal, general, and short-stay hospitals. NHAMCS uses a multistage probability design with samples of geographic primary sampling units, hospitals within primary sampling units, and patient visits within EDs. Analyses for this report were conducted using data from restricted-use data files. Public-use versions of these files are available from: https://www.cdc.gov/nchs/ahcd/datasets_documentation_related.htm . Count estimates and measures of variance could differ between the restricted-use and public-use files. Information for accessing the restricted-use data file is available from: https://www.cdc.gov/rdc/index.htm . Additional information on the methodology of NHAMCS is available online ( 7 , 8 ). This report presents results combining data for 2020 and 2021 for more detailed subgroup analyses. In addition to the 2020–2021 data, Figure 4 includes individual data years from the 2012–2021 NHAMCS.

Data analyses were performed using the statistical packages SAS version 9.4 (SAS Institute, Cary, N.C.) and SAS-callable SUDAAN version 11.0 (RTI International, Research Triangle Park, N.C.). To test for linear and quadratic trends over time, the null hypothesis of nonlinear or quadratic trend was examined using the POLY option in SUDAAN. If a quadratic trend was significant, Joinpoint software ( 9 ) was used to determine the change point in the trend line. Piecewise linear regression was used to test the significance of slopes according to National Center for Health Statistics trend analysis guidelines ( 10 ). Differences among groups were evaluated using two-sided significance tests at the p < 0.05 level.

Loredana Santo, Susan M. Schappert, and Jill J. Ashman are with the National Center for Health Statistics, Division of Health Care Statistics.

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• Uppal TS, Chehal PK, Fernandes G, Haw JS, Shah M, Turbow S, et al. Trends and variations in emergency department use associated with diabetes in the U.S. by sociodemographic factors, 2008–2017. JAMA Netw Open 5(5):e2213867. 2022.
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Santo L, Schappert SM, Ashman JJ. Emergency department visit rates by adults with diabetes: United States, 2020–2021. NCHS Data Brief, no 487. Hyattsville, MD: National Center for Health Statistics. 2023. DOI: https://dx.doi.org/10.15620/cdc:134505 .

Copyright information

All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.

National Center for Health Statistics

Brian C. Moyer, Ph.D., Director Amy M. Branum, Ph.D., Associate Director for Science

Division of Health Care Statistics

Carol J. DeFrances, Ph.D. , Director Alexander Strashny, Ph.D. , Associate Director for Science

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