The Identification of Subphenotypes and Associations with Health Outcomes in Patients with Opioid-Related Emergency Department Encounters Using Latent Class Analysis
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ABSTRACT:
SUBMITTER: Chhabra N
PROVIDER: S-EPMC9321801 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Study objectiveWe describe the prevalence, trends, and factors associated with repeated emergency department (ED) encounters for opioid usage across multiple, independent hospital systems.MethodsA statewide regional health information exchange system provided ED encounters from 4 Indiana hospital systems for 2012 to 2017. In accordance with a series of International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 diagnosis codes for opioid abuse, adverse effects of opioids, opioid dependence and unspecified use, and opioid poisoning, we identified patients with an ED encounter associated with opioid usage (9,295 individuals; 12,642 encounters). Multivariate logistic regression models then described the patient, encounter, prescription history, and community characteristics associated with the odds of a patient's incurring a subsequent opioid-related ED encounter.ResultsThe prevalence of repeated nonfirst opioid-related ED encounters increased from 9.0% of all opioid encounters in 2012 to 34.3% in 2017. The number of previous opioid-related ED encounters, unique institutions at which the individual had had encounters, the encounter's being heroin-related, the individual's having a benzodiazepine prescription filled within 30 days before the encounter, and being either Medicaid insured or uninsured compared with private insurance were associated with significantly greater odds of having a subsequent encounter.ConclusionThe ED is increasingly a site utilized as the setting for repeated opioid-related care. Characteristics of the individual, encounter, and community associated with repeated opioid-related encounters may inform real-time risk-prediction tools in the ED setting. Additionally, the number of institutions to which the individual has presented may suggest the utility of health information exchange data and usage in the ED setting.
| S-EPMC10929732 | biostudies-literature
Project description:IntroductionOpioid addiction and misuse constitute a public health crisis in the United States. Recent research supports buprenorphine induction in the emergency department (ED) setting for patients with opioid use disorder (OUD). However, education regarding buprenorphine induction for emergency medicine (EM) physicians, residents, and students is still limited.MethodsWe created a 1-hour introductory workshop for the identification and treatment of opioid withdrawal and OUD in the ED for medical students going into EM and for EM interns. The workshop consisted to two distinct curricular sections: (1) a didactic session providing an overview of the basic knowledge and skills to identify and treat patients with OUD in the ED and (2) a case-based session in which students worked through the identification of opioid withdrawal; discussion of opioid use with the patient, going through the steps of SBIRT (screening, brief intervention, and referral to treatment); and considerations when starting buprenorphine. The workshop was evaluated using a pre- and posttest examining medical knowledge around buprenorphine use in the ED.ResultsA total of 48 students and interns participated in the curriculum. The students showed a significant improvement in medical knowledge between the pre- and posttests, with an average 45% higher score on the posttest (p < .001).DiscussionOur workshop resulted in a short-term improvement in medical students' and interns' knowledge of the identification and treatment of patients with OUD in the ED.
| S-EPMC7331957 | biostudies-literature
Project description:BackgroundSince COVID-19 was identified, its clinical and biological heterogeneity has been recognized. Identifying COVID-19 phenotypes might help guide basic, clinical, and translational research efforts.Research questionDoes the clinical spectrum of patients with COVID-19 contain distinct phenotypes and subphenotypes?Study design and methodsWe included adult patients (≥ 18 years) positive for laboratory-confirmed SARS-CoV-2 infection from a prospective COVID-19 registry database in the Cleveland Clinic Health System in Ohio and Florida. The patients were split into training and testing sets. Using latent class analysis (LCA), we first identified phenotypic clusters of patients with COVID-19 based on demographics, comorbidities, and presenting symptoms. We then identified subphenotypes of hospitalized patients with additional blood biomarker data measured on hospital admission. The associations of phenotypes/subphenotypes and clinical outcomes were investigated. Multivariable prediction models were established to predict assignment to the LCA-defined phenotypes and subphenotypes and then evaluated on an independent testing set.ResultsWe analyzed data for 20,572 patients. Seven phenotypes were identified on the basis of different profiles of presenting COVID-19 symptoms and existing comorbidities, including the following groups: young, no symptoms; young, symptoms; middle-aged, no symptoms; middle-aged, symptoms; middle-aged, comorbidities; old, no symptoms; and old, symptoms. The rates of inpatient hospitalization for the phenotypes were significantly different (P < .001). Five subphenotypes were identified for the subgroup of hospitalized patients, including the following subgroups: young, elevated WBC and platelet counts; middle-aged, lymphopenic with elevated C-reactive protein; middle-aged, hyperinflammatory; old, leukopenic with comorbidities; and old, hyperinflammatory with kidney dysfunction. The hospital mortality and the times from hospitalization to ICU transfer or death were significantly different (P < .001). The models for predicting the LCA-defined phenotypes and subphenotypes showed high discrimination (concordance index, 0.92 and 0.91).InterpretationHypothesis-free LCA-defined phenotypes and subphenotypes of patients with COVID-19 can be identified. These may help clinical investigators conduct stratified analyses in clinical trials and assist basic science researchers in characterizing the pathobiology of the spectrum of COVID-19 presentations.
| S-EPMC7907753 | biostudies-literature
Project description:PurposeSeptic shock is a highly heterogeneous condition which is part of the challenge in its diagnosis and treatment. In this study we aim to identify clinically relevant subphenotypes of septic shock using a novel statistic al approach.MethodsBaseline patient data from a large global clinical trial of septic shock (n = 1696) was analysed using latent class analysis (LCA). This approach allowed investigators to identify subgroups in a heterogeneous population by estimating a categorical latent variable that detects relatively homogeneous subgroups within a complex phenomenon.ResultsLCA identified six different, clinically meaningful subphenotypes of septic shock each with a typical profile: (1) "Uncomplicated Septic Shock, (2) "Pneumonia with adult respiratory distress syndrome (ARDS)", (3) "Postoperative Abdominal", (4) "Severe Septic Shock", (5): "Pneumonia with ARDS and multiple organ dysfunction syndrome (MODS)", (6) "Late Septic Shock". The 6-class solution showed high entropy approaching 1 (i.e., 0.92), indicating there was excellent separation between estimated classes.ConclusionsLCA appears to be an applicable statistical tool in analysing a heterogenous clinical cohort of septic shock. The results may lead to a better understanding of septic shock complexity and form a basis for considering targeted therapies and selecting patients for future clinical trials.
| S-EPMC7416734 | biostudies-literature
Project description:ImportanceCannabis hyperemesis syndrome is an emerging clinical issue associated with cannabis use. Legalization of cannabis has led to an increase in vomiting-related illnesses in health care settings.ObjectiveTo examine whether legalization of cannabis in Colorado has been associated with increases in vomiting-related emergency department (ED) visits.Design, setting, and participantsA cross-sectional design was used to assess the increase in ED claims for vomiting reported to the Colorado Hospital Association between January 1, 2013, and December 31, 2018, in counties that had no prior cannabis dispensaries before legalization compared with those that did. A total of 820 778 patients seeking care through Colorado EDs were included in the analysis.ExposuresThe number of medical and recreational cannabis dispensaries per county per quarter.Main outcomes and measuresCounty per capita rate of vomiting-related ED claims per quarter.ResultsVomiting-related ED health care encounters increased from 119 312 in 2013 to 153 699 in 2018 (29% increase). Over this period, 203 861 patients (25%) were aged 0 to 18 years; 114 201 (14%) were aged 19 to 25 years, and 502 771 (61%) were aged 26 years or older; 510 584 patients (62%) were female. Additional recreational dispensaries were associated with increased vomiting-related ED visits (incidence rate ratio, 1.03; 95% CI, 1.01-1.05), but counties with high baseline medical dispensary exposure experienced smaller increases in vomiting-related ED visits than counties with no baseline medical dispensary exposure (incidence rate ratio, 0.97; 95% CI, 0.95-0.99). Counties with a high number of medical marijuana dispensaries had increases at a 5.8% slower rate than counties with none.Conclusions and relevanceThe findings of this study suggest that cannabis legalization in Colorado is associated with an increase in annual vomiting-related health care encounters with regard to exposure to these markets. It may be useful for health care clinicians to be aware of cannabis hyperemesis syndrome and inquire about cannabis use when appropriate.
| S-EPMC8449280 | biostudies-literature
Project description:Background We describe sex-differential disease patterns and outcomes of >20.6 million cardiovascular emergency department encounters in the United States. Methods and Results We analyzed primary cardiovascular encounters from the Nationwide Emergency Department Sample between 2016 and 2018. We grouped cardiovascular diagnoses into 15 disease categories. The sample included 48.7% women; median age was 67 (interquartile range, 54-78) years. Men had greater overall baseline comorbidity burden; however, women had higher rates of obesity, hypertension, and cerebrovascular disease. For women, the most common emergency department encounters were essential hypertension (16.0%), hypertensive heart or kidney disease (14.1%), and atrial fibrillation/flutter (10.2%). For men, the most common encounters were hypertensive heart or kidney disease (14.7%), essential hypertension (10.8%), and acute myocardial infarction (10.7%). Women were more likely to present with essential hypertension, hypertensive crisis, atrial fibrillation/flutter, supraventricular tachycardia, pulmonary embolism, or ischemic stroke. Men were more likely to present with acute myocardial infarction or cardiac arrest. In logistic regression models adjusted for baseline covariates, compared with men, women with intracranial hemorrhage had higher risk of hospitalization and death. Women presenting with pulmonary embolism or deep vein thrombosis were less likely to be hospitalized. Women with aortic aneurysm/dissection had higher odds of hospitalization and death. Men were more likely to die following presentations with hypertensive heart or kidney disease, atrial fibrillation/flutter, acute myocardial infarction, or cardiac arrest. Conclusions In this large nationally representative sample of cardiovascular emergency department presentations, we demonstrate significant sex differences in disease distribution, hospitalization, and death.
| S-EPMC9673731 | biostudies-literature
Project description:BackgroundSubphenotypes have been identified within heterogeneous diseases such as asthma and breast cancer, with important therapeutic implications. We assessed whether subphenotypes exist within acute respiratory distress syndrome (ARDS), another heterogeneous disorder.MethodsWe used data from two ARDS randomised controlled trials (ARMA trial and ALVEOLI trial), sponsored by the National Heart, Lung, and Blood Institute. We applied latent class modelling to identify subphenotypes using clinical and biological data. We modelled data from both studies independently. We then tested the association of subphenotypes with clinical outcomes in both cohorts and with the response to positive end-expiratory pressure (PEEP) in the ALVEOLI cohort.FindingsWe analysed data for 1022 patients: 473 in the ARMA cohort and 549 in the ALVEOLI cohort. Independent latent class models indicated that a two-class (ie, two subphenotype) model was the best fit for both cohorts. In both cohorts, we identified a hyperinflammatory subphenotype (phenotype 2) that was characterised by higher plasma concentrations of inflammatory biomarkers, a higher prevalence of vasopressor use, lower serum bicarbonate concentrations, and a higher prevalence of sepsis than phenotype 1. Participants in phenotype 2 had higher mortality and fewer ventilator-free days and organ failure-free days in both cohorts than did those in phenotype 1 (p<0·007 for all). In the ALVEOLI cohort, the effects of ventilation strategy (high PEEP vs low PEEP) on mortality, ventilator-free days and organ failure-free days differed by phenotype (p=0·049 for mortality, p=0·018 for ventilator-free days, p=0·003 for organ-failure-free days).InterpretationWe have identified two subphenotypes within ARDS, one of which is categorised by more severe inflammation, shock, and metabolic acidosis and by worse clinical outcomes. Response to treatment in a randomised trial of PEEP strategies differed on the basis of subphenotype. Identification of ARDS subphenotypes might be useful in selecting patients for future clinical trials.FundingNational Institutes of Health.
| S-EPMC4154544 | biostudies-literature
Project description:Vital signs are critical markers of illness severity in the emergency department (ED). Providers need to understand the abnormal vital signs in older adults that are problematic. We hypothesized that in patients age > 65 years discharged from the ED, there are abnormal vital signs that are associated with an admission to an inpatient bed within 7 days of discharge.We conducted a retrospective cohort study using data from a regional integrated health system of members age > 65 years during the years 2009 to 2010. We used univariate contingency tables to assess the relationship between hospital admission within 7 days of discharge and vital sign (including systolic blood pressure [sBP], heart rate [HR], body temperature, and pulse oximetry [SpO2 ] values measured closest to discharge) using standard thresholds for abnormal and thresholds derived from the study data.Of 104,025 ED discharges, 4,638 (4.5%) were followed by inpatient admission within 7 days. Vital signs had a greater odds of admission beyond a single cutoff. The vital signs with at least twice the odds of admission were sBP < 97 mm Hg (odds ratio [OR] = 2.02, 95% CI = 1.57-2.60), HR > 101 beats/min (OR = 2.00 95% CI = 1.75-2.29), body temperature > 37.3°C (OR = 2.14, 95% CI = 1.90-2.41), and pulse oximetry < 92 SpO2 (OR = 2.04, 95% CI = 1.55-2.68). Patients with two vital sign abnormalities per the analysis had the highest odds of admission. A majority of patients discharged with abnormal vital signs per the analysis were not admitted within 7 days of ED discharge.While we found a majority of patients discharged with abnormal vital signs as defined by the analysis, not to be admitted after discharge, we identified vital signs associated with at least twice the odds of admission.
| S-EPMC5935002 | biostudies-other
Project description:ImportanceAlthough substantial evidence supports buprenorphine for treatment of opioid use disorder (OUD) in controlled trials, prospective study of patient outcomes in clinical implementation of emergency department (ED) buprenorphine treatment is lacking.ObjectiveTo examine the association between buprenorphine treatment in the ED and follow-up engagement in OUD treatment 1 month later.Design, setting, and participantsThis multisite cohort study was conducted in 7 California EDs participating in a statewide implementation project to improve access to buprenorphine treatment. The study population included ED patients aged at least 18 years identified with OUD between April 1, 2021, and June 30, 2022. Data analysis was performed in October 2023.ExposureAll participants were offered buprenorphine treatment for OUD (either in ED administration, prescription, or both), the uptake of which was examined as the exposure of interest.Main outcomes and measuresThe primary outcome was engagement in OUD treatment 30 days after the ED visit, determined by patient report or clinical documentation. The association of ED buprenorphine treatment with subsequent OUD treatment engagement was estimated using hierarchical generalized linear models.ResultsThis analysis included 464 ED patients with OUD. Their median age was 36.0 (IQR, 29.0-38.7) years, and most were men (343 [73.9%]). With regard to race and ethnicity, 64 patients (13.8%) self-identified as non-Hispanic Black, 183 (39.4%) as Hispanic, and 185 as non-Hispanic White (39.9%). Most patients (396 [85.3%]) had Medicaid insurance, and more than half (262 [57.8%]) had unstable housing. Self-reported fentanyl use (242 [52.2%]) and a comorbid mental health condition (328 [71.5%]) were common. Interest in buprenorphine treatment was high: 398 patients (85.8%) received buprenorphine treatment; 269 (58.0%) were administered buprenorphine in the ED and 339 (73.1%) were prescribed buprenorphine. With regard to OUD treatment engagement at 30 days after the ED visit, 198 participants (49.7%) who received ED buprenorphine treatment remained engaged compared with 15 participants (22.7%) who did not receive ED buprenorphine treatment. An association of ED buprenorphine treatment with subsequent OUD treatment engagement at 30 days was observed (adjusted risk ratio, 1.97 [95% CI, 1.27-3.07]).Conclusions and relevanceThe findings of this cohort study suggest that among patients with OUD presenting to EDs implementing low-threshold access to medications for OUD, buprenorphine treatment was associated with a substantially higher likelihood of follow-up treatment engagement 1 month later. Future research should investigate techniques to optimize both the uptake and effectiveness of buprenorphine initiation in low-threshold settings such as the ED.
| S-EPMC10825722 | biostudies-literature
Project description:IntroductionTo date, there is limited literature to guide emergency providers (EPs) on the proper dosing of prescription opioids. Our study aims to assess the self-reported opioid use, storage, and disposal practices of patients presenting to the emergency department (ED) with acute pain.MethodsThis prospective cohort study employed a validated, cross-sectional survey of subjects identified using electronic medical records. The survey link was e-mailed to a continuous sample of eligible participants 3-4 weeks following ED discharge. Nonrespondents were surveyed through telephone after 1 week. We used descriptive and nonparametric statistics to report survey results.ResultsOf 500 eligible subjects, 97 completed the questionnaire. Only 28% of respondents reported that they took all of the prescribed pills. Of the remaining responses, 20% stated that they did not take any pills, 33% took about one-fourth, 7.2% took about half, and 12.4% took about three-fourths of the pills. Among those who did not take any pills, 42% filled the prescription. Most (71.2%) reported storing their leftover pills; among those who stored their pills, less than one-fourth (23.8%) used a locked storage location.ConclusionsOur findings suggest that less than one-third of patients who receive prescriptions in the ED for acute pain use all of their prescribed pills, suggesting that many patients are unnecessarily prescribed opioids for acute conditions. The findings of this study also suggest that many patients with unused prescription opioids do not practice safe storage or proper disposal of leftover pills. This represents a potential opportunity for EPs to improve medication safety by educating patients on proper storage and disposal practices. Limitations include low response rate and the use of self-reporting.
| S-EPMC10824224 | biostudies-literature