BACKGROUND Little is known about emergency department (ED) use among pediatric patients with cancer. We explored reasons prompting emergency department (ED) visits and factors associated with hospital admission. PROCEDURE A retrospective cohort analysis of pediatric ED visits from 2006-2010 using the Nationwide Emergency Department Sample, the largest all-payer database of United States ED visits. Pediatric patients with cancer (ages ≤19 years) were identified using Clinical Classification Software. Proportion of visits and disposition for the top ten-ranking non-cancer diagnoses were determined. Weighted multivariate logistic regression was performed to analyze factors associated with admission versus discharge. RESULTS There were 294,289 ED visits by pediatric patients with cancer in the US over the study period. Fever and fever with neutropenia (FN) were the two most common diagnoses, accounting for almost 20% of visits. Forty-four percent of pediatric patients with cancer were admitted to the same hospital, with admission rates up to 82% for FN. Risk factors for admission were: FN (odds ratio (OR) 8.58; 95% confidence interval (CI) 5.97-12.34); neutropenia alone (OR 7.28; 95% CI 5.08-10.43), ages 0-4 years compared with 15-19 years (OR 1.19; 95% CI 1.08-1.31) and highest median household income ZIP code (OR 1.27; 95% CI 1.08-1.49) compared with lowest. “Self-pay” visits had lower odds of admission (OR 0.42; 95% CI 0.35-0.51) compared with public payer. CONCLUSION FN was the most common reason for ED visits among pediatric patients with cancer and is the condition most strongly associated with admission. Socioeconomic factors appear to influence ED disposition for this population.

The emergency department (ED) is now the primary source for hospitalizations in the United States, and admission rates for all causes differ widely between EDs. In this study we used a national sample of ED visits to examine variation in risk-standardized hospital admission rates from EDs and the relationship of this variation to inpatient mortality for the fifteen most commonly admitted medical and surgical conditions. We then estimated the impact of variation on national health expenditures under different utilization scenarios. Risk-standardized admission rates differed substantially across EDs, ranging from 1.03-fold for sepsis to 6.55-fold for chest pain between the twenty-fifth and seventy-fifth percentiles of the visits. Conditions such as chest pain, soft tissue infection, asthma, chronic obstructive pulmonary disease, and urinary tract infection were low-mortality conditions that showed the greatest variation. This suggests that some of these admissions might not be necessary, thus representing opportunities to improve efficiency and reduce health spending. Our data indicate that there may be sizeable savings to US payers if differences in ED hospitalization practices could be narrowed among a few of these high-variation, low-mortality conditions.

IMPORTANCE Unscheduled short-term return visits to the emergency department (ED) are increasingly monitored as a hospital performance measure and have been proposed as a measure of the quality of emergency care. OBJECTIVE To examine in-hospital clinical outcomes and resource use among patients who are hospitalized during an unscheduled return visit to the ED. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of adult ED visits to acute care hospitals in Florida and New York in 2013 using data from the Healthcare Cost and Utilization Project. Patients with index ED visits were identified and followed up for return visits to the ED within 7, 14, and 30 days. EXPOSURES Hospital admission occurring during an initial visit to the ED vs during a return visit to the ED. MAIN OUTCOMES AND MEASURES In-hospital mortality, intensive care unit (ICU) admission, length of stay, and inpatient costs. RESULTS Among the 9 036 483 index ED visits to 424 hospitals in the study sample, 1 758 359 patients were admitted to the hospital during the index ED visit. Of these patients, 149 214 (8.5%) had a return visit to the ED within 7 days of the index ED visit, 228 370 (13.0%) within 14 days, and 349 335 (19.9%) within 30 days, and 76 151 (51.0%), 122 040 (53.4%), and 190 768 (54.6%), respectively, were readmitted to the hospital. Among the 7 278 124 patients who were discharged during the index ED visit, 598 404 (8.2%) had a return visit to the ED within 7 days, 839 386 (11.5%) within 14 days, and 1 205 865 (16.6%) within 30 days. Of these patients, 86 012 (14.4%) were admitted to the hospital within 7 days, 121 587 (14.5%) within 14 days, and 173 279 (14.4%) within 30 days. The 86 012 patients discharged from the ED and admitted to the hospital during a return ED visit within 7 days had significantly lower rates of in-hospital mortality (1.85%) compared with the 1 609 145 patients who were admitted during the index ED visit without a return ED visit (2.48%)

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IntroductionSeveral European studies suggest that some patients with appendicitis can be treated safely with antibiotics. A portion of patients eventually undergo appendectomy within a year, with 10%–15% failing to respond in the initial period and a similar additional proportion with suspected recurrent episodes requiring appendectomy. Nearly all patients with appendicitis in the USA are still treated with surgery. A rigorous comparative effectiveness trial in the USA that is sufficiently large and pragmatic to incorporate usual variations in care and measures the patient experience is needed to determine whether antibiotics are as good as appendectomy.ObjectivesThe Comparing Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial for acute appendicitis aims to determine whether the antibiotic treatment strategy is non-inferior to appendectomy.Methods/AnalysisCODA is a randomised, pragmatic non-inferiority trial that aims to recruit 1552 English-speaking and Spanish-speaking adults with imaging-confirmed appendicitis. Participants are randomised to appendectomy or 10 days of antibiotics (including an option for complete outpatient therapy). A total of 500 patients who decline randomisation but consent to follow-up will be included in a parallel observational cohort. The primary analytic outcome is quality of life (measured by the EuroQol five dimension index) at 4 weeks. Clinical adverse events, rate of eventual appendectomy, decisional regret, return to work/school, work productivity and healthcare utilisation will be compared. Planned exploratory analyses will identify subpopulations that may have a differential risk of eventual appendectomy in the antibiotic treatment arm.Ethics and disseminationThis trial was approved by the University of Washington’s Human Subjects Division. Results from this trial will be presented in international conferences and published in peer-reviewed journals.Trial registration numberNCT02800785.