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BIBTEX RIS

Predictors of Regional Variations in Hospitalizations Following Emergency Department Visits for Atrial Fibrillation

2013; Elsevier BV; Volume: 112; Issue: 9 Linguagem: Inglês

10.1016/j.amjcard.2013.07.005

ISSN

1879-1913

Autores

Tyler W. Barrett, Wesley H. Self, Cathy A. Jenkins, Alan B. Storrow, B.S. Heavrin, Candace D. McNaughton, Sean P. Collins, Jeffrey J. Goldberger,

Tópico(s)

Cardiovascular Syncope and Autonomic Disorders

Resumo

The emergency department (ED) is often where atrial fibrillation (AF) is first detected and acutely treated and affected patients dispositioned. We used the Nationwide Emergency Department Sample to estimate the percentage of visits resulting in hospitalization and investigate associations between patient and hospital characteristics with hospitalization at the national and regional levels. We conducted a cross-sectional study of adults with AF listed as the primary ED diagnosis in the 2007 to 2009 Nationwide Emergency Department Sample. We performed multivariate logistic regression analyses investigating the associations between prespecified patient and hospital characteristics with hospitalization. From 2007 to 2009, there were 1,320,123 weighted ED visits for AF, with 69% hospitalized nationally. Mean regional hospitalization proportions were: Northeast (74%), Midwest (68%), South (74%), and West (57%). The highest odds ratios for predicting hospitalization were heart failure (3.85, 95% confidence interval [CI] 3.66 to 4.02), chronic obstructive pulmonary disease (2.47, 95% CI 2.34 to 2.61), and coronary artery disease (1.65, 95% CI 1.58 to 1.73). After adjusting for age, privately insured (0.77, 95% CI 0.73 to 0.81) and self-pay (0.77 95% CI 0.66 to 0.90) patients had lower odds compared with Medicare recipients, whereas Medicaid (1.21, 95% CI 1.11 to 1.32) patients tended to have higher odds. Patients living in low-income zip codes (1.18, 95% CI 1.12 to 1.25) and patients treated at large metropolitan hospitals (1.75, 95% CI 1.59 to 1.93) had higher odds. In conclusion, our analysis showed considerable regional variation in the management of patients with AF in the ED and in associations between patient socioeconomic and hospital characteristics with ED disposition; adapting best practices from among these variations in management could reduce hospitalizations and health-care expenses. The emergency department (ED) is often where atrial fibrillation (AF) is first detected and acutely treated and affected patients dispositioned. We used the Nationwide Emergency Department Sample to estimate the percentage of visits resulting in hospitalization and investigate associations between patient and hospital characteristics with hospitalization at the national and regional levels. We conducted a cross-sectional study of adults with AF listed as the primary ED diagnosis in the 2007 to 2009 Nationwide Emergency Department Sample. We performed multivariate logistic regression analyses investigating the associations between prespecified patient and hospital characteristics with hospitalization. From 2007 to 2009, there were 1,320,123 weighted ED visits for AF, with 69% hospitalized nationally. Mean regional hospitalization proportions were: Northeast (74%), Midwest (68%), South (74%), and West (57%). The highest odds ratios for predicting hospitalization were heart failure (3.85, 95% confidence interval [CI] 3.66 to 4.02), chronic obstructive pulmonary disease (2.47, 95% CI 2.34 to 2.61), and coronary artery disease (1.65, 95% CI 1.58 to 1.73). After adjusting for age, privately insured (0.77, 95% CI 0.73 to 0.81) and self-pay (0.77 95% CI 0.66 to 0.90) patients had lower odds compared with Medicare recipients, whereas Medicaid (1.21, 95% CI 1.11 to 1.32) patients tended to have higher odds. Patients living in low-income zip codes (1.18, 95% CI 1.12 to 1.25) and patients treated at large metropolitan hospitals (1.75, 95% CI 1.59 to 1.93) had higher odds. In conclusion, our analysis showed considerable regional variation in the management of patients with AF in the ED and in associations between patient socioeconomic and hospital characteristics with ED disposition; adapting best practices from among these variations in management could reduce hospitalizations and health-care expenses. Atrial fibrillation (AF) affects from 3 to 6 million Americans, with estimated national incremental health-care costs ranging from $6 to $26 billion per year.1Go A.S. Hylek E.M. Phillips K.A. Chang Y. Henault L.E. Selby J.V. Singer D.E. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study.JAMA. 2001; 285: 2370-2375Crossref PubMed Scopus (5270) Google Scholar, 2Go A.S. Mozaffarian D. Roger V.L. Benjamin E.J. Berry J.D. Borden W.B. Bravata D.M. Dai S. Ford E.S. Fox C.S. Franco S. Fullerton H.J. Gillespie C. Hailpern S.M. Heit J.A. Howard V.J. Huffman M.D. Kissela B.M. Kittner S.J. Lackland D.T. Lichtman J.H. Lisabeth L.D. Magid D. Marcus G.M. Marelli A. Matchar D.B. McGuire D.K. Mohler E.R. Moy C.S. Mussolino M.E. Nichol G. Paynter N.P. Schreiner P.J. Sorlie P.D. Stein J. Turan T.N. Virani S.S. Wong N.D. Woo D. Turner M.B. Heart disease and stroke statistics—2013 update: a report from the American Heart Association.Circulation. 2013; 127: e6-e245Crossref PubMed Scopus (4405) Google Scholar, 3Kim M.H. Johnston S.S. Chu B.C. Dalal M.R. Schulman K.L. Estimation of total incremental health care costs in patients with atrial fibrillation in the United States.Circ Cardiovasc Qual Outcomes. 2011; 4: 313-320Crossref PubMed Scopus (563) Google Scholar The emergency department (ED) is often where AF is first detected and acutely treated and affected patients dispositioned.4Barrett T.W. Martin A.R. Storrow A.B. Jenkins C.A. Harrell Jr., F.E. Russ S. Roden D.M. Darbar D. A clinical prediction model to estimate risk for 30-day adverse events in emergency department patients with symptomatic atrial fibrillation.Ann Emerg Med. 2011; 57: 1-12Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar, 5McDonald A.J. Pelletier A.J. Ellinor P.T. Camargo Jr., C.A. Increasing US emergency department visit rates and subsequent hospital admissions for atrial fibrillation from 1993 to 2004.Ann Emerg Med. 2008; 51: 58-65Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar ED visits for AF increased by 88% from 1993 to 2004, with 64% of these visits resulting in hospitalization.5McDonald A.J. Pelletier A.J. Ellinor P.T. Camargo Jr., C.A. Increasing US emergency department visit rates and subsequent hospital admissions for atrial fibrillation from 1993 to 2004.Ann Emerg Med. 2008; 51: 58-65Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar Understanding factors that influence hospitalization may result in more informed acute AF management. Specifically, our health-care system may benefit from a greater knowledge of how health-care disparities impact the significant United States (US) regional variation in hospitalizations for AF. The frequency of ED visits for AF, national and regional AF hospitalizations, and ED cardioversions have not been studied after the publication of the 2006 American College of Cardiology/American Heart Association/European Society of Cardiology guidelines.6Fuster V. Ryden L.E. Cannom D.S. Crijns H.J. Curtis A.B. Ellenbogen K.A. Halperin J.L. Le Heuzey J.Y. Kay G.N. Lowe J.E. Olsson S.B. Prystowsky E.N. Tamargo J.L. Wann S. Smith Jr., S.C. Jacobs A.K. Adams C.D. Anderson J.L. Antman E.M. Halperin J.L. Hunt S.A. Nishimura R. Ornato J.P. Page R.L. Riegel B. Priori S.G. Blanc J.J. Budaj A. Camm A.J. Dean V. Deckers J.W. Despres C. Dickstein K. Lekakis J. McGregor K. Metra M. Morais J. Osterspey A. Tamargo J.L. Zamorano J.L. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.Circulation. 2006; 114: e257-e354Crossref PubMed Scopus (2007) Google Scholar We used the Nationwide Emergency Department Sample (NEDS) to investigate age-specific ED visit rates for AF, percentage of ED visits resulting in hospitalization, as well as associations between specific patient and hospital characteristics with hospitalization at the national and regional levels.7Agency for Healthcare Research and Quality. Healthcare cost and utilization Project (HCUP). HCUP Nationwide Emerg Department Sample (NEDS). 2007, 2008, 2009. Rockville, MD.Google Scholar NEDS is a US administrative database maintained by the Agency for Healthcare Research and Quality as a component of the Healthcare Cost and Utilization Project. NEDS contains data from 25 to 30 million unweighted hospital-based ED visits annually, representing about 20% of all US visits.7Agency for Healthcare Research and Quality. Healthcare cost and utilization Project (HCUP). HCUP Nationwide Emerg Department Sample (NEDS). 2007, 2008, 2009. Rockville, MD.Google Scholar NEDS includes data from approximately 29 states and stratifies the data by geographic region (Northeast, Midwest, South, and West), trauma center designation, urban-rural status, teaching hospital status, and ownership. The NEDS database includes weights for calculating national estimates from the 20% sample of measured ED visits. NEDS consists of 4 files: (1) a core file including demographic, diagnostic, ED charges, and disposition data, (2) a supplemental ED file with ED procedures, (3) an inpatient file with hospital procedures for those admitted, and (4) a hospital file describing the characteristics of the hospital-based ED. For each ED encounter, NEDS reports ≤15 diagnoses coded according to their respective International Classification of Diseases (ICD)-9 codes. NEDS also classifies each ICD-9 diagnosis as a nonchronic or chronic condition based on a validated algorithm.7Agency for Healthcare Research and Quality. Healthcare cost and utilization Project (HCUP). HCUP Nationwide Emerg Department Sample (NEDS). 2007, 2008, 2009. Rockville, MD.Google Scholar, 8Hwang W. Weller W. Ireys H. Anderson G. Out-of-pocket medical spending for care of chronic conditions.Health Aff (Millwood). 2001; 20: 267-278Crossref PubMed Scopus (323) Google Scholar We conducted a cross-sectional study of adults with AF, identified by the ICD-9 code 427.31 listed as the primary ED diagnosis from 2007 to 2009. We limited our analysis to the 3 years after publication of the 2006 American College of Cardiology/American Heart Association/European Society of Cardiology guidelines for the Management of Patients with AF.6Fuster V. Ryden L.E. Cannom D.S. Crijns H.J. Curtis A.B. Ellenbogen K.A. Halperin J.L. Le Heuzey J.Y. Kay G.N. Lowe J.E. Olsson S.B. Prystowsky E.N. Tamargo J.L. Wann S. Smith Jr., S.C. Jacobs A.K. Adams C.D. Anderson J.L. Antman E.M. Halperin J.L. Hunt S.A. Nishimura R. Ornato J.P. Page R.L. Riegel B. Priori S.G. Blanc J.J. Budaj A. Camm A.J. Dean V. Deckers J.W. Despres C. Dickstein K. Lekakis J. McGregor K. Metra M. Morais J. Osterspey A. Tamargo J.L. Zamorano J.L. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.Circulation. 2006; 114: e257-e354Crossref PubMed Scopus (2007) Google Scholar All outcomes referring to hospitalizations included visits in which the patient was admitted to the same hospital or transferred to a short-term acute care hospital. We calculated annual incidences of ED visits for AF from 2007 to 2009, percentages of ED visits for AF resulting in hospitalization, and the percentage of visits associated with ED or inpatient electrical cardioversions. We further stratified these incidences by US geographic region and age groups defined by the US census.9Centers for Disease Control and Prevention. National Vital Statistics System: US Census Population With Bridged Race Categories. Available at: http://www.cdc.gov/nchs/nvss/bridged_race.htm. Accessed September 3, 2012.Google Scholar We documented ED cardioversion frequencies to determine whether regional variation in hospitalization may be explained by increased frequency of ED cardioversion in the regions with lower hospitalization percentages. Electrical cardioversions performed in the ED and inpatient settings were measured using specific Current Procedural Terminology codes 92960 and 92961 in the ED procedures section and Clinical Classifications Software code 225 in the inpatient procedures section. National and regional estimates of frequencies and percentages, and all regression analyses, accounted for the NEDS sampling design. Age-specific annual incidences of ED visits for AF were calculated by dividing the weighted annual number of ED visits for AF by July population estimates from the US Census Bureau, then expressing this quantity as ED visits per 1,000 persons. Two multivariate logistic regression analyses were used to investigate the association between a priori selected patient and hospital characteristics with hospitalization. The models evaluated associations between these independent variables, including US geographic region as an independent variable, and hospitalization from the ED at the national level stratified by region. The Supplementary Table 1 provides a detailed description of the independent variables. We chose these patient and hospital characteristics based on our previous investigations, an extensive review of the medical works, and our clinical experience.4Barrett T.W. Martin A.R. Storrow A.B. Jenkins C.A. Harrell Jr., F.E. Russ S. Roden D.M. Darbar D. A clinical prediction model to estimate risk for 30-day adverse events in emergency department patients with symptomatic atrial fibrillation.Ann Emerg Med. 2011; 57: 1-12Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar, 5McDonald A.J. Pelletier A.J. Ellinor P.T. Camargo Jr., C.A. Increasing US emergency department visit rates and subsequent hospital admissions for atrial fibrillation from 1993 to 2004.Ann Emerg Med. 2008; 51: 58-65Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar, 10Barrett T.W. Abraham R.L. Jenkins C.A. Russ S. Storrow A.B. Darbar D. Risk factors for bradycardia requiring pacemaker implantation in patients with atrial fibrillation.Am J Cardiol. 2012; 110: 1315-1321Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 11Barrett T.W. Storrow A.B. Jenkins C.A. Harrell Jr., F.E. Miller K.F. Moser K.M. Russ S. Roden D.M. Darbar D. Atrial fibrillation and flutter outcomes and risk determination (AFFORD): design and rationale.J Cardiol. 2011; 58: 124-130Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 12Gage B.F. Waterman A.D. Shannon W. Boechler M. Rich M.W. Radford M.J. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation.JAMA. 2001; 285: 2864-2870Crossref PubMed Scopus (4205) Google Scholar, 13Miyasaka Y. Barnes M.E. Gersh B.J. Cha S.S. Bailey K.R. Seward J.B. Tsang T.S. Changing trends of hospital utilization in patients after their first episode of atrial fibrillation.Am J Cardiol. 2008; 102: 568-572Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 14Perrea D.N. Ekmektzoglou K.A. Vlachos I.S. Tsitsilonis S. Koudouna E. Stroumpoulis K. Xanthos T. A formula for the stratified selection of patients with paroxysmal atrial fibrillation in the emergency setting: a retrospective pilot study.J Emerg Med. 2011; 40: 374-379Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 15Wang T.J. Massaro J.M. Levy D. Vasan R.S. Wolf P.A. D'Agostino R.B. Larson M.G. Kannel W.B. Benjamin E.J. A risk score for predicting stroke or death in individuals with new-onset atrial fibrillation in the community: the Framingham Heart Study.JAMA. 2003; 290: 1049-1056Crossref PubMed Scopus (672) Google Scholar, 16Zimetbaum P. Reynolds M.R. Ho K.K. Gaziano T. McDonald M.J. McClennen S. Berezin R. Josephson M.E. Cohen D.J. Impact of a practice guideline for patients with atrial fibrillation on medical resource utilization and costs.Am J Cardiol. 2003; 92: 677-681Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar, 17Burt C.W. Arispe I.E. Characteristics of emergency departments serving high volumes of safety-net patients: United States, 2000.Vital Health Stat 13. 2004; : 1-16Google Scholar This study was conducted with de-identified data and was approved by the local institutional review board as nonhuman research. All analyses were done using the statistical programming language SAS software, version 9.2 of the SAS System for Linux (Cary, North Carolina). From 2007 to 2009, there were 376,162,043 (95% confidence interval [CI] 362,625,877 to 389,698,208) total weighted ED visits including 1,320,123 (95% CI 1,258,776 to 1,381,471) weighted ED visits for AF. Table 1 lists the characteristics for the ED visits for AF overall including regional hospitalization frequencies. Characteristics stratified by census age groups are listed in Table 2. Figure 1 shows what appears to be a consistent trend in all 4 US geographic regions, with greater hospitalization percentages associated with increasing patient age. The percentage of patients with AF who underwent ED electrical cardioversion nationwide during 2007 to 2009 was 3.5% (95% CI 2.9 to 4.1). Regional percentages of ED cardioversion were Northeast 4.3% (95% CI 3.2 to 5.5), Midwest 4.0% (95% CI 2.5 to 5.5), South 1.0% (95% CI 0.7 to 1.2), and West 5.6% (95% CI 4.1 to 7.1). Electrical cardioversions were most frequently performed in the youngest adults (Figure 2) and in the inpatient setting, with reported frequencies of 9.4% (95% CI 8.8 to 10) in 2007, 9.5% (95% CI 8.8 to 10.2) in 2008, and 10.1% (95% CI 9.4 to 10.8) in 2009. There was less regional variation in the performance of inpatient cardioversions (Supplementary Table 2—online only).Table 1Characteristics for emergency department (ED) visits for atrial fibrillation (AF)Characteristic2007 (Nonweighted ED Visits for AF, n = 89,056)2008 (Nonweighted ED Visits for AF, n = 101,211)2009 (Nonweighted ED Visits for AF, n = 102,979)Overall weighted ED visits for AF (95% CI)411,406 (381,029–441,783)445,924 (412,503–479,345)462,794 (429,160–496,427)ED visits for AF per 1,000 person-yrs, %∗Data are reported as mean with (95% CI).1.8 (1.6–2.0)1.9 (1.7–2.2)2.0 (1.8–2.2)Northeast85,834 (20.9)88,987 (20.0)90,547 (19.6)Midwest100,160 (24.4)103,923 (23.3)111,942 (24.2)South154,313 (37.5)166,748 (37.4)172,070 (37.2)West71,098 (17.3)86,267 (19.4)88,235 (19.1)Age (yrs)∗Data are reported as mean with (95% CI).69.2 (68.9–69.4)69.4 (69.2–69.7)69.5 (69.3–69.8)Women215,406 (52.4)233,940 (52.5)243,443 (52.6)ED disposition Treated and released119,836 (29.1)138,045 (31.0)141,679 (30.6) Admitted to same hospital275,663 (67.0)291,822 (65.4)306,495 (66.2) Transferred to short-term hospital12,563 (3.1)14,731 (3.3)13,636 (3.0) Died in ED152.48 (0.04)243.91 (0.05)292.95 (0.06) Died in hospital2,981 (0.7)3,092 (0.7)3,166 (0.7)Regional hospitalization, % (95% CI) Northeast74.2 (71.3–77.2)73.6 (70.4–76.8)74.5 (71.4–77.6) Midwest67.5 (65.2–70.0)65.7 (63.3–68.0)70.2 (67.9–72.4) South74.1 (72.1–76.0)73.7 (71.8–75.7)73.5 (71.7–75.2) West59.9 (56.5–63.2)57.9 (54.4–61.4)54.1 (49.7–58.5)Length of stay (days)∗Data are reported as mean with (95% CI).3.7 (3.6–3.7)3.7 (3.7–3.8)3.7 (3.6–3.7)ED cardioversion3,929 (2.9)5,374 (3.5)6,368 (4.1)Inpatient cardioversion25,855 (9.4)27,838 (9.5)30,852 (10.1)Total ED charge ($)∗Data are reported as mean with (95% CI).1,892 (1,803–1,980)2,169 (2,061–2,276)2,437 (2,334–2,540)Total combined ED and inpatient charge ($)∗Data are reported as mean with (95% CI).21,771 (20,712–22,828)23,667 (22,406–24,927)24,752 (23,635–25,869)Weekend ED visit103,331 (25.2)112,360 (25.2)115,567 (25.0)Hypertension†Frequencies of documented chronic disease are reported as weighted frequency (%).145,815 (35.4)160,797 (36.1)167,623 (36.2)Diabetes†Frequencies of documented chronic disease are reported as weighted frequency (%).44,476 (10.8)50,835 (11.4)52,930 (11.4)Coronary artery disease†Frequencies of documented chronic disease are reported as weighted frequency (%).60,409 (14.7)68,173 (15.3)68,426 (14.8)Chronic obstructive pulmonary disease†Frequencies of documented chronic disease are reported as weighted frequency (%).40,501 (9.8)33,220 (7.5)34,344 (7.4)Heart failure†Frequencies of documented chronic disease are reported as weighted frequency (%).70,589 (17.2)72,452 (16.3)82,929 (17.9)Insurance type, % (95% CI) Medicare66.2 (65.2–37.1)66.7 (65.8–67.7)66.7 (65.7–67.7) Medicaid4.0 (3.6–4.3)4.3 (3.9–4.7)4.7 (4.3–5.2) Private, including HMO24.0 (23.2–24.8)23.3 (22.5–24.2)22.8 (22.1–23.6) Self-pay3.7 (3.3–4.0)3.3 (3.0–3.6)3.5 (3.2–3.8) No charge0.4 (0.2–0.6)0.4 (0.2–0.5)0.4 (0.2–0.6) Other1.9 (1.6–2.2)2.0 (1.7–2.3)1.9 (1.6–2.1)Low income98,359 (24.4)102,227 (23.5)105,674 (23.4)Large metropolitan179,112 (48.9)189,144 (47.7)197,803 (48.0)Teaching hospital145,749 (35.4)149,259 (33.5)158,999 (34.4)Safety net hospital185,127 (45.0)213,410 (47.9)241,649 (52.2)Data are presented as national weighted frequencies (percentages of total annual ED visits for AF) unless otherwise specified.HMO = health maintenance organization.∗ Data are reported as mean with (95% CI).† Frequencies of documented chronic disease are reported as weighted frequency (%). Open table in a new tab Table 2Characteristics for emergency department (ED) visits for atrial fibrillation (AF) by age groupCharacteristicAge (yrs)18–3940–6465–7475–84>85OverallOverall weighted ED visits for AF0.04 (0.04–0.04)0.4 (0.4–0.4)1.2 (1.2–1.3)1.5 (1.5–1.5)1.4 (1.4–1.4)0.4 (0.3–0.4)Women20.5 (19.6–21.5)36.0 (35.5–36.5)52.5 (51.9–53.1)63.6 (63.1–64.1)73.4 (72.8–74.0)52.5 (52.2–52.8)ED disposition Discharged44.2 (42.4–45.9)35.8 (34.6–37.0)31.2 (30.1–32.3)26.4 (25.4–27.4)21.3 (20.4–22.2)30.3 (29.3–31.3) Admitted to same hospital52.3 (50.5–54.0)60.9 (59.7–62.2)64.9 (63.7–66.2)70.0 (68.8–71.2)75.4 (74.3–76.4)66.2 (65.1–67.3) Transferred to short-term hospital3.0 (2.6–3.4)27.8 (2.5–3.1)3.5 (3.0–4.0)3.2 (2.8–3.7)2.9 (2.5–3.4)3.1 (2.7–3.5) Died in ED0.02 (0–0.04)0.03 (0.02–0.05)0.04 (.02–0.06)0.06 (0.04–0.07)0.1 (0.1–0.1)0.05 (0.04–0.06)Medicare3.7 (3.2–4.2)12.8 (12.4–13.2)83.0 (82.3–83.8)91.5 (90.9–92.1)93.6 (93.0–94.2)62.8 (62.1–63.5)Medicaid11.6 (10.7–12.5)9.4 (8.9–9.9)1.6 (1.3–1.8)1.0 (0.8–1.2)0.6 (0.5–0.7)4.0 (3.8–4.3)Private, including HMO62.1 (60.6–63.6)63.5 (62.4–64.6)13.6 (12.9–14.3)6.2 (5.7–6.8)4.7 (4.2–5.2)27.1 (26.4–27.7)Self-pay17.5 (16.3–18.6)8.9 (8.4–9.4)0.9 (0.8–1.1)0.6 (0.5–0.7)0.5 (0.3–0.6)3.8 (3.6–4.1)No charge0.9 (0.6–1.3)0.9 (0.6–1.2)0.1 (0.03–0.1)0.04 (0.01–0.06)0.03 (0.01–0.04)0.3 (0.2–0.5)Other4.3 (3.7–4.9)4.5 (4.0–4.9)0.8 (0.7–1.0)0.7 (0.5–0.8)0.6 (0.5–0.8)2.0 (1.8–2.2)Low income25.1 (23.3–26.9)24.0 (22.5–25.4)24.6 (23.1–26.2)23.3 (21.8–24.8)22.5 (20.9–24.1)23.8 (22.3–25.2)Weekend ED visit28.1 (27.2–28.9)25.2 (24.9–25.6)25.0 (24.7–25.5)24.5 (24.2–24.9)25.1 (24.6–25.5)25.1 (24.9–25.3)Hypertension17.2 (16.2–18.1)34.9 (34.3–35.5)40.2 (39.6–40.9)37.6 (36.9–38.2)33.5 (32.8–34.2)35.9 (35.4–36.4)Diabetes3.6 (3.1–4.1)12.1 (11.7–12.4)13.9 (13.5–14.3)11.2 (10.9–11.5)7.5 (7.2–7.8)11.2 (11.0–11.5)Coronary artery disease1.5 (1.3–1.8)11.0 (10.6–11.3)17.4 (17.0–17.9)18.6 (18.2–19.0)15.8 (15.3–16.3)14.9 (14.6–15.2)Chronic obstructive pulmonary disease0.4 (0.3–0.5)5.7 (5.5–6.0)10.0 (9.7–10.4)10.4 (10.1–10.7)8.4 (8.0–8.7)8.2 (8.0–8.4)Heart failure3.6 (3.2–4.0)12.0 (11.6–12.4)15.0 (14.6–15.5)20.3 (19.7–20.8)28.2 (27.5–29.0)17.1 (16.7–17.5)Large metropolitan53.3 (50.6–56.1)49.3 (46.9–51.8)45.5 (43.1–47.9)47.5 (45.1–50.0)49.8 (47.2–52.3)48.2 (45.8–50.5)Teaching hospital40.3 (37.5–43.1)37.8 (35.3–40.2)32.5 (30.0–34.9)32.6 (30.1–35.1)32.5 (29.9–35.1)34.4 (32.0–36.8)Safety net hospital52.0 (48.5–55.5)50.5 (47.3–53.7)49.7 (46.5–52.9)46.7 (43.4–50.0)45.0 (41.7–48.4)48.5 (45.3–51.7)ED electrical cardioversion performed8.0 (6.5–9.4)5.4 (4.4–6.4)3.0 (2.4–3.6)1.6 (1.2–1.9)0.7 (0.4–1.0)3.5 (2.9–4.1)Inpatient electrical cardioversion performed14.2 (13.1–15.3)13.1 (12.5–13.8)10.7 (10.1–11.3)8.2 (7.7–8.7)4.6 (4.2–4.9)9.7 (9.2–10.1)Data are presented as frequencies per age group and overall with % (95% CIs).HMO = health maintenance organization. Open table in a new tab Figure 2ED cardioversions by adult census age category and region. Figures are stratified by region and illustrate percentages calculated from weighted frequencies. Each dot represents a year and each line type an age group, including the overall estimate for each region ignoring age.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Data are presented as national weighted frequencies (percentages of total annual ED visits for AF) unless otherwise specified. HMO = health maintenance organization. Data are presented as frequencies per age group and overall with % (95% CIs). HMO = health maintenance organization. Multivariate analyses found that the Midwest and West regions had lower odds of admission compared with the Northeast (Table 3). The strongest predictors of hospitalization were a history of heart failure, chronic obstructive pulmonary disease, and coronary artery disease. After adjusting for age, privately insured and self-pay patients had lower odds of hospitalization compared with Medicare patients, whereas Medicaid patients tended to have higher odds. Patients living in a low-income zip code and those treated at large metropolitan, safety net, and private investor-owned hospitals had higher odds of hospitalization. We investigated insurance status in patients identified as low income and found that 65% had Medicare, 6% Medicaid, 20% private insurance, 5% self-pay, and 2.5% with no charge or other insurance.Table 3Multivariate analysis investigating association between covariates and hospitalization for emergency department (ED) patients with atrial fibrillation at the national and regional levelsCharacteristicRegionAdjusted OR (95% CI)pAgeNational1.008 (1.007–1.010)<0.0001Northeast1.003 (1.00–1.007)0.0517Midwest1.011 (1.009–1.014)<0.0001South1.006 (1.003–1.008)<0.0001West1.013 (1.010–1.016)<0.0001WomenNational1.064 (1.040–1.088)<0.0001Northeast1.101 (1.045–1.160)0.0003Midwest1.035 (0.989–1.083)0.1419South1.057 (1.022–1.093)0.0014West1.072 (1.013–1.133)0.0152US regionNortheast (ref)1.00Midwest0.762 (0.655–0.886)0.0004South0.846 (0.690–1.036)0.1058West0.44 (0.357–0.543)<0.0001Heart failureNational3.845 (3.655–4.017)<0.0001Northeast6.154 (5.419–6.989)<0.0001Midwest3.577 (3.302–3.874)<0.0001South3.229 (2.966–3.515)<0.0001West3.882 (3.445–4.374)<0.0001Chronic obstructive pulmonary diseaseNational2.469 (2.340–2.605)<0.0001Northeast3.346 (2.916–3.840)<0.0001Midwest2.343 (2.118–2.605)<0.0001South2.285 (2.108–2.477)<0.0001West2.242 (1.959–2.566)<0.0001Coronary artery diseaseNational1.651 (1.576–1.729)<0.0001Northeast2.105 (1.850–2.396)<0.0001Midwest1.492 (1.374–1.619)<0.0001South1.535 (1.420–1.632)<0.0001West1.797 (1.581–2.043)<0.0001HypertensionNational1.131 (1.094–1.205)<0.0001Northeast1.437 (1.266–1.630)<0.0001Midwest1.105 (1.017–1.200)0.0177South0.943 (0.889–1.001)0.0523West1.263 (1.105–1.443)0.00006DiabetesNational1.147 (1.104–1.193)<0.0001Northeast1.22 (1.112–1.340)<0.0001Midwest1.147 (1.061–1.240)0.0006South1.093 (1.030–1.160)0.0033West1.154 (1.057–1.261)0.0014Payer status Medicare (ref)1.00 MedicaidNational1.21 (1.110–1.319)<0.0001Northeast0.982 (0.797–1.211)0.8677Midwest1.179 (0.986–1.410)0.0718South1.138 (0.996–1.281)0.0580West1.516 (1.284–1.790)<0.0001 Private insuranceNational0.77 (0.729–0.812)<0.0001Northeast0.599 (0.498–0.720)<0.0001Midwest0.852 (0.794–0.914)<0.0001South0.792 (0.739–0.849)<0.0001West0.849 (0.767–0.940)0.0016 Self-payNational0.772 (0.659–0.903)0.0013Northeast0.753 (0.612–0.925)0.0071Midwest1.082 (0.937–1.249)0.2852South0.628 (0.471–0.839)0.0017West0.923 (0.731–1.166)0.5002Low incomeNational1.182 (1.117–1.252)<0.0001Northeast1.14 (0.981–1.325)0.0883Midwest1.201 (1.098–1.313)<0.0001South1.142 (1.056–1.234)0.0008West1.379 (1.140–1.666)0.0009Large metropolitan hospitalNational1.75 (1.589–1.928)<0.0001Northeast1.99 (1.570–2.522)<0.0001Midwest1.554 (1.299–1.859)<0.0001South1.785 (1.521–2.094)<0.0001West1.689 (1.352–2.111)<0.0001Teaching hospitalNational1.161 (1.011–1.333)0.0342Northeast1.236 (0.979–1.561)0.0752Midwest1.222 (1.018–1.466)0.0313South0.79 (0.470–1.328)0.3730West1.047 (0.569–1.927)0.8835Safety net hospitalNational1.219 (1.105–1.344)<0.0001Northeast0.882 (0.685–1.137)0.3323Midwest1.107 (0.954–1.284)0.1808South1.234 (1.047–1.455)0.0123West1.667 (1.410–2.191)<0.0001Hospital ownership: government or private, collapsed (ref)1.00Government, nonfederal, publicNational0.964 (0.807–1.150)0.6821Northeast0.107 (0.086–0.134)<0.0001Midwest0.876 (0.684–1.121)0.2929South0.618 (0.371–1.030)0.0646West1.15 (0.651–2.033)0.6297Private, nonprofitNational1.089 (0.898–1.322)0.3849Northeast0.105 (0.087–0.127)<0.0001Midwest0.129 (0.112–0.149)<0.0001South0.675 (0.408–1.116)0.1254West1.532 (0.866–2.711)0.1430Private, investor-ownedNational1.514 (1.250–1.833)<0.0001Northeast0.124 (0.100–0.153)<0.0001Midwest0.15 (0.128–0.176)<0.0001South0.999 (0.601–1.659)0.9955West1.836 (1.055–3.195)0.0315Weekend ED visitNational0.995 (0.971–1.019)0.6914Northeast0.971 (0.922–1.022)0.2602Midwest1.008 (1.351–1.839)0.7076South1.016 (1.541–2.108)0.3789West0.97 (0.901–1.406)0.4306 Open tab

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