Because high rates of cocaine and methamphetamine use have been noted among younger heart failure patients and heart failure due to stimulant use may have a reversible component, targeted preventive and treatment efforts for young patients with drug use disorder may reduce the burden of heart failure. There is a paucity of literature investigating tobacco and substance use disorders in heart failure patients especially amongst racial/ethnic subgroups. While Native American race was associated with increased risk of alcohol use disorder, these patients also had high rates of tobacco and drug use disorders. Recent data from the National Survey on Drug Use and Health shows that American Indians or Alaska Natives have higher prevalence of tobacco use and cigarette smoking than all other racial/ethnic groups.Black race was associated with substance, alcohol, and drug use disorder. Cocaine use disorder was highest among black heart failure hospitalizations, while amphetamine use disorder was highest for Asian/PI heart failure hospitalizations. A prior study of 11,258 heart failure patients from the ADHERE-EM database found that self-reported illicit drug use with cocaine or methamphetamines was associated with black race compared to Caucasian.Black men and women present with heart failure at a younger age and have the highest age-standardized hospitalization rates compared to other race/ethnicities in the US.Addressing underlying substance use disorders in black patients may reduce the burden of heart failure attributed to substances and reduce hospitalizations.
Conversely, Asian/PI males and females have the lowest hospitalization rates for heart failure compared to other races in the US.34 However,grow racks with lights the Asian/PI population in the US is rapidly growing with high rates of amphetamine use, which may contribute to future heart failure hospitalizations. Geographically, the Pacific region stands out for high rates of substance use disorder, especially drug use disorder. Data from NSDUH reports high prevalence of past-month illicit drug use by individuals 18 years or older within Pacific states.Patterns of use in heart failure patients may mirror those of the general population. Providers should be aware of types of substance use prevalent in their region. Rates of tobacco and substance use disorders were higher for patients of lower socioeconomic status as represented by payer status and median household income quartiles. Socioeconomic factors mediate differences in tobacco and substance use disorders based on race/ethnicity. While we cannot adjust for complex community stressors predisposing to tobacco or substance use disorders, evaluating community risk factors for tobacco and substance use disorders, such as density of tobacco stores,and identifying vulnerable groups may help develop preventive and treatment strategies, reducing observed disparities. Tobacco and substance use disorders in heart failure patients have implications for the broader health system. Substance use leads to increased costs from decreased productivity, healthcare costs, and crime.Tobacco,alcohol,and cocaine use are associated with increased readmission risk in heart failure patients. Screening for tobacco and substance use disorders has historically been deficient in primary care, emergency room, and hospital settings;despite efforts to improve screening, rates are likely under-appreciated.
Heart failure patients who actively smoke but are attempting to quit may be coded with a different ICD-9-CM code than tobacco use disorder, further underestimating numbers.Tobacco and substance use disorders may have even larger negative effects on the healthcare system than currently reported. The NIS does not use unique patient identifiers; a hospitalization may represent a new patient or a patient already captured in the sample being readmitted, which may increase rates. We are unable to account for geographic or provider coding variation in ICD-9-CM coding. Some conditions, notably tobacco use disorder, may be under-coded. Due to constraints within ICD-9-CM codes, we could not quantify amount or duration of tobacco or substance use disorders. Heavier or prolonged tobacco or substance use may have more detrimental cardiotoxic effects, but even substance use that does not qualify for a diagnosis may contribute to heart failure. Many hospitalized heart failure patients with drug use disorder used “other drugs,” illustrating the complexity of coding for specific drug use. Finally, unmeasured confounding, related to other lifestyle or cardiovascular risk factors not measured, may influence some of these associations, especially as related to socioeconomic status or race/ethnicity.Substance use is associated with multiple adverse health outcomes, including increased rates of infectious disease, mental health disorders, and mortality.Methods: We performed a retrospective, cross-sectional study using the National Hospital Ambulatory Medical Care Survey data from 2013–2018. All ED visits in the United States for patients ≥18 years of age were included. The primary exposure was having substance use included as a chief complaint or diagnosis, which we identified using the International Classification of Diseases, 9th and 10th revisions, codes. The primary outcome was the use of diagnostic services or imaging studies in the ED. Results: The study sample included 95,506 visits in the US, extrapolating to over 619 million ED visits nationwide.
The total number of ED visits remained stable during the study period, but substance userelated visits increased by 45%, with these visits making up 2.93% of total ED visits in 2013 and 4.25% in 2018. This increase was primarily driven by stimulant-, sedative- , and hallucinogen-related visits. Mental health-related visits rose in parallel by 66% during the same period. Compared to non-substance use-related visits, substance use-related visits were more likely to undergo any diagnostic study : 1.11-1.47; P = 0.001, toxicology screening , but less likely to have imaging studies . In stratified analyses, substance use-related visits with concurrent mental health disorders were more likely to undergo imaging studies , while findings were opposite for those without concurrent mental health disorders . Conclusion: Substance use- and mental health-related ED visits are rising, and they are associated with increased resource utilization. Further studies are needed to provide more guidance in the approach to acute services in this vulnerable population. [West J Emerg Med. 2022;22X–X.] data showing that the age-standardized mortality rate due to substance use disorders increased by 618.3% between 1980–2014 in the United States.The most common causes of death associated with substance use were injuries and poisoning, along with other external causes.Among people ages 15-49 in the US, SUDs and intentional injuries make up close to one third of all deaths.The poor outcomes associated with substance use, along with its rising prevalence and low treatment rates, create a significant public health issue.From 2004–2013 the proportion of US adults receiving treatment for SUDs stayed at 1.2-1.3%, representing less than 20% of the population affected.In light of the low treatment rates, it is not surprising that emergency department visits related to substance use have risen rapidly.This increase has created predictable challenges for emergency clinicians and the healthcare system overall, as substance use-related ED visits have been linked to increased length of stay, higher service delivery costs,rolling benches for growing and higher rates of hospital admissions. In addition, increasing ED utilization has outpaced similar increases in hospital inpatient care, meaning the burden of these increased visits has fallen disproportionately on EDs and emergency clinicians.While resource utilization is high in this population, it remains unclear which specific resources are used in the ED for these visits on a national scale. Identifying the resource utilization pattern for substance use-related visits could help inform resource allocation and potentially increase standardization of care. This could in turn lead to reduction in unnecessary testing or treatment, and eventually reduce the strain on emergency physicians and the healthcare system overall. With this rationale in mind, we aimed to describe the trends of substance use-related ED visits among US adults nationwide over a five-year period, beginning in 2013, and to evaluate the relationship between substance use and ED resource utilization.This was a retrospective, cross-sectional study using data from the National Hospital Ambulatory Medical Care Survey , which is conducted by the National Center for Health Statistics .We included data from January 1, 2013–December 31, 2018. The NHAMCS is an annual, national probability sample of ambulatory care visits throughout the US and collects data on visits to hospital based EDs. The survey employs a four-stage probability design with samples of area primary sampling units . Within each ESA, patient visits were systematically selected over a randomly assigned four-week reporting period. There were approximately 2000 PSUs that covered 50 states and the District of Columbia, and approximately 600 hospitals. Data collection was overseen by the US Bureau of the Census, which provided field training on data abstraction for participating hospital staff. Ethics approval was obtained from the research ethics board at our home institution. The primary exposure was defined as having substance use listed as a chief complaint or diagnosis in the visit, as identified by the International Classification of Diseases 9th and 10th revisions codes.
The ICD codes were taken from previously published briefs by the Health Care Utilization Project.Substances of interest included alcohol , opioids, cannabis, cocaine, amphetamines, hallucinogens, and other recreational substances of abuse that affect the central nervous system. Substances were further broken down into five categories as defined by previous literature: 1) alcohol; 2) opioid, sedative/hypnotic, or anxiolytic; 3) cocaine, amphetamine, psychostimulant, or sympathomimetic; 4) cannabis or hallucinogen; and 5) other/unspecified or combined.The reference group consisted of ED visits without substance use as a diagnosis or chief complaint. Covariates of interest were defined a priori and identified from literature review.They included age, gender, ethnicity, homelessness, burden of comorbidities, presence of mental health disorder, geographical region, metropolitan statistical area, payment source, day of visit, and arrival time. Mental health disorder was treated as a separate diagnosis from SUD to specifically examine the trend of substance use-related visits and to emulate previous studies in this area. The primary outcomes of interest consisted of the use of any diagnostic services, toxicology screens or imaging studies in the ED. Diagnostic services included laboratory investigations, toxicology screens, imaging studies, electrocardiograms, and cardiac monitoring. Imaging studies included all imaging carried out in the ED, such as radiographs, ultrasounds, computed tomography , and magnetic resonance imaging. Secondary outcomes consisted of number of procedures performed , number of medications administered, disposition, and use of mental health consultation services in the ED. These variables were identified using pre-existing matching labels in the NHAMCS database.11The NHAMCS used a multistage estimation procedure to produce essentially unbiased estimates. The first step included inflation by reciprocals of selection probabilities, which was the product of the probability at each sampling stage. The second step adjusted for survey non-response, which included inflating weights of visits to hospitals or EDs similar to non-respondent units, depending on the pattern of missingness. During data analysis, survey procedures were used and patient visit weights were applied to obtain the total estimated ED visits from sampled visits . As per the NHCS, sampled visits with relative standard error of 30% or more and observations that were based on fewer than 30 sampling records may yield unstable estimates. We performed univariate analysis using chi-squared test to assess the association between substance use and each of the categorical covariates. To test for linear trend in substance use-related visits over time, we applied a logistic regression model with substance use as the dependent variable and time as the independent variable. Univariate and multi-variable logistic regression were used to assess the unadjusted and adjusted associations between substance use and each of the outcomes, respectively. All listed covariates, with the exception of mental health disorder, were included in the multi-variable model. We reported odds ratios for all logistic regression analyses, along with 95% confidence intervals. For the primary and secondary outcomes of interest, P-value for significance was determined to be 0.005 after applying Bonferroni correction, to minimize family-wise error rate in the setting of multiple comparisons. To evaluate mental health disorder as a potential effect modifier, we assessed the relationship between substance use and primary outcomes using a stratified analysis. The P-value for interaction was obtained from a multi-variable logistic regression model. Missing data were handled using complete case analysis, given that the percentage of missingness was small, and complete data were available for both the exposures and outcomes. All data analyses were carried out using STATA version 15 . From 2013–2018, substance use-related ED visits increased from 2.926 to 4.132 million visits, or from 2.93% to 4.25% of total ED visits during the same period, which translates to a 45% relative increase. Non-substance use related ED visits remained stable during the same period, with 93.17 million visits in 2018 compared to 96.98 million visits in 2013.