Health care utilization of patients with acute abdominal pain before and after emergency department visits

Health care utilization of patients with acute abdominal pain before and after emergency department visits | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Health care utilization of patients with acute abdominal pain before and after emergency department visits Katharina Masal Verleger, Antje Fischer-Rosinsky, Martin Möckel, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4381552/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Aug, 2024 Read the published version in Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine → Version 1 posted 5 You are reading this latest preprint version Abstract Background Acute abdominal pain (AAP) is a major driver for capacity-use in emergency departments (EDs) worldwide. Yet, the association of health care utilization of patients with AAP before and after the ED remains unclear. The primary objective of this study was to describe adult patients presenting to the ED with AAP and their outpatient care (OC) use before and after the ED. Secondary objectives included description of hospitalization rates, in-hospital mortality, ED re-visits, and exploration of potential risk factors for hospitalization and ED re-visits. Methods For the analysis, we combined routine hospital data from patients who visited 15 EDs in Germany in 2016 with their statutory health insurance OC claims data from 2014 to 2017. Adult patients were included based on a chief complaint or an ED diagnosis indicating unspecific AAP or the Manchester Triage System indicator “Abdominal pain in adults”. Baseline characteristics, ED diagnosis, frequency and reason of hospitalization, frequency and type of prior-OC (prOC) use up to 3 days before and of post-OC use up to 30 days after the ED visit. Main results We identified 28085 adults aged ≥20 years with AAP. 39.8% were hospitalized, 33.9% sought prOC before the ED visit (48.6% of them were hospitalized) and 62.7% sought post-OC up to 30 days after the ED visit. Hospitalization was significantly more likely for elderly patients (aged 65 and above vs. younger; adjusted OR 3.05 [95% CI: 2.87; 3.25]), prOC users (1.71 [1.61; 1.90]) and men (1.44 [1.37; 1.52]). In-hospital mortality rate was 3.1% overall. Re-visiting the ED within 30 days was more likely for elderly patients (1.32 [1.13; 1.55) and less likely for those with prOC use (0.37 [0.31; 0.44]). Conclusions prOC use was associated with more frequent hospitalizations but fewer ED re-visits. ED visits by prOC patients without subsequent hospitalization may indicate difficulties of OC resources to meet the complex diagnostic requirements and expectations of this patient population. Less ED re-visits in prOC users indicate effective care in this subgroup. Emergency care abdominal pain routine health care data cross-sectoral health care Figures Figure 1 Figure 2 Figure 3 Background Even though acute abdominal pain (AAP) - defined as atraumatic abdominal pain with a maximum duration of 7 days - accounts for 6–20% of all visits to emergency departments (ED) in Western Europe [ 1 – 4 ], has an in-hospital mortality of 5.1% - which is high compared to other common chief complaints such as chest pain (0.6%) [ 3 ] -, substantial long-term burden [ 5 ], and frequent ED re-visits [ 1 , 6 ], it is often dismissed as trivial. While it is assumed that patients with AAP swing back and forth between different types of primary, secondary and tertiary health care, little is known on the exact treatment paths of patients before and after their ED visit. This may be due to the variety of diagnoses that present with AAP, of which many are not well suited to be treated, let alone followed-up at the ED [ 7 ]. Sectoral barriers between outpatient primary and secondary care (OC) and hospital care are typically high in Germany, making it difficult to bridge the gap between procedures necessary for the diagnosis of AAP and follow-up treatment in OC. This is particularly true for procedures such as sonography and computed tomography (CT), which are – as in many health care systems worldwide - more readily available in hospitals through the ED than in OC care settings. Thus, a better knowledge of patient pathways is necessary to ensure (more) appropriate and efficient patient care [ 8 ]. Up to 2.1 million patients with AAP are estimated to be treated in in Germany’s EDs each year [ 3 , 9 ]. Given the fact that AAP is not only very common but also causes the highest costs among all chief complaints at the ED, more efficient patient pathways would have a major impact on ED resources and budgets [ 10 , 11 ]. Despite the heterogeneity of EDs, characterizations of patients with AAP as well as diagnostic and treatment decisions, are mostly informed by single-center studies [ 1 , 2 , 6 , 7 , 12 – 14 ]. Since a better understanding of the patient profile of AAP in emergency care is needed to improve patient care, outcomes and resource allocation, generalizable real-world data need to be analyzed on a nationally representative level. Therefore, this analysis was based on data from the INDEED (Utilization and cross-sectoral patterns of care for patients admitted to emergency departments in Germany) study [ 15 ], which collected data on all patients treated in 16 German structurally different EDs, their subsequent hospital stay, and their OC before and after the ED visit. The primary objective of this study was to describe the adult patient population presenting to the ED with AAP in Germany and their OC use before and after the ED. Secondary objectives included hospitalization rates, in-hospital mortality, and ED re-visits, as well as the exploration of risk factors. Methods Study design and variables INDEED was a large-scale database study funded by the Innovation Fund of the German Joint Federal Committee (01NVF19025). It combined routine data from 16 EDs in Germany from 2016 and claims data from OC of these ED patients from 2014 to 2017. Further study details including variables, data management and protection measures as well as ethical aspects were published by Fischer-Rosinsky et al in 2021 [ 15 ]. One ED was excluded from this study since it did not provide data on non-hospitalized patients. Patient data from the ED and the OC sector were linked using a unique patient identifier. Sample characteristics (sex, age, ED district type, Manchester Triage System [MTS] status) and ED/hospital care characteristics (ED date and time of visit, ED diagnosis, hospitalization, hospital diagnosis, data of OC utilization before and after ED visit, and recurrent ED visits [re-visits] within 30 days) were analyzed. Elderly patients were defined as being ≥ 65 years of age at ED visit. Participating EDs were categorized into district types (urban vs. rural areas) according to the Federal Office for Building and Regional Planning (BBSR) and modified by the number of EDs in the area [ 16 ]. If there was not more than one ED in the municipality, an area was categorized as “rural”. MTS status was categorized as urgent (i.e., triage category red, orange or yellow) or non-urgent (i.e., green or blue) [ 13 ]. To examine cross-sectoral patterns of care, which may be acutely related to the cause of the ED visit, the number and type of OC visits were determined 3 days prior (“prOC”), and 30 days after the ED visit (“post-OC”). These time periods were defined in line with previous studies and clinical advice: patients must have been able to – at least theoretically - seek outpatient primary care outside of weekends (thus 3 days including a weekday) [ 1 , 6 ]. The dates of all OC visits were based on physicians’ tariffs claims data [ 17 ]. OC visits on the same day as the ED visit were considered to occur before the ED visit. Data from laboratories, as well as any tariffs indicating lab analysis, were excluded because a lab analysis claim may refer to the date that the analysis was performed, not to the day the sample was collected/an OC visit was made. If a patient visited both a general practitioner (GP) and a specialist, only the utilization of the specialist was included in the analysis presuming that the patient was referred to the specialist by the GP, as is the typical procedure in Germany. Inclusion criteria In the INDEED-AAP dataset, analyses were performed on adult patients (≥ 20 years) with statutory health insurance meeting one or more of the following inclusion criteria: i) chief complaint indicating AAP, including upper AAP, lower AAP, flank pain, and stomach pain; ii) any ED diagnosis indicating unspecific AAP in line with the International Classification of Diseases (ICD) category R10 (Abdominal and pelvic pain) at the ED visit; iii) MTS indicator “abdominal pain in adults”. Patients were excluded from analysis if the date of the ED visit was missing, since their prOC and post-OC use could not be determined. Statistical analyses Categorical variables were summarized using counts and percentages; continuous variables using the mean, median, 95% standard deviation (SD) and range. Chi-squared, Fisher’s exact, and Student’s t-tests were used to determine univariate associations between dichotomized sample characteristics: elderly (aged 65 + years) vs. non-elderly (< 65 years); men vs women; rural vs urban; prOC users (patients who used OC 3 days before their ED visit) vs non-prOC users pre-ED (patients who did not seek OC within 3 days before their ED visit). Odds ratios (ORs) were computed with corresponding 95% confidence intervals (CIs). Missing data were reported. Subsequently, a multivariable logistic regression was conducted to examine risk factors using a set of variables that was defined a priori. As sensitivity analyses, a fixed-effects multilevel model was used to account for clustering within clinics. Data analyses were conducted using SAS version 9.4. Sankey diagrams were re-formatted using sankeyMATIC. Results In 15 participating EDs with 435386 visits in total, 31576 visits were identified (7.3%) by 28376 patients with AAP. After exclusion of 291 patients (1.0%) with missing date of the ED visit, the final sample included 28085 patients (Figure 1). Sample characteristics Table 1 shows sample characteristics, differentiated by prOC utilization. An extended version of Table 1 differentiating by age group and sex is available as an additional file. The patients’ mean age was 47.7 years (SD 19.9, Figure 2); a higher proportion of patients (58.3%) were women (Table 1). The majority of all patients (22404; 79.9%) were treated in one of the nine EDs in an urban area. Of the 28085 patients, 33.9% used prOC up to 3 days before their ED visit, with 14.1% seeking specialist care (Table 1). After the ED visit, 62.7% used post-OC and 3.9% re-visited the ED within 30 days. Use of prOC/post-OC was significantly more frequent among women (35.8%/65.9%) and elderly patients (44.1%/69.4%) than among men (31.8%/57.5%) and non-elderly patients (31.4%/60.3%). In-hospital mortality rate was 3.1% (N =354), with significant increases for elderly patients (3.8%) and prOC users (3.7%, Table 1). The percentage of patients who re-visited the ED was significantly lower in prOC users versus non-prOC users (Table 1;). ICD-10 diagnoses An ED diagnosis was reported in 21348 of 28085 ED patients with AAP (76.0%). In line with inclusion criteria, ‘abdominal and pelvic pain’ (ICD-10 R10) was the most common diagnosis (10807 patients; 38.5%), followed by ‘Acute hemorrhagic gastritis’ (K29; 1613 patients; 5.7%) and ‘Other gastroenteritis’ (A09; 1289 patients; 4.6%). A hospital diagnosis was reported for 11033 of 11166 hospitalized patients (98.8%), the most common diagnostic groups were ‘Diseases of the digestive system’ (ICD K; 5255 admissions [18.7% of all patients with AAP]), ‘Diseases of the genitourinary system’ (ICD N; 1454 [5.2%]), and ‘Symptoms, signs and abnormal clinical and laboratory findings’ (ICD R; 1196 [4.3%]). With 12.2% (3425 admissions), the top 5 specific diagnoses explained only a minority of cases, reflecting the heterogeneity of causes for AAP as well as the commonness of symptom-based diagnoses in our study sample. The hospital diagnoses with the highest in-hospital mortality were ‘Sepsis’ (A41; N = 29), ‘Acute vascular disorders of the intestine’ (K55; N = 18), ‘Malignant neoplasm of the pancreas’ (C25; N = 17), and ‘Paralytic ileus and intestinal obstruction’ (K56; N = 14). Treatment patterns of ED patients Figure 3 show care trajectories of patients with and without prOC utilization. PrOC use was associated with hospitalization in 48.6% of the ED patients and followed by post-OC use in 82.1%. Patients who did not use prOC were less often hospitalized; 52.7% of them used post-OC within 30 days after the ED visit. The latter appeared to be independent of whether patients were hospitalized or not in both groups. Determinants for hospitalization and re-visits to the emergency department In the multivariable logistic regression analysis, hospitalization after the ED was associated particularly with older age, and to a lesser extent with male sex, MTS category ‘urgent’, prOC use and ED district type (Table 2). As in bivariate analysis, prOC use strongly decreased the likelihood to re-visit the ED, independently of age, sex, MTS category, hospitalization, and ED district type (Table 2). In sensitivity analyses (adjusting for ED), the impact of MTS was increased for both endpoints (Hospitalization: 2.32; CI: 2.17; 2.47. ED re-visit: 1.16; CI: 1.01; 1.34) while the other results remained stable. Table 1. Sociodemographic, medical and outpatient care characteristics of ED patients with acute abdominal pain All (N=28085) prOC user (N=9531; 33.6%) Non-prOC user (N=18554; 65.4%) Age, mean (SD) 47.7 (19.9) 51.6 (20.6) 45.7 (19.3) Female, N (%) 16375 (58.3) 5803 (60.9) 10572 (57.0) Urban area, N (%) 22404 (79.8) 7716 (81.0) 14688 (79.2) MTS status “urgent”, N (%) 15905 (56.6) 5317 (55.8) 10588 (57.1) Missing, N (%) 2978 (10.6) 1129 (11.8) 1849 (10.0) prOC use, N (%) 9531 (33.9) 9531 (100) 0 (0.0) Type of prOC provider, N (%) General Practitioner 5293 (18.8) 5293 (55.5) 0 (0.0) Specialist 4003 (14.3) 4003 (42.0) 0 (0.0) Not documented 235 (0.8) 235 (2.5) 0 (0.0) Hospitalized, N (% of total N) 11166 (39.8) 4632 (48.6) 6534 (35.2) ICD-10 hospital diagnoses Missing, N (% of hospitalized) 133 (1.2) 98 (2.1) 35 (0.5) Top1 (% of total) R10 (3.4) R10 (4.5) R10 (2.7) Top2 (% of total) K80 (2.6) K80 (3.0) K35 (2.5) Top3 (% of total) K35 (2.4) K56 (2.7) K80 (2.4) Top4 (% of total) K56 (2.1) K35 (2.4) K56 (1.8) Top5 (% of total) K57 (1.8) K57 (2.4) K85 (1.7) In-hospital mortality N (% of hospitalized) Death reported 349 (3.1) 170 (3.7) 179 (2.7) Missing 530 (4.8) 382 (8.2) 148 (2.3) Post-OC use, N (%) 17603 (62.7) 7826 (82.1) 9777 (52.7) Type of post-OC provider, N (%) General Practitioner 6799 (24.2) 2783 (29.2) 4016 (21.6) Specialist 10781 (38.4) 5033 (52.8) 5748 (31.0) Not documented 23 (<0.1) 10 (0.1) 13 (0.1) Post-OC use after hospital, N (% of hospitalized) 7451 (66.7) 3786 (81.7) 3665 (56.1) Type of post-OC provider after hospital, N (% of hospitalized)) General Practitioner 3448 (30.9) 1637 (35.3) 1811 (27.7) Specialist 3989 (35.7) 2142 (46.2) 1847 (28.3) Not documented 14 (0.1) 7 (0.2) 7 (0.1) ED re-visit in 30 days 1101 (3.9) 181 (1.9) 920 (5.0) Abbreviations: ED, Emergency department; ICD, International classification of disease; N, Number; N10, Acute tubulo-interstitial nephritis; N13, Obstructive and reflux uropathy; OC, Outpatient care; post-OC, post-outpatient care (up to 30 days after ED visit); prOC, prior outpatient care (up to 3 days before ED visit); R10, Abdominal and pelvic pain; K35, Acute appendicitis; K56, Paralytic ileus and intestinal obstruction without hernia; K57, Diverticular disease of intestine; K80, Cholelithiasis; K85, Acute pancreatitis. Table 2. Potential risk factors of hospitalization, and ED re-visits within 30 days Endpoint: Hospitalization (n=25107; 89.4%) Endpoint: ED re-visit within 30 days (n=25107; 89.4%) Independent variable Adjusted Odds ratio 95% confidence interval Adjusted Odds ratio 95% confidence interval Elderly (≥65 years vs. non-elderly) 3.05 2.87; 3.25 1.32 1.13; 1.55 Male (vs. female) 1.44 1.37; 1.52 0.96 0.84; 1.09 MTS status urgent (vs. non-urgent) 1.84 1.74; 1.95 1.10 0.96; 1.26 prOC use within 3 days before the ED (vs. non-prOC use) 1.71 1.61; 1.90 0.37 0.31; 0.44 Urban district ED type (vs. rural) 0.50 0.47; 054 1.08 0.92; 1.28 Hospitalized after the ED (vs. not) n/i n/i 0.78 0.67; 0.90 Results from multivariable logistic regression. Abbreviations: CI, confidence interval; ED, Emergency department; MTS, Manchester Triage System; n/I, Not included; prOC, prior outpatient care; Discussion Main findings This study provided an overview of patients with AAP in ED care in Germany regarding their characteristics, outpatient care utilization before and after the ED visit, hospitalization rate, and in-hospital mortality. The hospitalization rate in our study was 41.6% after the ED visit, with the most common diagnoses being diseases of the digestive or genitourinary system, or symptom-based diagnoses (R10). Approximately two thirds of the AAP patients did not seek prOC 3 days before attending the ED. Overall almost 4% re-visited the ED within 30 days. The number of re-visit were significantly lower in patients who used OC 3 days before their ED visit compared to patients who did not (1.9% vs 4.0%, respectively). Comparison with other studies and outlook In line with other studies, the average AAP patient at the ED was 47.7 years old, female, and diagnosed with a symptomatic R10 diagnosis in the ED [1, 4, 12, 18]. An in-depth characterization by Pemmerl et al (2021) of a comparatively smaller and younger AAP population in the ED of a German urban community hospital (N = 1,417) found a significantly higher hospitalization rate of 48.2% (p = 0.002) compared to our study. Yet, Helbig et al (2023) - whose study in two EDs in an urban area was similar in study design and inclusion criteria to our study - found a significantly lower hospitalization rate of 25.8% in (n=49430). Small single-center studies from Italy, Greece, and Poland showed also vastly differing hospitalization rates between 16.6% and 36.0% [1, 4, 6, 12, 14, 19]. Two of these studies also reported ED re-visit rates up to 30 days post ED, which were significantly higher than in our study (6.5% and 10.9%, respectively; p<0.001) [1, 6]. Differences in sample size, age, sex and urgency distribution, admission policies and remuneration-related incentives, the availability of hospital beds, as well as different study designs and small sample sizes may contribute to these differences. We would argue that these differences underline the importance of large-scale studies, and that our study reports the most reliable data on hospitalization rates of patients with AAP to date. The low hospitalization rate of patients who did not seek prOC up to 3 days before attending the ED (35.2%) may indicate that patients with low urgency experienced barriers to accessing prOC before coming to the ED [20]. In a sectoralized health care system such as Germany, the OC provider is meant to serve as a gate-keeper to primary and secondary care as well as to secure continuity and coordination of care [21]. Due to insufficient capacity of primary and secondary OC providers, patients may opt to visit an ED for a specialist opinion or diagnostic imaging. Of the one third of patients who sought prOC before attending the ED, the hospitalization rate was also unexpectedly low (48.6%). This may indicate potential difficulties of OC resources to meet the complex clinical requirements or expectations of this patient population [20, 22, 23], in particular to provide diagnostic imaging procedures such as sonographies and CTs in a timely manner. As expected, in addition to old age and urgent MTS status we found that prOC use had considerable impact on hospitalization, pointing towards the role of prOC as a navigator for seeking acute care [24, 25]. The role of prOC for hospitalizations, ED re-visits and OC use after the ED is unclear. It may be impacted by timely access to outpatient primary care including diagnostic imaging procedures, improved health literacy in patients, and discharge planning services for hospitalized patients [21, 25-29]. Further investigations are needed, in particular with OC data that should be collected prospectively in European health care systems, to better determine the impact of these factors on the relationship between OC use and ED re-visits. Strengths and Limitations The present analyses were part of the INDEED study that collected data from 454,747 visits to 16 EDs. It is the largest study of ED patients in Germany to date. INDEED’s unique strength was that it linked ED data with outpatient care data on the individual patient-level, which was unprecedented in Germany at this sample size. For Europe, the present analysis was the first evaluation of data from patients with AAP across treatment sectors including a large sample of 28376 patients with 31576 visits to 15 EDs. Another strength of our study was the retrospectively collected routine healthcare data of good quality allowing insights into the real-world care of statutory health insurance companies’ patients. However, our study had also some potential limitations. First, data availability and quality differed across EDs, making the data susceptible to systematic errors in documentation, availability bias, and diagnostic access bias. For example, ED diagnoses were not available or could not be retrieved for 23.4% of the ED patients. We did not have the information if a diagnosis was missing because it was not made, not documented or not retrieved during data extraction. The majority of diagnosis captured were ICD symptom diagnoses and confer little for clinical relevance. Second, ED patients with specific diseases, amongst them diverticulitis or Morbus Crohn, may present with AAP but might not have been picked up by the inclusion criteria of this study depending on triage and diagnostic standards at the participating centers. Third, for patients who were included due to their ED diagnosis and for whom multiple ED diagnoses were documented, it was impossible to deduce if the AAP diagnosis was the leading diagnosis. Similarly, it could not be determined if AAP was the leading cause for prOC and post-OC visits. Fourth, for the outcomes ‘post-OC use’ and ‘revisit to ED’ within 30 days’ we did not focus only on AAP-related reasons but included all reasons for such visits and utilization. However, the results of a subgroup analysis indicated that this was unlikely to have influenced our results. Less than 1% of patients visited only physicians from specialties without relation to AAP, such as ophthalmologists. Still, we do not know if the OC physician referred the patients to the ED or if the decision to visit the ED was made independently by the patients. In addition, ED visits as well as hospitalizations may be underreported since patients may have visited EDs/hospitals that did not participate in the study. Fifth, our study included only patients with AAP who appeared at the ED (index patient) but not patients with AAP who were successfully treated by their GPs. Thus, our approach did not allow us to examine more comprehensively if going to a GP with AAP may affect hospitalization after ED visit or the revisit rate to ED. Conclusions AAP is a leading cause for hospitalization of ED patients in Germany, with a large variety of underlying diagnoses and considerable in-hospital mortality. Our findings underline the severity as well as the clinical complexity of diagnosing and treating these conditions, not only but especially in the ED. Hospitalization after an ED visit with AAP was significantly more likely for the elderly, prOC users and men. Approximately one third of ED patients with AAP sought OC before and two thirds after attending the ED. The frequency of ED visits by AAP patients with prOC but without subsequent hospitalization may indicate difficulties of prOC resources to meet the complex diagnostic requirements and expectations of this patient population. A lower number of ED re-visits was associated with proC use and age ≤65 years. Less ED re-visits in prOC users indicate effective care in this subgroup. The interaction between ED and prOC services of patients with AAP needs to be further investigated including prospective studies with primary data collection to consider more confounding factors related to comorbidities and lifestyle including substance abuse. Abbreviations AAP Acute abdominal pain BBSR German Federal Office for Building and Regional Planning CI confidence intervals CT Computed tomography ED Emergency department GP General practitioner ICD International Classification of Diseases K35 Acute appendicitis K56 Paralytic ileus and intestinal obstruction without hernia K57 Diverticular disease of intestine K80 Cholelithiasis K85 Acute pancreatitis MTS Manchester triage system N10 Acute tubulo-interstitial nephritis N13 Obstructive and reflux uropathy OC Outpatient care OR Odds ratio post-OC Post-outpatient care up to 30 days after ED visit prOC Outpatient care up to 3 days prior to the ED visit R10 Abdominal and pelvic pain SD standard deviation Declarations Ethics approval and consent to participate The study was approved by the ethics committee of the Charité – Universitätsmedizin Berlin (EA4/086/17). Details on the data protection concept are described elsewhere [15]. Consent for publication In line with the ethics approval, only aggregated data were reported. Availability of data and materials The data that support the findings of this study are not publicly available due to the high sensitivity of clinical data of the patients treated in the emergency department. Competing interests The authors declare that they have no competing interests. Funding The INDEED study was funded by the Innovation Fund of the German Joint Federal Committee (G-BA), grant number 01VSF16044. G-BA is the highest decision-making body of the joint self-government of physicians, dentists, hospitals, and public health insurance companies in Germany. Author’s contributions All authors have made substantial contributions to the design of the work, the acquisition or analysis of data (except ASch), the interpretation of data, and the drafting or revision of the work. 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Why patients attend emergency department for primary care type problems: views of healthcare providers working in a remote community. Rural Remote Health. 2022;22(1):7054. Ghazali DA, Richard A, Chaudet A, Choquet C, Guericolas M, Casalino E. Profile and Motivation of Patients Consulting in Emergency Departments While not Requiring Such a Level of Care. Int J Environ Res Public Health, 2019. 16(22). Cowling TE, Cecil EV, Soljak MA, Lee JT, Millett C, Majeed A, et al. Access to primary care and visits to emergency departments in England: a cross-sectional, population-based study. PLoS ONE. 2013;8(6):e66699. MacKichan F, Brangan E, Wye L, Checkland K, Lasserson D, Huntley A, et al. Why do patients seek primary medical care in emergency departments? An ethnographic exploration of access to general practice. BMJ Open. 2017;7(4):e013816. Shahid R, Shoker M, Chu LM, Frehlick R, Ward H, Pahwa P. Impact of low health literacy on patients' health outcomes: a multicenter cohort study. BMC Health Serv Res. 2022;22(1):1148. Henke RM, Karaca Z, Jackson P, Marder WD, Wong HS. Discharge Planning and Hospital Readmissions. Med Care Res Rev. 2017;74(3):345–68. Afilalo M, Xue X, Colacone A, Jourdenais E, Boivin JF, Grad R. Association between access to primary care and unplanned emergency department return visits among patients 75 years and older. Can Fam Physician. 2022;68(8):599–606. Mason S, Mountain G, Turner J, Arain M, Revue E, Weber EJ. Innovations to reduce demand and crowding in emergency care; a review study. Scand J Trauma Resusc Emerg Med. 2014;22:55. Supplementary Files AdditionalfilesExtendedTable1.docx Additional materials “Additional files – Extended Table 1.docx” includes a version of Table 1 stratified by age group and sex. Cite Share Download PDF Status: Published Journal Publication published 12 Aug, 2024 Read the published version in Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine → Version 1 posted Editorial decision: Minor Revision 06 Jun, 2024 Reviewers agreed at journal 09 May, 2024 Reviewers invited by journal 09 May, 2024 Editor assigned by journal 09 May, 2024 First submitted to journal 07 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4381552","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":300695111,"identity":"895791e3-82a2-46b5-a942-d373b374ac94","order_by":0,"name":"Katharina Masal Verleger","email":"data:image/png;base64,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","orcid":"https://orcid.org/0009-0005-7348-0409","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Katharina","middleName":"Masal","lastName":"Verleger","suffix":""},{"id":300695112,"identity":"ee9499ec-293b-4465-95df-ab2cf3500335","order_by":1,"name":"Antje Fischer-Rosinsky","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Antje","middleName":"","lastName":"Fischer-Rosinsky","suffix":""},{"id":300695114,"identity":"bb73c4a1-959a-49ca-ae51-c1a31cfd7368","order_by":2,"name":"Martin Möckel","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Martin","middleName":"","lastName":"Möckel","suffix":""},{"id":300695116,"identity":"1b4290b5-57ee-4c4a-8f79-3c2ca8d949fa","order_by":3,"name":"Anna Schneider","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Anna","middleName":"","lastName":"Schneider","suffix":""},{"id":300695118,"identity":"26a1be32-ad7f-4a2e-9446-6fe4f02de656","order_by":4,"name":"Anna Slagman","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Anna","middleName":"","lastName":"Slagman","suffix":""},{"id":300695119,"identity":"3b352723-552b-4c11-8afd-70c60777aa89","order_by":5,"name":"Thomas Keil","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"","lastName":"Keil","suffix":""},{"id":300695120,"identity":"4cbd97fd-195d-447a-810c-8e82603b93f4","order_by":6,"name":"Liane Schenk","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Liane","middleName":"","lastName":"Schenk","suffix":""}],"badges":[],"createdAt":"2024-05-07 08:42:55","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4381552/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4381552/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13049-024-01237-7","type":"published","date":"2024-08-12T15:57:23+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":56811140,"identity":"63343893-2b38-4e0f-9a9e-1569bb1f8192","added_by":"auto","created_at":"2024-05-20 19:00:34","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":48093,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of patients\u003c/p\u003e\n\u003cp\u003eAbbreviations: AAP, Acute abdominal pain; ICD, International classification of disease; MTS, Manchester triage system; R10, Abdominal and pelvic pain.\u0026nbsp; \u0026nbsp;\u003csup\u003e1\u003c/sup\u003e For 3,904 of these patients, an additional ICD 10 diagnosis R10 was recorded, for 3,384 patients, the MTS indicator “AAP in adults” was recorded, and for 1,348 all three categories were recorded. \u003csup\u003e2\u003c/sup\u003e For 1,306 of these patients an additional MTS indicator “AAP in adults” was recorded.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4381552/v1/19ae1faa0fdb2b99adf9bb05.png"},{"id":56811141,"identity":"dd442ac1-d203-44f6-9843-dfbd68ad3142","added_by":"auto","created_at":"2024-05-20 19:00:34","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":356937,"visible":true,"origin":"","legend":"\u003cp\u003eHistogram of patient's age, by sex and outpatient care use before the ED\u003c/p\u003e\n\u003cp\u003eThe graphs shows the distribution of age (in 2-year categories) and sex (blue = men, red = women), separately for patients who sought outpatient care up to 3 days before their emergency department visit (left) and patients who did not utilize outpatient care (right).\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4381552/v1/53d9eb2eb148b707c17a9e23.png"},{"id":56811138,"identity":"71e04576-6be9-4414-b989-b55d0eb92881","added_by":"auto","created_at":"2024-05-20 19:00:34","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":246521,"visible":true,"origin":"","legend":"\u003cp\u003eTreatment pathways of patients with AAP before and after their ED visit\u003c/p\u003e\n\u003cp\u003eThe graph compares treatment pathways of 9,531 patients who visited a general practitioner (including 235 patients for whom the type of OC was not documented) or specialist practice within 3 days before their ED visit (left Sankey diagram) vs 18,554 patients who did not (right Sankey diagram). Abbreviations: AAP, Acute abdominal pain; ED, Emergency department; GP, General practitioner; OC, Outpatient care; prOC, prior outpatient care.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4381552/v1/58a9eab6732206af00796dfc.png"},{"id":63070875,"identity":"a61445db-421d-40a6-9ce8-1fc3aa6589f8","added_by":"auto","created_at":"2024-08-22 19:56:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1080686,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4381552/v1/abce83ec-6e82-4afc-bf5b-64e84c544557.pdf"},{"id":56811142,"identity":"78d7d47e-fc05-4661-a673-3ecd55694621","added_by":"auto","created_at":"2024-05-20 19:00:34","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":42602,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional materials\u003c/p\u003e\n\u003cp\u003e“Additional files – Extended Table 1.docx” includes a version of Table 1 stratified by age group and sex.\u003c/p\u003e","description":"","filename":"AdditionalfilesExtendedTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4381552/v1/b995f3e598053c4dc1a4b8e6.docx"}],"financialInterests":"","formattedTitle":"Health care utilization of patients with acute abdominal pain before and after emergency department visits","fulltext":[{"header":"Background","content":"\u003cp\u003eEven though acute abdominal pain (AAP) - defined as atraumatic abdominal pain with a maximum duration of 7 days - accounts for 6\u0026ndash;20% of all visits to emergency departments (ED) in Western Europe [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], has an in-hospital mortality of 5.1% - which is high compared to other common chief complaints such as chest pain (0.6%) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] -, substantial long-term burden [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], and frequent ED re-visits [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], it is often dismissed as trivial. While it is assumed that patients with AAP swing back and forth between different types of primary, secondary and tertiary health care, little is known on the exact treatment paths of patients before and after their ED visit. This may be due to the variety of diagnoses that present with AAP, of which many are not well suited to be treated, let alone followed-up at the ED [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Sectoral barriers between outpatient primary and secondary care (OC) and hospital care are typically high in Germany, making it difficult to bridge the gap between procedures necessary for the diagnosis of AAP and follow-up treatment in OC. This is particularly true for procedures such as sonography and computed tomography (CT), which are \u0026ndash; as in many health care systems worldwide - more readily available in hospitals through the ED than in OC care settings. Thus, a better knowledge of patient pathways is necessary to ensure (more) appropriate and efficient patient care [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUp to 2.1\u0026nbsp;million patients with AAP are estimated to be treated in in Germany\u0026rsquo;s EDs each year [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Given the fact that AAP is not only very common but also causes the highest costs among all chief complaints at the ED, more efficient patient pathways would have a major impact on ED resources and budgets [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Despite the heterogeneity of EDs, characterizations of patients with AAP as well as diagnostic and treatment decisions, are mostly informed by single-center studies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Since a better understanding of the patient profile of AAP in emergency care is needed to improve patient care, outcomes and resource allocation, generalizable real-world data need to be analyzed on a nationally representative level. Therefore, this analysis was based on data from the INDEED (Utilization and cross-sectoral patterns of care for patients admitted to emergency departments in Germany) study [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], which collected data on all patients treated in 16 German structurally different EDs, their subsequent hospital stay, and their OC before and after the ED visit. The primary objective of this study was to describe the adult patient population presenting to the ED with AAP in Germany and their OC use before and after the ED. Secondary objectives included hospitalization rates, in-hospital mortality, and ED re-visits, as well as the exploration of risk factors.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design and variables\u003c/p\u003e \u003cp\u003e INDEED was a large-scale database study funded by the Innovation Fund of the German Joint Federal Committee (01NVF19025). It combined routine data from 16 EDs in Germany from 2016 and claims data from OC of these ED patients from 2014 to 2017. Further study details including variables, data management and protection measures as well as ethical aspects were published by Fischer-Rosinsky et al in 2021 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. One ED was excluded from this study since it did not provide data on non-hospitalized patients.\u003c/p\u003e \u003cp\u003ePatient data from the ED and the OC sector were linked using a unique patient identifier. Sample characteristics (sex, age, ED district type, Manchester Triage System [MTS] status) and ED/hospital care characteristics (ED date and time of visit, ED diagnosis, hospitalization, hospital diagnosis, data of OC utilization before and after ED visit, and recurrent ED visits [re-visits] within 30 days) were analyzed. Elderly patients were defined as being \u0026ge;\u0026thinsp;65 years of age at ED visit. Participating EDs were categorized into district types (urban vs. rural areas) according to the Federal Office for Building and Regional Planning (BBSR) and modified by the number of EDs in the area [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. If there was not more than one ED in the municipality, an area was categorized as \u0026ldquo;rural\u0026rdquo;. MTS status was categorized as urgent (i.e., triage category red, orange or yellow) or non-urgent (i.e., green or blue) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. To examine cross-sectoral patterns of care, which may be acutely related to the cause of the ED visit, the number and type of OC visits were determined 3 days prior (\u0026ldquo;prOC\u0026rdquo;), and 30 days after the ED visit (\u0026ldquo;post-OC\u0026rdquo;). These time periods were defined in line with previous studies and clinical advice: patients must have been able to \u0026ndash; at least theoretically - seek outpatient primary care outside of weekends (thus 3 days including a weekday) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The dates of all OC visits were based on physicians\u0026rsquo; tariffs claims data [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. OC visits on the same day as the ED visit were considered to occur before the ED visit. Data from laboratories, as well as any tariffs indicating lab analysis, were excluded because a lab analysis claim may refer to the date that the analysis was performed, not to the day the sample was collected/an OC visit was made. If a patient visited both a general practitioner (GP) and a specialist, only the utilization of the specialist was included in the analysis presuming that the patient was referred to the specialist by the GP, as is the typical procedure in Germany.\u003c/p\u003e \u003cp\u003eInclusion criteria\u003c/p\u003e \u003cp\u003eIn the INDEED-AAP dataset, analyses were performed on adult patients (\u0026ge;\u0026thinsp;20 years) with statutory health insurance meeting one or more of the following inclusion criteria: i) chief complaint indicating AAP, including upper AAP, lower AAP, flank pain, and stomach pain; ii) any ED diagnosis indicating unspecific AAP in line with the International Classification of Diseases (ICD) category R10 (Abdominal and pelvic pain) at the ED visit; iii) MTS indicator \u0026ldquo;abdominal pain in adults\u0026rdquo;. Patients were excluded from analysis if the date of the ED visit was missing, since their prOC and post-OC use could not be determined.\u003c/p\u003e \u003cp\u003eStatistical analyses\u003c/p\u003e \u003cp\u003eCategorical variables were summarized using counts and percentages; continuous variables using the mean, median, 95% standard deviation (SD) and range. Chi-squared, Fisher\u0026rsquo;s exact, and Student\u0026rsquo;s t-tests were used to determine univariate associations between dichotomized sample characteristics: elderly (aged 65\u0026thinsp;+\u0026thinsp;years) vs. non-elderly (\u0026lt;\u0026thinsp;65 years); men vs women; rural vs urban; prOC users (patients who used OC 3 days before their ED visit) vs non-prOC users pre-ED (patients who did not seek OC within 3 days before their ED visit). Odds ratios (ORs) were computed with corresponding 95% confidence intervals (CIs). Missing data were reported. Subsequently, a multivariable logistic regression was conducted to examine risk factors using a set of variables that was defined a priori. As sensitivity analyses, a fixed-effects multilevel model was used to account for clustering within clinics. Data analyses were conducted using SAS version 9.4. Sankey diagrams were re-formatted using sankeyMATIC.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn 15 participating EDs with 435386 visits in total, 31576 visits were identified (7.3%) by 28376 patients with AAP. After exclusion of 291 patients (1.0%) with missing date of the ED visit, the final sample included 28085 patients (Figure 1).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eSample characteristics\u003c/h2\u003e\n\u003cp\u003eTable 1 shows sample characteristics, differentiated by prOC utilization. An extended version of Table 1 differentiating by age group and sex is available as an additional file. The patients\u0026rsquo; mean age was 47.7 years (SD 19.9, Figure 2); a higher proportion of patients (58.3%) were women (Table 1). The majority of all patients (22404; 79.9%) were treated in one of the nine EDs in an urban area.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOf the 28085 patients, 33.9% used prOC up to 3 days before their ED visit, with 14.1% seeking specialist care (Table 1). After the ED visit, 62.7% used post-OC and 3.9% re-visited the ED within 30 days. Use of prOC/post-OC was significantly more frequent among women (35.8%/65.9%) and elderly patients (44.1%/69.4%) than among men (31.8%/57.5%) and non-elderly patients (31.4%/60.3%). In-hospital mortality rate was 3.1% (N =354), with significant increases for elderly patients (3.8%) and prOC users (3.7%,\u0026nbsp;Table 1). The percentage of patients who re-visited the ED was significantly lower in prOC users versus non-prOC users (Table 1;).\u003c/p\u003e\n\u003ch2\u003eICD-10 diagnoses\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eAn ED diagnosis was reported in 21348 of 28085 ED patients with AAP (76.0%). In line with inclusion criteria, \u0026lsquo;abdominal and pelvic pain\u0026rsquo; (ICD-10 R10) was the most common diagnosis (10807 patients; 38.5%), followed by \u0026lsquo;Acute hemorrhagic gastritis\u0026rsquo; (K29; 1613 patients; 5.7%) and \u0026lsquo;Other gastroenteritis\u0026rsquo; (A09; 1289 patients; 4.6%). A hospital diagnosis was reported for 11033 of 11166 hospitalized patients (98.8%), the most common diagnostic groups were \u0026lsquo;Diseases of the digestive system\u0026rsquo; (ICD K; 5255 admissions [18.7% of all patients with AAP]), \u0026lsquo;Diseases of the genitourinary system\u0026rsquo; (ICD N; 1454 [5.2%]), and \u0026lsquo;Symptoms, signs and abnormal clinical and laboratory findings\u0026rsquo; (ICD R; 1196 [4.3%]). With 12.2% (3425 admissions), the top 5 specific diagnoses explained only a minority of cases, reflecting the heterogeneity of causes for AAP as well as the commonness of symptom-based diagnoses in our study sample. The hospital diagnoses with the highest in-hospital mortality were \u0026lsquo;Sepsis\u0026rsquo; (A41; N = 29), \u0026lsquo;Acute vascular disorders of the intestine\u0026rsquo; (K55; N = 18), \u0026lsquo;Malignant neoplasm of the pancreas\u0026rsquo; (C25; N = 17), and \u0026lsquo;Paralytic ileus and intestinal obstruction\u0026rsquo; (K56; N = 14).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eTreatment patterns of ED patients\u003c/h2\u003e\n\u003cp\u003eFigure 3\u0026nbsp;show care trajectories of patients with and without prOC utilization. PrOC use was associated with hospitalization in 48.6% of the ED patients and followed by post-OC use in 82.1%. Patients who did not use prOC were less often hospitalized; 52.7% of them used post-OC within 30 days after the ED visit. The latter appeared to be independent of whether patients were hospitalized or not in both groups.\u003c/p\u003e\n\u003ch2\u003eDeterminants for hospitalization and re-visits to the emergency department\u003c/h2\u003e\n\u003cp\u003eIn the multivariable logistic regression analysis, hospitalization after the ED was associated particularly with older age, and to a lesser extent with male sex, MTS category \u0026lsquo;urgent\u0026rsquo;, prOC use and ED district type (Table 2). As in bivariate analysis, prOC use strongly decreased the likelihood to re-visit the ED, independently of age, sex, MTS category, hospitalization, and ED district type (Table 2). In sensitivity analyses (adjusting for ED), the impact of MTS was increased for both endpoints (Hospitalization: 2.32; CI: 2.17; 2.47. ED re-visit: 1.16; CI: 1.01; 1.34) while the other results remained stable.\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;1. Sociodemographic, medical and outpatient care characteristics of ED patients with acute abdominal pain\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N=28085)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eprOC user\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N=9531; 33.6%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-prOC user (N=18554; 65.4%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003eAge, mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e47.7 (19.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003e51.6 (20.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003e45.7 (19.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003eFemale, N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e16375 (58.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003e5803 (60.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003e10572 (57.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003eUrban area, N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e22404 (79.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003e7716 (81.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003e14688 (79.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003eMTS status \u0026ldquo;urgent\u0026rdquo;, N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e15905 (56.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003e5317 (55.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003e10588 (57.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Missing, N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e2978 (10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003e1129 (11.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003e1849 (10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003eprOC use, N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e9531 (33.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003e9531 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003eType of prOC provider, N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;General Practitioner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e5293 (18.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003e5293 (55.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Specialist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e4003 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003e4003 (42.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Not documented\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e235 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003e235 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003eHospitalized, N (% of total N)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e11166 (39.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003e4632 (48.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003e6534 (35.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003eICD-10 hospital diagnoses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Missing, N (% of hospitalized)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e133 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003e98 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003e35 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Top1 (% of total)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003eR10 (3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003eR10 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003eR10 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Top2 (% of total)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003eK80 (2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003eK80 (3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003eK35 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Top3 (% of total)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003eK35 (2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003eK56 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003eK80 (2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Top4 (% of total)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003eK56 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003eK35 (2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003eK56 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Top5 (% of total)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003eK57 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003eK57 (2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003eK85\u0026nbsp;(1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003eIn-hospital mortality N (% of hospitalized)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Death reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e349 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003e170 (3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003e179 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Missing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e530 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003e382 (8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003e148 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003ePost-OC use, N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e17603 (62.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003e7826 (82.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003e9777 (52.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003eType of post-OC provider, N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; General Practitioner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e6799 (24.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003e2783 (29.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003e4016 (21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Specialist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e10781 (38.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003e5033 (52.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003e5748 (31.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Not documented\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e23 (\u0026lt;0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003e10 (0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003e13 (0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003ePost-OC use after hospital, N (% of hospitalized)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e7451 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003e3786 (81.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003e3665 (56.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003eType of post-OC provider after hospital, N (% of hospitalized))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;General Practitioner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e3448 (30.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003e1637 (35.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003e1811 (27.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Specialist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e3989 (35.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003e2142 (46.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003e1847 (28.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Not documented\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e14 (0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003e7 (0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003e7 (0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.54716981132076%\" valign=\"top\"\u003e\n \u003cp\u003eED re-visit in 30 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e1101 (3.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.566037735849058%\" valign=\"top\"\u003e\n \u003cp\u003e181 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.50943396226415%\" valign=\"top\"\u003e\n \u003cp\u003e920 (5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: ED, Emergency department; ICD, International classification of disease; N, Number; N10, Acute tubulo-interstitial nephritis; N13, Obstructive and reflux uropathy; OC, Outpatient care; post-OC, post-outpatient care (up to 30 days after ED visit); prOC, prior outpatient care (up to 3 days before ED visit); R10, Abdominal and pelvic pain; K35, Acute appendicitis; K56, Paralytic ileus and intestinal obstruction without hernia; K57, Diverticular disease of intestine; K80, Cholelithiasis; K85, Acute pancreatitis.\u003c/p\u003e\n\u003cp\u003eTable 2. Potential risk factors of hospitalization, and ED re-visits within 30 days\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.033112582781456%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"27.980132450331126%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEndpoint: Hospitalization (n=25107; 89.4%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.986754966887418%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEndpoint: ED re-visit within 30 days (n=25107; 89.4%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.033112582781456%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndependent variable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.582781456953642%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted Odds ratio\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.397350993377483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% confidence interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.42384105960265%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted Odds ratio\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% confidence interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.033112582781456%\" valign=\"top\"\u003e\n \u003cp\u003eElderly (\u0026ge;65 years vs. non-elderly)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.582781456953642%\" valign=\"top\"\u003e\n \u003cp\u003e3.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.397350993377483%\" valign=\"top\"\u003e\n \u003cp\u003e2.87; 3.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.42384105960265%\" valign=\"top\"\u003e\n \u003cp\u003e1.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e1.13; 1.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.033112582781456%\" valign=\"top\"\u003e\n \u003cp\u003eMale (vs. female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.582781456953642%\" valign=\"top\"\u003e\n \u003cp\u003e1.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.397350993377483%\" valign=\"top\"\u003e\n \u003cp\u003e1.37; 1.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.42384105960265%\" valign=\"top\"\u003e\n \u003cp\u003e0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.84; 1.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.033112582781456%\" valign=\"top\"\u003e\n \u003cp\u003eMTS status urgent (vs. non-urgent)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.582781456953642%\" valign=\"top\"\u003e\n \u003cp\u003e1.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.397350993377483%\" valign=\"top\"\u003e\n \u003cp\u003e1.74; 1.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.42384105960265%\" valign=\"top\"\u003e\n \u003cp\u003e1.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.96; 1.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.033112582781456%\" valign=\"top\"\u003e\n \u003cp\u003eprOC use within 3 days before the ED (vs. non-prOC use)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.582781456953642%\" valign=\"top\"\u003e\n \u003cp\u003e1.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.397350993377483%\" valign=\"top\"\u003e\n \u003cp\u003e1.61; 1.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.42384105960265%\" valign=\"top\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.31; 0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.033112582781456%\" valign=\"top\"\u003e\n \u003cp\u003eUrban district ED type (vs. rural)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.582781456953642%\" valign=\"top\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.397350993377483%\" valign=\"top\"\u003e\n \u003cp\u003e0.47; 054\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.42384105960265%\" valign=\"top\"\u003e\n \u003cp\u003e1.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.92; 1.28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.033112582781456%\" valign=\"top\"\u003e\n \u003cp\u003eHospitalized after the ED (vs. not)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.582781456953642%\" valign=\"top\"\u003e\n \u003cp\u003en/i\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.397350993377483%\" valign=\"top\"\u003e\n \u003cp\u003en/i\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.42384105960265%\" valign=\"top\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.67; 0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eResults from multivariable logistic regression. Abbreviations: CI, confidence interval; ED, Emergency department; MTS, Manchester Triage System; n/I, Not included; prOC, prior outpatient care;\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003ch2\u003eMain findings\u003c/h2\u003e\n\u003cp\u003eThis study provided an overview of patients with AAP in ED care in Germany regarding their characteristics, outpatient care utilization before and after the ED visit, hospitalization rate, and in-hospital mortality. The hospitalization rate in our study was 41.6% after the ED visit, with the most common diagnoses being diseases of the digestive or genitourinary system, or symptom-based diagnoses (R10). Approximately two thirds of the AAP patients did not seek prOC 3 days before attending the ED. Overall almost 4% re-visited the ED within 30 days. The number of re-visit were significantly lower in patients who used OC 3 days before their ED visit compared to patients who did not (1.9% vs 4.0%, respectively).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eComparison with other studies and outlook\u003c/h2\u003e\n\u003cp\u003eIn line with other studies, the average AAP patient at the ED was 47.7 years old, female, and diagnosed with a symptomatic R10 diagnosis in the ED\u0026nbsp;[1, 4, 12, 18]. An in-depth characterization by Pemmerl et al (2021) of a comparatively smaller and younger AAP population in the ED of a German urban community hospital (N = 1,417) found a significantly higher hospitalization rate of 48.2% (p = 0.002) compared to our study. Yet, Helbig et al (2023) - whose study in two EDs in an urban area was similar in study design and inclusion criteria to our study - found a significantly lower hospitalization rate of 25.8% in (n=49430). Small single-center studies from Italy, Greece, and Poland showed also vastly differing hospitalization rates between 16.6% and 36.0%\u0026nbsp;[1, 4, 6, 12, 14, 19]. Two of these studies also reported ED re-visit rates up to 30 days post ED, which were significantly higher than in our study (6.5% and 10.9%, respectively; p\u0026lt;0.001)\u0026nbsp;[1, 6]. Differences in sample size, age, sex and urgency distribution, admission policies and remuneration-related incentives, the availability of hospital beds, as well as different study designs and small sample sizes may contribute to these differences. We would argue that these differences underline the importance of large-scale studies, and that our study reports the most reliable data on hospitalization rates of patients with AAP to date.\u003c/p\u003e\n\u003cp\u003eThe low hospitalization rate of patients who did not seek prOC up to 3 days before attending the ED (35.2%) may indicate that patients with low urgency experienced barriers to accessing prOC before coming to the ED\u0026nbsp;[20]. In a sectoralized health care system such as Germany, the OC provider is meant to serve as a gate-keeper to primary and secondary care as well as to secure continuity and coordination of care\u0026nbsp;[21]. Due to insufficient capacity of primary and secondary OC providers, patients may opt to visit an ED for a specialist opinion or diagnostic imaging. Of the one third of patients who sought prOC before attending the ED, the hospitalization rate was also unexpectedly low (48.6%). This may indicate potential difficulties of OC resources to meet the complex clinical requirements or expectations of this patient population\u0026nbsp;[20, 22, 23], in particular to provide diagnostic imaging procedures such as sonographies and CTs in a timely manner. \u0026nbsp;As expected, in addition to old age and urgent MTS status we found that prOC use had considerable impact on hospitalization, pointing towards the role of prOC as a navigator for seeking acute care\u0026nbsp;[24, 25].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe role of prOC for hospitalizations, ED re-visits and OC use after the ED is unclear. It may be impacted by timely access to outpatient primary care including diagnostic imaging procedures, improved health literacy in patients, and discharge planning services for hospitalized patients\u0026nbsp;[21, 25-29]. Further investigations are needed, in particular with OC data that should be collected prospectively in European health care systems, to better determine the impact of these factors on the relationship between OC use and ED re-visits.\u003c/p\u003e\n\u003ch2\u003eStrengths and Limitations\u003c/h2\u003e\n\u003cp\u003eThe present analyses were part of the INDEED study that collected data from 454,747 visits to 16 EDs. It is the largest study of ED patients in Germany to date. INDEED\u0026rsquo;s unique strength was that it linked ED data with outpatient care data on the individual patient-level, which was unprecedented in Germany at this sample size. For Europe, the present analysis was the first evaluation of data from patients with AAP across treatment sectors including a large sample of 28376 patients with 31576 visits to 15 EDs. Another strength of our study was the retrospectively collected routine healthcare data of good quality allowing insights into the real-world care of statutory health insurance companies\u0026rsquo; patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, our study had also some potential limitations. First, data availability and quality differed across EDs, making the data susceptible to systematic errors in documentation, availability bias, and diagnostic access bias. For example, ED diagnoses were not available or could not be retrieved for 23.4% of the ED patients. We did not have the information if a diagnosis was missing because it was not made, not documented or not retrieved during data extraction. The majority of diagnosis captured were ICD symptom diagnoses and confer little for clinical relevance. Second, ED patients with specific diseases, amongst them diverticulitis or Morbus Crohn, may present with AAP but might not have been picked up by the inclusion criteria of this study depending on triage and diagnostic standards at the participating centers. Third, for patients who were included due to their ED diagnosis and for whom multiple ED diagnoses were documented, it was impossible to deduce if the AAP diagnosis was the leading diagnosis. Similarly, it could not be determined if AAP was the leading cause for prOC and post-OC visits. Fourth, for the outcomes \u0026lsquo;post-OC use\u0026rsquo; and \u0026lsquo;revisit to ED\u0026rsquo; within 30 days\u0026rsquo; we did not focus only on AAP-related reasons but included all reasons for such visits and utilization. However, the results of a subgroup analysis indicated that this was unlikely to have influenced our results. Less than 1% of patients visited only physicians from specialties without relation to AAP, such as ophthalmologists. Still, we do not know if the OC physician referred the patients to the ED or if the decision to visit the ED was made independently by the patients. In addition, ED visits as well as hospitalizations may be underreported since patients may have visited EDs/hospitals that did not participate in the study. Fifth, our study included only patients with AAP who appeared at the ED (index patient) but not patients with AAP who were successfully treated by their GPs. Thus, our approach did not allow us to examine more comprehensively if going to a GP with AAP may affect hospitalization after ED visit or the revisit rate to ED. \u0026nbsp; \u0026nbsp;\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eAAP is a leading cause for hospitalization of ED patients in Germany, with a large variety of underlying diagnoses and considerable in-hospital mortality. Our findings underline the severity as well as the clinical complexity of diagnosing and treating these conditions, not only but especially in the ED. Hospitalization after an ED visit with AAP was significantly more likely for the elderly, prOC users and men. Approximately one third of ED patients with AAP sought OC before and two thirds after attending the ED. The frequency of ED visits by AAP patients with prOC but without subsequent hospitalization may indicate difficulties of prOC resources to meet the complex diagnostic requirements and expectations of this patient population. A lower number of ED re-visits was associated with proC use and age \u0026le;65 years. Less ED re-visits in prOC users indicate effective care in this subgroup. The interaction between ED and prOC services of patients with AAP needs to be further investigated including prospective studies with primary data collection to consider more confounding factors related to comorbidities and lifestyle including substance abuse.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAAP \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Acute abdominal pain\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBBSR\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;German Federal Office for Building and Regional Planning\u003c/p\u003e\n\u003cp\u003eCI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;confidence intervals\u003c/p\u003e\n\u003cp\u003eCT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Computed tomography\u003c/p\u003e\n\u003cp\u003eED \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Emergency department\u003c/p\u003e\n\u003cp\u003eGP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;General practitioner\u003c/p\u003e\n\u003cp\u003eICD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;International Classification of Diseases\u003c/p\u003e\n\u003cp\u003eK35\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Acute appendicitis\u003c/p\u003e\n\u003cp\u003eK56\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Paralytic ileus and intestinal obstruction without hernia\u003c/p\u003e\n\u003cp\u003eK57\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Diverticular disease of intestine\u003c/p\u003e\n\u003cp\u003eK80\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Cholelithiasis\u003c/p\u003e\n\u003cp\u003eK85\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Acute pancreatitis\u003c/p\u003e\n\u003cp\u003eMTS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Manchester triage system\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eN10\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Acute tubulo-interstitial nephritis\u003c/p\u003e\n\u003cp\u003eN13\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Obstructive and reflux uropathy\u003c/p\u003e\n\u003cp\u003eOC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Outpatient care\u003c/p\u003e\n\u003cp\u003eOR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Odds ratio\u003c/p\u003e\n\u003cp\u003epost-OC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Post-outpatient care up to 30 days after ED visit\u003c/p\u003e\n\u003cp\u003eprOC\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Outpatient care up to 3 days prior to the ED visit\u003c/p\u003e\n\u003cp\u003eR10\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Abdominal and pelvic pain\u003c/p\u003e\n\u003cp\u003eSD \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;standard deviation\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThe study was approved by the ethics committee of the Charit\u0026eacute; \u0026ndash; Universit\u0026auml;tsmedizin Berlin (EA4/086/17). Details on the data protection concept are described elsewhere\u0026nbsp;[15].\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eIn line with the ethics approval, only aggregated data were reported.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe data that support the findings of this study are not publicly available due to the high sensitivity of clinical data of the patients treated in the emergency department.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThe INDEED study was funded by the Innovation Fund of the German Joint Federal Committee (G-BA), grant number 01VSF16044. G-BA is the highest decision-making body of the joint self-government of physicians, dentists, hospitals, and public health insurance companies in Germany.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAuthor\u0026rsquo;s contributions\u003c/h2\u003e\n\u003cp\u003eAll authors have made substantial contributions to the design of the work, the acquisition or analysis of data (except ASch), the interpretation of data, and the drafting or revision of the work.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eThe authors would like to thank Britta Stier and Lukas Helbig who served as clinical advisors for the present analyses and writing of the manuscript. The\u0026nbsp;\u003cem\u003eINDEED-research group included\u0026nbsp;\u003c/em\u003eNatalie Baier,\u0026nbsp;Reinhard Busse, Dominik Brammen, Johannes Drepper, Patrik Dr\u0026ouml;ge, Felix Greiner, Cornelia Henschke, Stella Kuhlmann, Bj\u0026ouml;rn Kreye, Christian L\u0026uuml;pkes, Thomas Reinhold, Burgi Riens, Marie-Luise Rosenbusch, Felix Staeps, Kristin Schmieder, Daniel Schreiber, Dominik von Stillfried, Maike Below, Rainer R\u0026ouml;hrig, Stephanie Roll, Thomas Ruhnke, Felix Walcher, and Grit Zimmermann (all Germany), and Ryan King (Australia).\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCervellin G, Mora R, Ticinesi A, Meschi T, Comelli I, Catena F, Lippi G. Epidemiology and outcomes of acute abdominal pain in a large urban Emergency Department: retrospective analysis of 5,340 cases. Ann Transl Med. 2016;4(19):362.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFagerstr\u0026ouml;m A, Paajanen P, Saarelainen H, Ahonen-Siirtola M, Ukkonen M, Miettinen P, Paajanen H. Non-specific abdominal pain remains as the most common reason for acute abdomen: 26-year retrospective audit in one emergency unit. Scand J Gastroenterol. 2017;52(10):1072\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMockel M, Searle J, Muller R, Slagman A, Storchmann H, Oestereich P, et al. Chief complaints in medical emergencies: do they relate to underlying disease and outcome? The Charite Emergency Medicine Study (CHARITEM). Eur J Emerg Med. 2013;20(2):103\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaporale N, Morselli-Labate AM, Nardi E, Cogliandro R, Cavazza M, Stanghellini V. Acute abdominal pain in the emergency department of a university hospital in Italy. 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Indikatoren und Karten zur Raum- und Stadtentwicklung\u003c/em\u003e. 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKassen\u0026auml;rztliche, Bundesvereinigung. \u003cem\u003eEinheitlicher Bewertungsma\u0026szlig;stab (EBM)\u003c/em\u003e. 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHastings RS, Powers RD. Abdominal pain in the ED: a 35 year retrospective. Am J Emerg Med. 2011;29(7):711\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHelbig L. Nicht-traumatische Bauchschmerzen - Eine retrospektive Sekund\u0026auml;rdatenanalyse von 448.689 Behandlungsf\u0026auml;llen aus zwei Berliner Notaufnahmen. Deutsches \u0026Auml;rzteblatt; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGentile S, Vignally P, Durand AC, Gainotti S, Sambuc R, Gerbeaux P. Nonurgent patients in the emergency department? A French formula to prevent misuse. BMC Health Serv Res. 2010;10:66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNabieva K, McCutcheon T, Liddy C. Connecting unattached patients to comprehensive primary care: a rapid review. Prim Health Care Res Dev. 2023;24:e19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFatima Y, Hays R, Neilson A, Knight S, Jatrana S. Why patients attend emergency department for primary care type problems: views of healthcare providers working in a remote community. Rural Remote Health. 2022;22(1):7054.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGhazali DA, Richard A, Chaudet A, Choquet C, Guericolas M, Casalino E. Profile and Motivation of Patients Consulting in Emergency Departments While not Requiring Such a Level of Care. Int J Environ Res Public Health, 2019. 16(22).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCowling TE, Cecil EV, Soljak MA, Lee JT, Millett C, Majeed A, et al. Access to primary care and visits to emergency departments in England: a cross-sectional, population-based study. PLoS ONE. 2013;8(6):e66699.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacKichan F, Brangan E, Wye L, Checkland K, Lasserson D, Huntley A, et al. Why do patients seek primary medical care in emergency departments? An ethnographic exploration of access to general practice. BMJ Open. 2017;7(4):e013816.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShahid R, Shoker M, Chu LM, Frehlick R, Ward H, Pahwa P. Impact of low health literacy on patients' health outcomes: a multicenter cohort study. BMC Health Serv Res. 2022;22(1):1148.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHenke RM, Karaca Z, Jackson P, Marder WD, Wong HS. Discharge Planning and Hospital Readmissions. Med Care Res Rev. 2017;74(3):345\u0026ndash;68.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAfilalo M, Xue X, Colacone A, Jourdenais E, Boivin JF, Grad R. Association between access to primary care and unplanned emergency department return visits among patients 75 years and older. Can Fam Physician. 2022;68(8):599\u0026ndash;606.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMason S, Mountain G, Turner J, Arain M, Revue E, Weber EJ. Innovations to reduce demand and crowding in emergency care; a review study. Scand J Trauma Resusc Emerg Med. 2014;22:55.\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scandinavian-journal-of-trauma-resuscitation-and-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"stre","sideBox":"Learn more about [Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine](http://sjtrem.biomedcentral.com)","snPcode":"13049","submissionUrl":"https://submission.nature.com/new-submission/13049/3","title":"Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine","twitterHandle":"@SJTREM","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Emergency care, abdominal pain, routine health care data, cross-sectoral health care","lastPublishedDoi":"10.21203/rs.3.rs-4381552/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4381552/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\n\u003cp\u003eAcute abdominal pain (AAP) is a major driver for capacity-use in emergency departments (EDs) worldwide. Yet, the association of health care utilization of patients with AAP before and after the ED remains unclear. The primary objective of this study was to describe adult patients presenting to the ED with AAP and their outpatient care (OC) use before and after the ED. Secondary objectives included description of hospitalization rates, in-hospital mortality, ED re-visits, and exploration of potential risk factors for hospitalization and ED re-visits.\u003c/p\u003e\n\u003cp\u003eMethods\u003c/p\u003e\n\u003cp\u003eFor the analysis, we combined routine hospital data from patients who visited 15 EDs in Germany in 2016 with their statutory health insurance OC claims data from 2014 to 2017. Adult patients were included based on a chief complaint or an ED diagnosis indicating unspecific AAP or the Manchester Triage System indicator “Abdominal pain in adults”. Baseline characteristics, ED diagnosis, frequency and reason of hospitalization, frequency and type of prior-OC (prOC) use up to 3 days before and of post-OC use up to 30 days after the ED visit.\u003c/p\u003e\n\u003cp\u003eMain results\u003c/p\u003e\n\u003cp\u003eWe identified 28085 adults aged ≥20 years with AAP. 39.8% were hospitalized, 33.9% sought prOC before the ED visit (48.6% of them were hospitalized) and 62.7% sought post-OC up to 30 days after the ED visit. Hospitalization was significantly more likely for elderly patients (aged 65 and above vs. younger; adjusted OR 3.05 [95% CI: 2.87; 3.25]), prOC users (1.71 [1.61; 1.90]) and men (1.44 [1.37; 1.52]). In-hospital mortality rate was 3.1% overall. Re-visiting the ED within 30 days was more likely for elderly patients (1.32 [1.13; 1.55) and less likely for those with prOC use (0.37 [0.31; 0.44]).\u003c/p\u003e\n\u003cp\u003eConclusions\u003c/p\u003e\n\u003cp\u003eprOC use was associated with more frequent hospitalizations but fewer ED re-visits. ED visits by prOC patients without subsequent hospitalization may indicate difficulties of OC resources to meet the complex diagnostic requirements and expectations of this patient population. Less ED re-visits in prOC users indicate effective care in this subgroup.\u003c/p\u003e","manuscriptTitle":"Health care utilization of patients with acute abdominal pain before and after emergency department visits","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-20 19:00:29","doi":"10.21203/rs.3.rs-4381552/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor Revision","date":"2024-06-06T19:41:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2024-05-09T17:05:14+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-09T15:20:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-09T05:25:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine","date":"2024-05-07T04:34:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scandinavian-journal-of-trauma-resuscitation-and-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"stre","sideBox":"Learn more about [Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine](http://sjtrem.biomedcentral.com)","snPcode":"13049","submissionUrl":"https://submission.nature.com/new-submission/13049/3","title":"Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine","twitterHandle":"@SJTREM","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"84eec958-393a-449b-9aea-d096ad6cb9fa","owner":[],"postedDate":"May 20th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-08-22T19:29:27+00:00","versionOfRecord":{"articleIdentity":"rs-4381552","link":"https://doi.org/10.1186/s13049-024-01237-7","journal":{"identity":"scandinavian-journal-of-trauma-resuscitation-and-emergency-medicine","isVorOnly":false,"title":"Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine"},"publishedOn":"2024-08-12 15:57:23","publishedOnDateReadable":"August 12th, 2024"},"versionCreatedAt":"2024-05-20 19:00:29","video":"","vorDoi":"10.1186/s13049-024-01237-7","vorDoiUrl":"https://doi.org/10.1186/s13049-024-01237-7","workflowStages":[]},"version":"v1","identity":"rs-4381552","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4381552","identity":"rs-4381552","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}