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hospital resource utilization. Despite numerous society recommendations and incorporation into many local hospital guidelines, adoption by ED providers has been slow. One potential barrier is provider concern about "high risk" features on CTPE that are not included in the Pulmonary Embolism Severity Index (PESI) score.Our study objective was to determine the frequency and assess the outcomes of aPE-ED patients with low risk PESI scores but concerning findings on CTPE.Methods: We performed retrospective chart review of aPE-ED cases from a oneyear period (1/1/2017-12/31/2017) at a single, tertiary academic center. aPE-ED cases were identified by a combination of EMR query and manual chart review by three emergency physicians (EPs). Clinical variables, including age, sex, ED vital signs, past medical history, and mental status were abstracted and used to calculate the Pulmonary Embolism Severity Index (PESI) score. Biomarkers (troponin I and B-type natriuretic protein), CTPE, point-of-care ultrasound (POCUS), and formal echocardiogram (TTE) results, length of stay, site of admission (ICU vs. non-ICU) and 7-and 30-day mortality were also recorded. Patients were grouped by risk based on PESI score, biomarkers, and presence of concerning findings on CTPE (bilateral PE with saddle, main, or lobar arteries involved OR infarct OR evidence of right heart strain).Results: We identified 250 patients with aPE-ED. Low PESI score (85), normal biomarkers, and no concerning CTPE findings were found in 53 (21.2%) of patients (Risk group 1). Low PESI score, normal biomarkers, but one or more concerning CTPE findings were identified in 47 (18.8%) of patients (Risk group 2). Elevated PESI score (>85) was identified in 150 (60.0%) of patients (Risk group 3). Risk group had a statistically effect on length of stay (LOS), ICU admission, and mortality at 7 and 30 days (all p < .001). Pairwise comparisons, however, showed no statistically significant differences between risk group 1 (mean LOS 59.2 hrs, 0% ICU admission, and no mortality at 7 or 30 days) and risk group 2 (mean LOS 56.4 hrs, 2.2% ICU admission, and no mortality at 7 or 30 days), while both groups were statistically different from risk group 3 across all measures (mean LOS 138.3 hrs, 17.6% ICU admission, and 8.1% and 15.3%, 7-and 30-day mortality, respectively, all p values < 0.001). The rate of echocardiography (POCUS and/or TTE) was significantly lower in risk group 1 (19.2%) than risk group 2 (58.7%) or risk group 3 (58.3%), p < 0.001, but the latter two groups were not statistically different, p ¼ 0.32. The rate of abnormal echo (dilated RV, abnormal RV function, or septal motion suggestive of RV pressure overload) was higher in risk group 2 (16%) than risk group 1 (0%) or risk group 3 (4.8%), although these differences were not statistically significant.Conclusion: Acute PE patients with low risk stratification scores and concerning CTPE findings accounted for nearly 20% of our cohort. Despite a higher rate of abnormal echocardiogram findings, their outcomes were not st...

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Study Objectives To determine whether changes in emergency department (ED) use associated with Medicaid expansions differ between states undergoing waiver and traditional expansions. Methods: Cross-sectional difference-indifference study to compare ED use between expansion and non-expansion states, and within expansion states, between traditional and waiver expansion states, in the four years prior to expansion (2010-2013) compared to the three years post-expansion (2014-2016). Among expansion states, the post-expansion period was defined based on each state's date of Medicaid expansion. Consistent with prior work, four states (New York, Delaware, Massachusetts, and Vermont) and the District of Columbia were excluded, as these states already offered Medicaid coverage similar to the expansion level prior to 2014. In addition, Pennsylvania and Rhode Island were excluded from analysis, as these states underwent both traditional and waiver expansions at different time points. We use data from the National Health Interview Survey (NHIS), a nationally representative cross-sectional survey consisting of adults from all 50 states and the District of Columbia. Participants: 37,658 adults aged 19-65 with incomes <138% of the federal poverty level. The main outcome measures were ED use within the last 12 months and ED use two times or more in the last 12 months. Statistical Analysis: Multivariate regressions with interaction variables were used to calculate difference-indifference estimates. Regressions were adjusted for several confounders available in the NHIS dataset, including age, sex, and family type, as well as for fixed effects at the state and interview year levels. A two-tailed t-test was used to determine if differences between coefficients in states undergoing traditional or waiver expansions were statistically significant, with significance set a priori at p¼0.05. The NHIS complex survey design was taken into account by using Stata's survey commands, as well as by weighting according to sampling design. Standard errors were clustered at the state-level. Results: Compared to non-expansion states, individuals in states across all expansion types were more likely to report any ED use in the previous year (2.8, p¼0.05) and visiting an ED 2 times or more (2.0, p¼0.05). Individuals in states undergoing traditional expansions were also more likely to report visiting an ED 2 times or more in the previous year (2.3, p¼0.04) but were not more likely to report any ED use (1.7, p¼0.25). Conversely, among individuals in waiver states, increase in any ED use approached significance (5.2, p¼0.06), but use of EDs 2 times or more in the previous year did not statistically significantly increase (0.8, p¼0.69). The differences between traditional and waiver states in ED use once and ED use 2 times or more in the previous 12 months did not meet significance (p¼0.22 and p¼0.50, respectively). Conclusion: Three years post-expansion, there appears to be no difference between traditional and waiver expansion states in any ED use or mo...