Factors Associated With Increased Emergency Department Utilization in Patients With Acute Optic Neuritis

Abstract

Background: Symptoms of acute vision loss and eye pain may lead patients with optic neuritis to seek care in the emergency department (ED). Given the availability of lower cost alternatives for providing medical care for optic neuritis, this study aimed to identify factors associated with higher ED utilization. Methods: Subjects with acute optic neuritis were identified through a chart review of adults with International Classification of Diseases-9 (ICD-9) or ICD-10 codes for optic neuritis with corresponding gadolinium contrast enhancement of the optic nerve on MRI in the medical record research repository of a tertiary care institution. Subjects were grouped based on the number of ED visits (0–1 and 2–3) within 2 months of either ICD code or MRI. Demographics, characteristics of disease presentation, type and location of medical care, testing (chest imaging, lumbar puncture, optical coherence tomography, spine MRI, visual field, and laboratory tests), treatment, provider specialty of follow-up visits, and duration of care were extracted from the medical record. Results: Of 30 acute optic neuritis subjects (age 41 ± 16 years, range 18–76, 53% [16/30] female), 19 had 0–1 ED visit and 11 had 2–3 ED visits. Most subjects were Caucasian, non-Hispanic (47%), followed by Asian (23%), Hispanic/Latino (17%), Black (10%), and others (3%). Subjects had an initial clinical encounter primarily in the outpatient setting (63%) as compared with the ED (37%). The median time from symptom onset to initial clinical encounter was 4 days with a range of 0–13. Subjects were mostly insured through a private insurance (60%), followed by Medicare/Medicaid (23%) and uninsured (17%). Fewer ED visits were associated with an initial clinical encounter in an outpatient setting (P = 0.02, chi-square), but not residential distance from the hospital or insurance type. Subjects with a higher number of ED visits were more likely to be of Hispanic/Latino ethnicity (P = 0.047, Fisher exact). There was no significant difference in the ophthalmic, radiologic, or laboratory testing performed in both groups. Both groups presented in a similar time frame with similar symptoms and clinical signs. Treatment was similar in both groups. Conclusions: Subjects with their first clinical encounter for optic neuritis in the ED had more visits to the ED overall when compared with those first seen in an outpatient setting and thus strategies aimed at facilitating outpatient care may help reduce unnecessary ED visits, although some, such as insurance status, may be difficult to modify. Further study in a larger sample is needed to refine these observations.

Accuracy of International Classification of Diseases Codes for Identifying Acute Optic Neuritis

“…In fact, 110 (44%) had confirmed alternative diagnoses. For the cohort with optic nerve enhancement, our group previously reported that the most predominant alternative etiologies were neoplasm or lesions, followed by other optic neuropathies (13). For the cohort without enhancement, other etiologies were predominantly other optic neuropathies, followed by neoplasms or other lesions.…”

“…MRI was classified as positive for acute optic neuritis if there was gadolinium-contrast enhancement of the optic nerve noted on the MRI report and otherwise classified as negative. Subjects with positive MRI are the same as those in our previously published study (13). Subjects with negative MRI have not been previously reported.…”

“…A recent review found 3 studies that reported the positive predictive value (PPV) of algorithms for ON ranging from 25% to 100% using the treating clinician's diagnosis as ground truth (9–12). Our group previously reported 61% accuracy for acute ON in subjects with ICD code for ON, MRI performance within 2 months of ICD code and MRI report of optic nerve enhancement (13). This follow-up study aimed to determine the accuracy for acute ON of ICD code for acute optic neuritis with an MRI performed within 2 months regardless of MRI result and to identify strategies for increasing accuracy.…”

Big Data in Neuro-Ophthalmology: International Classification of Diseases Codes

“…Although ICD codes are a convenient source of big data, in isolation they are not guaranteed to provide an acceptable level of accuracy for use in neuro-ophthalmic research. Previous studies (9,(35)(36)(37)(38)(39)(40)(41) have used ICD codes to collect cases worthy of further review, followed by a time-intensive medical record review by the investigators to accurately identify cases that meet inclusion criteria. However, this level of manual review may not be compatible with an eventual goal of using big data to exponentially increase the number of research subjects or even possible the big data source is not linked to clinical records.…”

Optic neuropathy diagnosis in the emergency room - retrospective observational study of the last 18 years

“…ON can often be first clinically observed in the Emergency Room (ER). 3 Once that a major challenge is that the prognosis and the therapeutic strategy can differ according to the mechanism involved, the initial work-up is fundamental to determine the specific cause, efficient diagnostic assessment and appropriate therapeutic strategy. 1,2,4 In what concerns the clinical history and examination, ON can present with diverse neuro-ophthalmological findings,and vision loss may be preceded or simultaneous to eye pain/discomfort.…”