Emergency Department Utilization By Hemophilia Patients in United States
Authors: Zakieh Abdulhafiz , Al-Ghafry Maha , Nadella Divya , Imran Hamayun , Siddiqui Abdul H 
Published: October 2019

Abstract
INTRODUCTION:
Patients with hemophilia are prone to life threatening bleeds and central line associated morbidities. It is pivotal that emergency departments (ED) are both equipped and trained to address these complications with acuity. The purpose of this study is to determine the utilization of ED for hemophilia related complaints.
METHODS:
Retrospective review of information collected from the National Emergency Department Database Sample (NEDS) was performed. The NEDS is a stratified sample of hospital-based ED visits and publically available for purchase as a component of the Healthcare Cost and Utilization Project. We are presenting the results of comparative analysis and frequencies computed from the database.
The ED visits with hemophilia, listed as one of the diagnoses, were selected. Patient demographics and hospital stratification variables were recorded. A snapshot of these variables from years 2006 to 2013 was obtained but due to large sample size, we elected to perform detailed analysis on data from the year 2012. Hospital charges and other variables were computed from the database and projected to national levels using the discharge weighted variables. Study was funded by "Bayer Healthcare, Investigator Initiated Research Grant".
RESULTS:
During the 8 years period studied, ~163,000 ED visits were made by hemophilia patients. This represented 0.016% of total visits to EDs nationwide. The two age groups that were most likely to utilize ED were children under 18 years and adults under 45 years (37% each). More than half of these patients resided in large metropolitan cities or their suburbs. Interestingly 20% of patients had annual household income greater than $63,000. Although Medicaid and Medicare were the largest primary payers (54%), 30% had private insurance listed as primary payer. About 45% of the ED visits were at a non-teaching hospital. As a snap shot of frequencies the trends in above mentioned results had remained unchanged from 2006 to 2013.
Detailed analysis of the purchased database for the year 2012 was performed. Out of 31 million ED visits in the year 2012; 4,488 visits were made by patients with hemophilia and 84% of them had hemophilia A (Sample representing 20% of target universe). Mean age at presentation was 29 years. There was not a significant difference in the number of ED visits among different months of the year or days of the week. Most visits were made in June (358) and least visits during February (294). Average charge per visit was $4,000; the highest charge for a single ED visit was $150,000. National estimate of total charges for ED visits by patients with hemophilia in the year 2012 was over 60 million dollars. Average charge for ED visits at a private hospital was $2,988 compared to $2,254 at a public hospital (p=0.03). The cost of ED utilization by lower income group patients was greater than patients from higher income group; however the difference in average charges was not statistically significant.
There were over 21,000 diagnoses codes recorded during 4,488 ED visits by hemophilia patients. Cardiovascular complaints (n=2060) were the most frequently reported, followed by injuries and poisoning (n=2038). Hemorrhage was the presenting complaint 32% (n=1452) of times. The breakdown of bleeds included 682 contusions, 317 hemarthrosis, 163 gastrointestinal bleeds, 96 hematuria, 83 epistaxis, 47 intracranial bleeds and 18 menstrual bleeds. Injuries were reported as primary diagnosis, 26% of times. Septicemia was diagnosed during 147 visits. Around 70% of patients were treated and released from the ED. Two patients reportedly died in the ED while 35 died after being admitted to the hospital. Cause of death included Sepsis and brain hemorrhage in 26 and 4 patients respectively. In pediatric patients only, injuries were the most frequent complaints (n=870) followed by joint and soft tissue disorders (n=366); fever (n=92) and central line complications (n=63).
CONCLUSION:
Hemophilia is a rare hematologic disease but patients with hemophilia have a high tendency to utilize ED. Proper education of patients and ED staff could help reduce the economic burden and ensure optimum care delivery in the ED. To our knowledge this is the first study to analyze ED utilization by hemophilia patients from a national database. Based on our study results, patients were evenly distributed in low and high income groups and utilized teaching and non-teaching hospital EDs alike.

Disclosures
Zakieh: Bayer Healthcare Investigator Initiated research Grant: Research Funding. Al-Ghafry:Bayer Healthcare Investigator Initiated research Grant: Research Funding. Siddiqui:Bayer Healthcare Investigator Initiated research Grant: Research Funding.