Mullan, Aidan F.

ABSTRACTObjectivesWe describe the types of emergency department (ED) visits managed by non‐physician providers (NPPs), including physician assistants and nurse practitioners, and emergency medicine (EM) physicians, assessing shifts in care patterns over time.MethodsWe used data from the National Hospital Ambulatory Medical Care Survey collected from 2009 to 2021. We classified visits by provider type: physician only, physician with resident, physician with NPP, and NPP only. We described characteristics of visits by provider type, including patient demographics, triage urgency, imaging, length of stay, and disposition, and analyzed using Poisson regression. We described the change in type of provider seen over this study period and further analyzed by triage urgency and hospital location.ResultsOf 1.684 billion estimated ED visits from 2009 to 2021, 1.171 billion were managed by physicians without residents or NPPs (physicians only), 136.3 million by physicians with residents, 209.1 million by physicians with NPPs, and 167.4 million by NPPs only. Patients seen by physicians only were older, were triaged as having more urgent needs, had a longer ED length of stay, and were more likely to be admitted compared to those seen by NPPs only. Physician‐only visits decreased from 77% to 62%, while NPP‐only visits increased from 6% to 11%. The physician with the NPP group similarly grew from 9% to 17%. For visits assigned a triage urgency level of 2 (“emergent”), physician‐only visits decreased by 20%, physician with NPP visits increased by 13%, and NPP‐only visits increased by 3%. In metropolitan areas, physician‐only visits dropped 14%, with a 5% increase in NPP‐only visits. In non‐metropolitan areas, physician‐only visits decreased 17%, with a 9% increase in NPP‐only visits.ConclusionsThe EM workforce has shifted, with NPPs seeing a higher percentage of patients, including both lower‐ and higher‐acuity patients. This shift is particularly prominent in rural areas but is evident across all regions.

ABSTRACT Objective We sought to characterize patients presenting to emergency departments (EDs) with abdominal pain and to validate risk categories defined by the Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE‐2) for low‐risk recurrent abdominal pain. Methods We conducted a retrospective cohort study of patients presenting with abdominal pain between November 2019 and November 2023 across 21 EDs in Arizona, the Midwest, and Florida. Patients were categorized per GRACE‐2 into recurrent and non‐recurrent pain as well as low‐ and high‐risk groups. Primary outcomes included 72‐h returns and mortality at 30 and 90 days. Results The study included 162,494 visits (112,896 unique patients; median age 46 years; 61.2% female). Among these, 4.3% had low‐risk recurrent abdominal pain. Patients with recurrent and non‐recurrent low‐risk pain had similar ED length of stay and discharge rates to each other, compared to patients with high‐risk pain who had longer length of stay and lower discharge rates. At 30 days after the ED encounter, patients with low‐risk recurrent abdominal pain had similar mortality to patients with low‐risk non‐recurrent pain (0.4% vs. 0.3%; adjusted RR = 1.31, 95% CI: 0.85–2.03), while they had significantly lower mortality than patients with high‐risk recurrent abdominal pain (0.4% vs. 2.3; adjusted RR = 3.14, 95% CI: 2.02–4.89). Conclusions This study highlights the heterogeneity in patients presenting to the ED with abdominal pain. Among these patients, those with low‐risk recurrent pain demonstrated similar lengths of stay, discharges, and mortality rates to those with low‐risk non‐recurrent pain and less favorable lengths of stay, discharges, and mortality rates compared to those with any high‐risk features. These findings suggest that low‐ and high‐risk features may be more useful than recurrent or non‐recurrent pain in identifying patients who could benefit from more robust ED evaluations.

Background Early onset Parkinson's disease (EOPD), defined as Parkinson's disease (PD) diagnosed before age 50, often presents unique challenges compared to late-onset PD, particularly with regard to non-motor symptoms. Psychosis in EOPD is associated with increased functional impairment and may lead to a higher mortality risk. Objective Our study is aimed to determine the prevalence of psychosis in EOPD patients and its impact on all-cause mortality, along with examining the effects of antipsychotic medications and Selective Serotonin Reuptake Inhibitors (SSRIs) on mortality in EOPD patients. Methods Our retrospective cohort included EOPD patients diagnosed between 1990 and 2022 at Mayo Clinic, Rochester, Minnesota. Psychosis was defined using the National Institute of Neurological Disorders and Stroke/the National Institute of Mental Health (NINDS/NIMH) Work Group criteria. Cox proportional hazards models were used to analyze the association of psychosis and medications with mortality. Results Of 829 patients with EOPD, 158 (19.1%) developed psychosis at a median of 12.1 years after PD motor symptom onset. Psychosis was significantly associated with increased mortality in unadjusted (HR = 4.31, 95% CI: 2.59–7.18, p < 0.001) and adjusted (HR = 3.55, 95% CI: 2.10–6.01, p < 0.001) models. No significant difference in mortality risk was observed between patients treated with antipsychotics or SSRIs versus those who were not. Conclusions Psychosis is a possible complication in EOPD and is associated with a significant increase in all-cause mortality. The use of antipsychotics and SSRIs did not significantly alter the mortality risk in these patients. Further research is needed to understand the mechanisms driving this association and to develop tailored interventions.

Importance The role of pesticide exposure from golf courses in Parkinson disease (PD) risk remains unclear. Objective To assess whether proximity to golf courses is associated with increased PD risk and to use information on groundwater vulnerability and municipal well locations to investigate drinking water contamination as a potential route of exposure. Design, Setting, and Participants This case-control study included patients with incident PD and matched controls from the Rochester Epidemiology Project from 1991 to 2015. Data were analyzed between June and August 2024. Exposures Distance to golf courses, living in water service areas with a golf course, living in water service areas in vulnerable groundwater regions, living in water service areas with shallow municipal wells, and living in water service areas with a municipal well on a golf course. Main Outcome and Measures Risk of incident PD. All models adjusted for age, sex, race and ethnicity, year of index, median household income, and urban or rural category. Results A total of 419 incident PD cases were identified (median [IQR] age, 73 [65-80] years; 257 male [61.3%]) with 5113 matched controls (median [IQR] age, 72 [65-79] years; 3043 male [59.5%]; 4504 White [88.1%]). After adjusting for patient demographics and neighborhood characteristics, living within 1 mile of a golf course was associated with 126% increased odds of developing PD compared with individuals living more than 6 miles away from a golf course (adjusted odds ratio [aOR], 2.26; 95% CI, 1.09-4.70). Individuals living within water service areas with a golf course had nearly double the odds of PD compared with individuals in water service areas without golf courses (aOR, 1.96; 95% CI, 1.20-3.23) and 49% greater odds compared with individuals with private wells (aOR, 1.49; 95% CI, 1.05-2.13). Additionally, individuals living in water service areas with a golf course in vulnerable groundwater regions had 82% greater odds of developing PD compared with those in nonvulnerable groundwater regions (aOR, 1.82; 95% CI, 1.09-3.03). Conclusions and Relevance In this population-based case-control study, the greatest risk of PD was found within 1 to 3 miles of a golf course and risk generally decreased with distance. Associations with the largest effect sizes were in water service areas with a golf course and in vulnerable ground water regions.