Page 35 - Delaware Medical Journal - September/October 2018

ORIGINAL RESEARCH
of the same emergency providers when they are working at two very distinct hospital settings. With each individual physician or physician assistant spending approximately one-third of their time working in the urban center, personal prescribing preferences and practitioner biases should persist at both emergency department sites.
Our study demonstrated a significant increase in the rate of prescribing discharge opiates at the suburban ED in comparison to the urban ED. This difference in prescribing patterns by providers at the urban site compared to the suburban site could be due to many reasons. As shown, the population of patients at these two hospitals varies greatly. As seen in Table 1, there are statistically significant differences
in all demographic groups, including age, sex, race, payment, and severity index of presenting complaint. Any
of these factors could account for a change in a provider’s prescribing habits. For example, a clinician may be more hesitant to prescribe opioids to an elderly patient. This was demonstrated in a 2010 study at an urban academic ED where patients older than 80 years of age were less likely to receive
opiate analgesics at discharge.8 Studies have also shown that Caucasian patients are more likely to receive opiate prescriptions at discharge in comparison to non-white patients.4 As our urban center has a significantly higher percentage of non-white patients, this disparity may account for the decrease in discharge opiate prescriptions at that site.
Overall, our results are similar to other studies which conclude that urban populations are less likely to be given opioid prescription upon discharge from the ED.6 While prior studies demonstrate this disparity
between urban and rural settings, our investigation compares urban to suburban emergency departments.
These results expose an exciting area for further study. Future areas for research should compare prescribing patterns that account for chief complaint and discharge diagnoses
at two sites, focusing specifically on pain-related presentations such as fractures. As all prior research has been performed in a retrospective fashion, this invites the opportunity for a prospective study of prescribing habits between two distinct geographic sites. Additionally, in
an effort to further delineate which
of the demographic variances may
be contributing to the prescribing differences, a future study could focus on a narrower patient population such as the elderly or minorities.
LIMITATIONS
This study had several limitations. First, while most providers divide
their scheduled work hours between the two sites in a one-third/two-thirds distribution, there are a few providers who choose to primarily practice at one site versus the other. However, as there are a total of 137 providers, the few site are unlikely to result in a dramatic change in prescribing rates between the two sites.
As this study focused only on discharged patients from the ED, those patients with the most acute injuries or unstable presentations, and thus higher severity scores, are typically less likely to be discharged from the ED than those with lower severity scores. This is demonstrated in Table 1, as only 0.2% and 0.3%
of the level 1 severity index patients were discharged from the urban and suburban EDs, respectively. This demonstrates that those patients
who present with extreme traumatic injuries are typically not discharged from the ED after evaluation and do not significantly impact the number of opiate prescriptions at discharge.
There is a difference in the total
number of patients discharged in the demographic table as compared to the result z-test comparison. These two tables were obtained from two data sets: one of which included all patients who presented and those who were registered to be seen. The results table was extracted from ExitCare. ExitCare was used as discharge instruction software, had limited analytics and could only analyze patients who were discharged from the ED. This difference in patients is due to patients who left against medical advice and those who registered to be seen and left without treatment, resulting in a disparity between the two totals.
CONCLUSION
In conclusion, with a current national epidemic of opiate abuse and increase in use, focus has been on prescribers providing opiates to patients at discharge from medical visits, including the emergency department. Prior research has not included suburban populations in comparison to urban populations and their respective prescription rates of opiates. Our study demonstrates that patients visiting a suburban emergency department are opioid prescription at discharge than those who visit an urban emergency department, despite seeing the same medical providers at each site.
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