BACKGROUND: Chronic pain represents a widely prevalent disease state, estimated to affect greater than 30% of the US population, with increasing incidence in females, elderly, and patients of low socioeconomic status. 1 Total societal cost attributable to chronic pain in the U.S. is estimated at $560 to $635 billion per year.2 Patients with poorly managed pain are commonly high utilizers of acute care services and account for a disproportionate share of hospitalizations and emergency department visits3. Most chronic pain patients who heavily utilize acute care services have never been seen in a pain clinic.3 These patients are reported to have up to 4 times the number of annual inpatient admissions of matched controls.4 We evaluated the total number of patients who presented to the Emergency Department (ED) at Duke University Hospital (DUH) with a chief complaint of pain and were subsequently treated and released.
METHODS: Following Duke IRB approval, a retrospective cross-sectional analysis was conducted of patients who had at least 1 visit to the ED at DUH from June 1, 2014 to December 1, 2014. A subset of those patients was then identified with at least 1 ED visit for a chief complaint of ‘pain’ that were subsequently treated and released from the ED. For this cohort, number of ED visits for management of pain, total number of ED visits, patient age, gender, insurance status, ED arrival time, ED disposition time, ED departure time, chief complaint, means of arrival, level of acuity, and disposition were assessed. High utilizers defined as ≥ 5 total ED visits in a 6-month period were also evaluated.
RESULTS: Among 6,376 patients seen in the ED with a chief complaint of pain (out of 27,968) there were 7,669 pain-related ED encounters and 11,113 total ED encounters, (average: 1.2 pain-related encounters and 1.74 total encounters; maximum: 21 pain-related encounters and 165 total encounters; minimum: 1 encounter; standard deviation: 0.82 pain-related encounters and 2.63 total encounters). The 7,669 pain-related encounters corresponded to 20.1% of 38,074 total ED encounters and 26.7% of 28,712 patient encounters that were treated and released (i.e. not admitted). Notably, of 315 patients who had at least 5 ED visits, with a range up to 165 visits, 92 (29.2%) had > 50% of their ED visits due to a chief complaint of pain (Figure 1).
DISCUSSION: Approximately 25% of ED encounters at an academic quaternary care institution were found to be due to a chief complaint of pain. Nearly 30% of ED high utilizers [defined as ≥ 5 ED visits with at least 1 visit due to chief complaint of pain within the 6 month period] (> 1% of all patients seen) had > 50% of their admitting ED complaints due to pain. Improving care of chronic pain patients, both through intensive outpatient management and improvement in inpatient care should significantly decrease pain’s cost and work contribution to ED visits.
