The study initially included an additional 10 patients—6 in the prochlorperazine arm and 4 in the AAC arm—who demanded opiates or other drugs before the 60-minute mark. Those patients were excluded from the analysis.
Dr Deitch noted that migraine or presumed migraine annually accounts for several million ED visits. Guidelines vary for treatment of migraine in the ED and don’t rely on a strong evidence base. Oral narcotics are the most frequently prescribed agents, but the International Headache Society does not recommend them as first-line therapy because of their major drawbacks, which include nausea, constipation, and the potential for abuse and overuse. Other guidelines advocate triptans, but they’re not popular with emergency medicine physicians because of the cardiovascular risk profile.
Prochlorperazine—the most commonly prescribed dopamine agonist for acute migraine in the ED—does not have a Food and Drug Administration indication for migraine. The drug’s off-label usage in this setting is well established, however. Randomized trials have demonstrated that prochlorperazine is as effective as are narcotics and may be more effective than sumatriptan. Akathisia and dystonia are common side effects with prochlorperazine, and those adverse effects are often sufficiently severe to require rescue diphenhydramine, which prolongs the ED stay.
AAC (Excedrin) is the only OTC medication with FDA approval for the treatment of migraine. Its side effect profile is better than that of prochlorperazine, yet AAC is rarely used as first-line therapy for acute migraine in the ED. In part, the evidence was lacking. But even with demonstrated efficacy in a randomized head-to-head comparison with prochlorperazine, “Excedrin is an oral medication. Physicians and patients have an expectation that if a headache is bad enough to bring someone into the ED, the patient expects an IV, and we expect to do that for them.”
With fairly good evidence of efficacy even in patients with mild to moderate migraine with nausea, the situation may begin to change as the majority of patients who receive Excedrin have pain relief, he said.
Dr Deitch reported having no financial conflicts of interest with regard to this study, conducted free of commercial support.
ED a “profit center”; ACA may drive higher profits
BY ALICIA AULT
FROM THE JOURNAL HEALTH AFFAIRS
The emergency department is a profit center for many hospitals—and could help drive profits even higher as the Affordable Care Act extends insurance coverage to more Americans.
Dr Michael Wilson, an emergency physician at Brigham and Women’s Hospital, Boston, and David M. Cutler, PhD, an economics professor at Harvard University, Cambridge, Mass, looked at more than 11 million emergency department (ED) visits for which patient-level revenue information was available as well as 20 million observations with charge data.
Of those visits, 35% were covered by private insurance, 26% by Medicaid, 21% by Medicare, and 18% were uninsured.
They found that in 2009, hospitals generated ED revenues of about $79 billion, at a cost of $73 billion. The $6.1 billion profit translated into an almost 8% profit margin. The profits came primarily from private pay patients. Hospitals made a 40% margin on the privately insured, or about $17 billion, according to the analysis. This compensated for losses on Medicare (-6%), Medicaid (-40%), and the uninsured (-60%) ( Health Affairs 2014;5792-9 [doi 10.1377/hlthaff.2013.0754]).
“One of the more surprising findings was just how dependent the emergency department is on payer mix,” Dr Wilson said, adding that EDs that do not have a large number of private pay patients may not be as profitable.
Dr Wes Fields, former chairman of the American College of Emergency Physicians’ Emergency Medicine Action Fund, agreed that payer mix is a key.
“For patients or policy makers trying to interpret the meaning of this study for their own community, it is important to remember that hospital profitability is like real estate valuation: ‘location, location, location,’” Dr Fields said.
A spokeswoman with the American Hospital Association said that it’s not just about payer mix. “It is hard to really measure the costs of ED care,” said Marie Watteau, of the AHA. “Hospitals have to maintain the standby capacity of an ED 24/7 and that means having trauma teams at the ready. The costs to maintain that service is spread over all of the services provided by the hospital,” she said.
Under the ACA, the number of paying patients should improve, Dr Wilson said. He predicted that by 2023, profit margins would increase to 12%, using a scenario in which 50% of the uninsured remain uninsured, 25% gain private insurance, and 25% enroll in Medicaid. This also assumes that reimbursement for private insurance is at a rate that’s at the midpoint between employer-sponsored private insurance and Medicaid pay. Without the ACA, profit margins would continue to hover around 7%, they said.