Abstract
This study uses data from the National Hospital Ambulatory Medical Care Survey to analyze adults with a neurological complaint as their reason for an emergency department visit.
Patients with neurological symptoms can be challenging to diagnose and treat in the emergency setting,1,2 but population-level data on the number and characteristics of patients who present to US emergency departments (EDs) with neurological symptoms is scarce.
Methods
We analyzed data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2016 to 2019. NHAMCS is a cross-sectional, annual survey of a nationally representative sample of 361 to 378 EDs of nonfederal hospitals, constituting approximately 10% of US EDs.3 This project was exempted from review by the Weill Cornell institutional review board since NHAMCS data are publicly available and deidentified. We adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline in this study.4
We identified all patients 18 years and older with a neurological complaint listed as their first (most important) reason for ED visit (eTable in the Supplement); no patients with neurological complaints were excluded. Visit reasons are defined in the NHAMCS instrument as symptoms, problems, issues, and concerns of the patient. Free text information is entered in the reason for visit field in the survey instrument by trained local staff supervised by the US Census Bureau, then coded by professional coders using a previously developed classification system and included in the NHAMCS data set.3 We used demographic (including race and ethnicity), clinical, regional, and facility-level variables included in NHAMCS to describe our study sample. We used International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes (in any position) to define a suspected (probable, questionable, or rule out) ED diagnosis of a serious neurological condition. In NHAMCS, up to 5 suspected ED diagnoses can be entered into the survey instrument, which are then translated into ICD codes by professional coders.
We applied survey visit weights to obtain national estimates and 95% CIs. Survey-weighted tests of comparison were used to compare mean age and sex between patients with neurological complaints vs all other ED patients. All analyses were performed with Stata MP version 14.2 (StataCorp). Two-sided α level of .05 was statistically significant. Analysis took place between January and August 2022.
Results
From 7264 sampled cases, an estimated 55.8 million (95% CI, 52.7-59.1 million) patients presented from 2016 to 2019 to US EDs with a neurological complaint as the main reason for their visit. Of all ED visits during this period, 8.4% (95% CI, 8.0%-8.9%) were for neurological complaints. Among those with neurological complaints, 60% were female, 40% were younger than 45 years, and 63% were non-Hispanic White individuals (Table). Compared with all other ED patients, those with neurological complaints were older (mean [95% CI] age, 51.6 [50.6-52.6] years vs 47.3 [46.7-47.8] years; P < .001) and more often female (60.2% [95% CI, 57.3%-63.1%] vs 56.8% [95% CI, 56.0%-57.5%]; P = .03). The most common neurological complaints were nonspecific including headache, vertigo/dizziness, and general weakness (Figure).
Table. Sample Characteristics of Patients with Neurologic Complaints in US Emergency Departments, 2016-2019.
| Characteristic | Unweighted No. of patients | Patients, % (95% CI) |
|---|---|---|
| Age, y | ||
| 18-44 | 2939 | 40.4 (38.2-42.6) |
| 45-64 | 2128 | 28.4 (26.2-30.8) |
| >65 | 2003 | 27.1 (25.9-30.4) |
| Female | 4366 | 60.2 (57.3-63.1) |
| Male | 2898 | 9.8 (36.9-42.7) |
| Race and ethnicity | ||
| Black, non-Hispanic | 1425 | 19.7 (16.7-23.1) |
| Hispanic | 946 | 13.4 (11.1-16.6) |
| White, non-Hispanic | 4578 | 63.2 (0.6-0.7) |
| Other, non-Hispanica | 315 | 3.5 (2.3-5.3) |
| Geographic region | ||
| Northeast | 1149 | 16.5 (12.8-20.9) |
| Midwest | 1936 | 25.0 (20.5-30.2) |
| South | 2388 | 35.7 (31.2-40.5) |
| West | 1791 | 22.9 (18.8-27.5) |
| Medical history | ||
| Hypertension | 2774 | 38.7 (36.2-41.3) |
| Congestive heart failure | 344 | 4.4 (3.6-5.4) |
| Diabetes | 1230 | 18.5 (16.5-20.6) |
| Stroke/transient ischemic attack | 815 | 11.9 (10.4-13.6) |
| Cancer | 398 | 5.3 (4.5-6.2) |
| Substance misuse | 460 | 5.6 (4.5-6.9) |
| Alcohol misuse | 335 | 4.1 (3.3-5.1) |
| Dementia/Alzheimer disease | 227 | 3.0 (2.3-3.8) |
| Diagnostic evaluation | ||
| Any consultation obtained | 1091 | 13.6 (11.6-15.9) |
| Head computed tomography image obtained | 2630 | 37.6 (35.0-40.2) |
| Any magnetic resonance imaging obtained | 336 | 4.4 (3.47-5.7) |
| Lumbar puncture obtained | 44 | 0.9 (0.4-1.7) |
| Serious neurological condition suspected | ||
| Stroke (ischemic and hemorrhagic) | 399 | 6.03 (5.0-7.3) |
| Seizure disorder | 241 | 2.54 (2.1-3.1) |
| Other serious disorders of the nervous systemb | 95 | 1.30 (0.9-1.84) |
| Meningitis/encephalitis | NRc | |
| Malignant neoplasm of the nervous system | NRc | |
| Myasthenia gravis/other myoneural disorders | NRc | |
| Inflammatory polyneuropathies | NRc | |
| Disposition | ||
| Discharged to home | 5343 | 72.9 (70.6-75.2) |
| Hospitalized | 1098 | 15.3 (13.5-17.3) |
| Transferred to another facility | 329 | 4.2 (3.3-5.5) |
| Admitted to an observation unit | 291 | 3.8 (2.9-5.1) |
| Left against medical advice or before being seen | 154 | 2.4 (1.7-3.3) |
Abbreviation: NR, not reported.
The other race and ethnicity category included American Indian/Alaska Native, Asian, Native Hawaiian/Other Pacific Islander, and more than 1 race reported.
Other serious disorders of the nervous system included hydrocephalus, brain compression, cerebral edema, anoxic injury, intraspinal/intracranial abscess, other paralytic syndromes, and cerebrospinal fluid leak.
Less than 30 unweighted records available.
Figure. Prevalence of Specific Neurological Complaints.
Whiskers depict 95% CIs for each national estimate. There were fewer than 30 unweighted records available for patients with memory disturbance and therefore this reason for visit is not included.
A serious neurological condition was suspected in 10.1% (95% CI, 8.9%-11.3%) of patients, with stroke being the most frequently suspected condition. Computed tomography of the head was performed in 37.6% (95% CI, 35%-40.2%) of patients with neurological complaints, any magnetic resonance imaging in 4.4% (95% CI, 3.5%-5.7%), and lumbar puncture in 0.9% (95% CI, 0.4%-1.7%). Overall, 72.9% (95% CI, 70.6%-75.2%) of patients with neurological complaints were discharged to home from the ED (Table).
Discussion
Patients with a neurological symptom as their most important presenting complaint account for a high number of ED encounters nationally. Nonspecific neurological symptoms were much more frequently reported than focal weakness, speech issues, and vision changes. Currently, there are few screening tools, bedside tests, or risk-prediction models to identify or exclude serious neurological conditions in patients with nonspecific complaints despite their frequency in the ED.5 Additional research to determine how to best detect the small subset of patients with neurological complaints who harbor or are at increased short-term risk of disabling neurological conditions could help streamline ED-based care processes and resource utilization, including neurological consultation.
eTable. Neurological Complaints Included as Reason for Visit
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eTable. Neurological Complaints Included as Reason for Visit
