Investigators also found a high rate of misdiagnosis among patients with MS during emergency department visits.
TORONTO—The majority of emergency department visits for patients with multiple sclerosis (MS) are for medical comorbidities and complications indirectly related to MS, and not for neurologic problems, according to research presented at the 62nd Annual Meeting of the American Academy of Neurology (AAN). Investigators cautioned practitioners to avoid automatically ascribing symptoms of acutely ill patients to their underlying MS.
“MS is not simply a neurologic disease,” Megan Alcauskas, MD, and Stephen Krieger, MD, told Neurology Reviews. “It can have medical, urological, psychiatric, and other effects, and can touch almost all medical and surgical specialties.”
Drs. Krieger and Alcauskas and colleagues at the Corrine Goldsmith Dickinson Center for Multiple Sclerosis at the Mount Sinai School of Medicine, along with Svenja Oynhausen, MD, at University Hospital of Bonn, Germany, used a centralized, comprehensive database of patient visits to the emergency department of Mount Sinai Hospital in New York City between January 1, 2005, and December 31, 2007. The researchers identified 569 visits by 224 patients with MS as part of the Resource Utilization in MS (RESUMS) study. Slightly less than three-quarters of all emergency department visits (n = 424) were for nonneurologic complaints, while the remaining visits were for neurologic problems, including weakness, altered mental status, and sensory symptoms (see " Factors Affecting Frequent ER Use in MS Patients").
“Patients using the emergency department are more likely to be underinsured, have higher levels of disability, and are more likely to be undertreated with disease-modifying therapies [DMTs] than the general MS populations,” Dr. Oynhausen explained. “The acute care needs of patients change over the course of their disease, and as the disease progresses they are more likely to seek care for the comorbidities associated with MS than for relapses.”
Disability and DMTs
At each visit, a patient’s Expanded Disability Status Score (EDSS) was estimated to be either mild (less than 4), moderate (4 to 5.5), or severe (greater than 6) based on history, examination, and assistive device for ambulation. Although the majority of visits (63.8%) were made by patients with an EDSS in the severe range, the researchers noted that most emergency department visits “were attributable entirely to issues indirectly related to the MS diagnosis, such as urinary tract infections, falls, and indwelling hardware.” The majority of those with a mild or moderate EDSS also came to the emergency department for issues unrelated to MS, including abdominal pain, viral infections, respiratory problems, chest pain, or psychiatric issues.
“Our data show that the major proportion of MS patients seeking emergency department care suffer from nonneurologic, acute problems,” the investigators reported. “This validates the importance of interdisciplinary awareness of the medical needs within the MS population.”
Of the patients studied, 41.5% were taking DMTs, and slightly more than half of those with relapsing-remitting MS were taking DMTs. The majority of patients had either Medicaid or Medicare for insurance, 18.3% had private insurance, and 12.9% were uninsured. Half of all visits resulted in hospital admission, 54.7% of which were admissions to the medicine department and 25.6% were admissions to the neurology department.
Diagnostic Accuracy
A second part of the RESUMS study, also presented at the meeting, found that the accuracy of diagnoses made in the emergency department had room for improvement. In all, 42.1% of diagnoses were confirmed, 43.2% were modified, and 14.7% were altogether different.
“The emergency department is better at diagnosing nonneurologic problems than neurologic ones, even in a population of patients with a known diagnosis of relapsing neurologic illness,” Dr. Alcauskas and colleagues reported. “The emergency department was least accurate in diagnosing female patients presenting with neurologic complaints, a trend that has also been seen in the diagnosis of stroke patients.”
However, in men with neurologic complaints, the accuracy of diagnosis was similar to that of men presenting with nonneurologic complaints. The diagnostic accuracy was not significantly affected by patient age or EDSS scores.
As far as properly diagnosing an MS relapse, the emergency department diagnosed 55 relapses, 27 of which were false positives, and there were 10 false negatives, for a sensitivity of 76.7% and a specificity of 90.9%. The positive predictive value was 60%, and the negative predictive value was 95.6%.
Factors Affecting Frequent ER Use in MS Patients
SAN ANTONIO—One third of MS patient visits to the emergency department are by less than 10% of the patients, according to additional information from the RESUMS study presented at the 24th Annual Meeting of the Consortium for Multiple Sclerosis Centers. Using the same data set reported at AAN, Dr. Krieger and colleagues also reported that relapse accounted for only 13.2% of the visits and that one quarter of visits were for neurologic complaints.