Between 2014 and 2016, there were 278,699,057 total adult ED visits in the United States. Patients with ESRD made up approximately 2,168,075 (7.78% or 722,692 annually) of these visits. In addition, the proportion of ED visits by patients with ESRD increased between 2014 to 2016. Basic characteristics are described in Table 1. The proportion of ED visits by patients with ESRD varied by US census region: Northwest, 13.4%; Midwest, 19.8%; South, 45.6%; and West, 21.2% (p < 0.01). ESRD patients and non-ESRD patients differed significantly in age and race (p < 0.001).
Table 1. Baseline characteristics of patients presenting to the ED, stratified by ESRD, NHAMCS 2014–2016
|
Unweighted Sample
|
Weighted Sample
|
p value
|
|
All
|
No ESRD
|
ESRD
|
All
|
No ESRD
|
ESRD
|
|
42,832
|
42,465
|
367
|
278,699,057
|
276,530,981
|
2,168,075
|
|
Male
|
18,469(43.1)
|
18,283(43.1)
|
186(50.7)
|
119,751,766(43.0)
|
118,611,308(42.9)
|
1,140,459(52.6)
|
0.0033
|
Age
|
|
|
|
|
|
|
|
18–39
|
17,912(41.8)
|
17,862(42.1)
|
50(13.6)
|
118,068,691(42.4)
|
117,768,064(42.6)
|
300,627(13.9)
|
<0.001
|
40–49
|
6,662(15.6)
|
6,629(15.6)
|
33(9.0)
|
43,185,040(15.5)
|
43,021,286(15.6)
|
163,755(7.6)
|
50–59
|
6,707(15.7)
|
6,638(15.6)
|
69(18.8)
|
42,679,091(15.3)
|
42,215,775(15.3)
|
463,316(21.4)
|
60–74
|
6,678(15.6)
|
6,542(15.4)
|
136(37.1)
|
43,420,164(15.6)
|
42,634,581(15.4)
|
785,583(36.2)
|
>=75
|
4,873(11.4)
|
4,794(11.3)
|
79(21.5)
|
31,346,071(11.2)
|
30,891,277(11.2)
|
454,793(21.0)
|
Race/ethnicity
|
|
|
|
|
|
|
|
White
|
27,251(63.6)
|
27,079(63.8)
|
172(46.9)
|
175,775,546(63.1)
|
174,659,617(63.2)
|
1,115,929(51.5)
|
<0.001
|
Black
|
9,207(21.5)
|
9,092(21.4)
|
115(31.3)
|
62,663,628(22.5)
|
62,051,038(22.4)
|
612,590(28.3)
|
Hispanic
|
5,152(12.0)
|
5,094(12.0)
|
58(15.8)
|
33,391,671(12.0)
|
33,055,349(12.0)
|
336,322(15.5)
|
Asian
|
804(1.9)
|
793(1.9)
|
11(3.0)
|
4,392,213(1.6)
|
4,349,798(1.6)
|
42,415(2.0)
|
Other
|
418(1.0)
|
407(1.0)
|
11(3.0)
|
2,475,999(0.9)
|
2,415,180(0.9)
|
60,819(2.8)
|
Residence type
|
|
|
|
|
|
|
|
Private residence
|
39,819(95.1)
|
39,498(95.1)
|
321(89.7)
|
258,354,513(95.3)
|
256,528,244(95.3)
|
1,826,269(85.6)
|
<0.001
|
Nursing home
|
885(2.1)
|
856(2.1)
|
29(8.1)
|
5,875,161(2.2)
|
5,632,038(2.1)
|
243,123(11.4)
|
Homeless
|
534(1.3)
|
534(1.3)
|
0(0.0)
|
2,480,109(0.9)
|
2,480,109(0.9)
|
0(0.0)
|
Other
|
651(1.6)
|
643(1.5)
|
8(2.2)
|
4,501,686(1.7)
|
4,437,115(1.6)
|
64,571(3.0)
|
Insurance type
|
|
|
|
|
|
|
|
Private insurance
|
12,446(30.8)
|
12,411(31.0)
|
35(9.8)
|
79,443,111(30.5)
|
79,249,592(30.7)
|
193,519(9.1)
|
<0.001
|
Medicare
|
10,517(26.0)
|
10,278(25.7)
|
239(66.8)
|
66,956,323(25.7)
|
65,443,229(25.3)
|
1,513,093(71.2)
|
Medicaid or CHIP
|
11,148(27.6)
|
11,080(27.7)
|
68(19.0)
|
71,529,605(27.5)
|
71,197,275(27.6)
|
332,331(15.6)
|
Uninsured
|
4,886(12.1)
|
4,876(12.2)
|
10(2.8)
|
33,248,283(12.8)
|
33,203,302(12.8)
|
44,981(2.1)
|
Other
|
1,406(3.5)
|
1,400(3.5)
|
6(1.7)
|
9,371,908(3.6)
|
9,329,217(3.6)
|
42,691(2.0)
|
Arrive by ambulance
|
7,729(18.5)
|
7,600(18.4)
|
129(35.8)
|
49,769,047(18.3)
|
48,948,071(18.2)
|
820,977(38.3)
|
<0.001
|
Seen within last 72 hours
|
1,914(4.9)
|
1,898(4.9)
|
16(4.8)
|
11,953,039(4.8)
|
11,874,648(4.8)
|
78,391(4.1)
|
0.8948
|
Pain level
|
|
|
|
|
|
|
|
No pain
|
7,711(24.4)
|
7,610(24.2)
|
101(39.8)
|
46,478,004(23.1)
|
45,940,926(23.0)
|
537,078(37.6)
|
<0.001
|
Mild
|
2,916(9.2)
|
2,903(9.2)
|
13(5.1)
|
18,235,636(9.1)
|
18,178,674(9.1)
|
56,962(4.0)
|
Moderate
|
9,430(29.8)
|
9,363(29.8)
|
67(26.4)
|
60,509,861(30.1)
|
60,090,165(30.1)
|
419,696(29.4)
|
Severe
|
11,602(36.6)
|
11,529(36.7)
|
73(28.7)
|
75,762,102(37.7)
|
75,347,113(37.8)
|
414,989(29.0)
|
Temperature
|
|
|
|
|
|
|
|
36 °C–38 °C
|
38,083(94.6)
|
37,784(94.7)
|
299(90.6)
|
249,171,894(95.1)
|
247,406,971(95.1)
|
1,764,922(92.5)
|
<0.001
|
<=36 °C
|
1,522(3.8)
|
1,504(3.8)
|
18(5.5)
|
9,089,224(3.5)
|
9,001,036(3.5)
|
88,187(4.6)
|
>38 °C
|
635(1.6)
|
622(1.6)
|
13(3.9)
|
3,863,922(1.5)
|
3,808,689(1.5)
|
55,233(2.9)
|
Heart Rate
|
|
|
|
|
|
|
|
<=90
|
28,489(66.5)
|
28,242(66.5)
|
247(67.3)
|
184,822,552(66.3)
|
183,317,566(66.3)
|
1,504,986(69.4)
|
0.5082
|
90–100
|
7,169(16.7)
|
7,109(16.7)
|
60(16.3)
|
46,314,663(16.6)
|
45,999,951(16.6)
|
314,712(14.5)
|
100–110
|
3,906(9.1)
|
3,876(9.1)
|
30(8.2)
|
25,427,295(9.1)
|
25,268,229(9.1)
|
159,066(7.3)
|
110–120
|
1,988(4.6)
|
1,974(4.6)
|
14(3.8)
|
13,118,183(4.7)
|
13,062,583(4.7)
|
55,600(2.6)
|
>120
|
1,280(3.0)
|
1,264(3.0)
|
16(4.4)
|
9,016,363(3.2)
|
8,882,652(3.2)
|
133,711(6.2)
|
DBP
|
|
|
|
|
|
|
|
60–80
|
19,358(45.2)
|
19,213(45.2)
|
145(39.5)
|
125,677,278(45.1)
|
124,830,342(45.1)
|
846,937(39.1)
|
<0.001
|
<60
|
4,312(10.1)
|
4,233(10.0)
|
79(21.5)
|
26,198,088(9.4)
|
25,714,760(9.3)
|
483,328(22.3)
|
>80
|
19,162(44.7)
|
19,019(44.8)
|
143(39.0)
|
126,823,690(45.5)
|
125,985,881(45.6)
|
837,810(38.6)
|
SBP
|
|
|
|
|
|
|
|
80–120
|
9,773(22.8)
|
9,687(22.8)
|
86(23.4)
|
61,351,488(22.0)
|
60,857,637(22.0)
|
493,851(22.8)
|
0.4365
|
<80
|
1,588(3.7)
|
1,570(3.7)
|
18(4.9)
|
9,419,022(3.4)
|
9,310,953(3.4)
|
108,068(5.0)
|
>120
|
31,471(73.5)
|
31,208(73.5)
|
263(71.7)
|
207,928,547(74.6)
|
206,362,392(74.6)
|
1,566,155(72.2)
|
Census Region
|
|
|
|
|
|
|
|
Northeast
|
7,176(16.8)
|
7,140(16.8)
|
36(9.8)
|
43,967,048(15.8)
|
43,675,459(15.8)
|
291,588(13.4)
|
0.0004
|
Midwest
|
10,893(25.4)
|
10,807(25.4)
|
86(23.4)
|
74,304,118(26.7)
|
73,875,207(26.7)
|
428,911(19.8)
|
South
|
15,430(36.0)
|
15,268(36.0)
|
162(44.1)
|
105,760,507(37.9)
|
104,771,742(37.9)
|
988,765(45.6)
|
West
|
9,333(21.8)
|
9,250(21.8)
|
83(22.6)
|
54,667,385(19.6)
|
54,208,574(19.6)
|
458,811(21.2)
|
This visit is related to
|
|
|
|
|
|
|
|
Injury/trauma
|
12,286(30.1)
|
12,248(30.3)
|
38(11.0)
|
78,178,483(29.5)
|
77,992,283(29.6)
|
186,200(9.1)
|
<0.001
|
Overdose/poisoning
|
499(1.2)
|
498(1.2)
|
1(0.3)
|
3,358,380(1.3)
|
3,349,593(1.3)
|
8,787(0.4)
|
Adverse effect of medical/surgical treatment
|
1,099(2.7)
|
1,063(2.6)
|
36(10.4)
|
7,170,683(2.7)
|
6,961,906(2.6)
|
208,777(10.2)
|
Visit not related to any above
|
26,692(65.4)
|
26,424(65.3)
|
268(77.7)
|
174,903,611(66.0)
|
173,277,339(65.9)
|
1,626,272(79.4)
|
Questionable injury status
|
214(0.5)
|
212(0.5)
|
2(0.6)
|
1,546,669(0.6)
|
1,528,096(0.6)
|
18,573(0.9)
|
Table 2, Table 3, and Table 4 describe the proportions and associations of ESI, hospital admission, ICU admission, and medical resource utilization for ESRD and non-ESRD patients. The hospital admission rate among ED patients was 2.70 times higher for patients with ESRD (95% CI: 2.13–3.41); ESRD patients were also 4.72 times more likely to receive immediate or emergent vs. semi- or non-urgent ESI scores compared to patients without ESRD (95% CI: 3.00–7.41). The ICU admission rate was 2.21 times higher for patients with ESRD (95% CI: 1.45–3.38). ED patients with ESRD were 2.54 times more likely to receive blood tests (95% CI: 1.89–3.40) as well as more likely to utilize X-rays (95% CI: 1.43-2.24).
Table 2 Selected Reason for Visit and Emergency Department Diagnosis among ED Patients with ESRD, NHAMCS 2014–2016
|
Unweighted Sample
|
Weighted Sample
|
|
All
|
No ESRD
|
ESRD
|
All
|
No ESRD
|
ESRD
|
Reason for visit
|
|
|
|
|
|
|
General Symptoms
|
8,187(19.1)
|
8,069(19.0)
|
118(32.2)
|
53,664,580(19.3)
|
52,934,900(19.2)
|
729,680(33.7)
|
Symptoms Referable to Psychological and Mental Disorders
|
1,700(4.0)
|
1,687(4.0)
|
13(3.5)
|
9,426,523(3.4)
|
9,331,220(3.4)
|
95,303(4.4)
|
Symptoms Referable to the Nervous System
|
3,304(7.7)
|
3,279(7.7)
|
25(6.8)
|
20,833,741(7.5)
|
20,708,936(7.5)
|
124,805(5.8)
|
Symptoms Referable to the Cardiovascular and Lymphatic Systems
|
889(2.1)
|
877(2.1)
|
12(3.3)
|
5,993,917(2.2)
|
5,914,527(2.1)
|
79,390(3.7)
|
Symptoms Referable to the Eyes and Ears
|
848(2.0)
|
847(2.0)
|
1(0.3)
|
5,778,778(2.1)
|
5,772,695(2.1)
|
6,083(0.3)
|
Symptoms Referable to the Respiratory System
|
4,198(9.8)
|
4,135(9.8)
|
63(17.2)
|
27,856,021(10.0)
|
27,508,840(10.0)
|
347,181(16.0)
|
Symptoms Referable to the Digestive System
|
6,807(15.9)
|
6,758(15.9)
|
49(13.4)
|
46,038,272(16.5)
|
45,725,454(16.6)
|
312,819(14.4)
|
Symptoms Referable to the Genitourinary System
|
2,477(5.8)
|
2,462(5.8)
|
15(4.1)
|
14,984,361(5.4)
|
14,913,890(5.4)
|
70,470(3.3)
|
Symptoms Referable to the Skin, Nails, and Hair
|
1,333(3.1)
|
1,328(3.1)
|
5(1.4)
|
8,716,118(3.1)
|
8,690,203(3.1)
|
25,915(1.2)
|
Symptoms Referable to the Musculoskeletal System
|
6,519(15.2)
|
6,493(15.3)
|
26(7.1)
|
42,820,579(15.4)
|
42,682,302(15.5)
|
138,277(6.4)
|
Other
|
6,501(15.2)
|
6,461(15.2)
|
40(10.9)
|
42,147,135(15.1)
|
41,908,983(15.2)
|
238,152(11.0)
|
Table 3. Proportion of Emergency Severity Index, Hospital admission, ICU admission, Medical resources utilization, stratified by ESRD, NHAMCS 2014–2016
|
Unweighted Sample
|
Weighted Sample
|
|
|
All
|
No ESRD
|
ESRD
|
All
|
No ESRD
|
ESRD
|
p value
|
ESI score
|
|
|
|
|
|
|
|
Immediate
|
239(0.8)
|
235(0.8)
|
4(1.5)
|
1,496,327(0.8)
|
1,471,879(0.7)
|
24,448(1.7)
|
<0.001
|
Emergent
|
3,615(11.6)
|
3,529(11.5)
|
86(32.8)
|
23,433,327(11.8)
|
22,976,847(11.7)
|
456,480(31.6)
|
Urgent
|
15,392(49.5)
|
15,248(49.5)
|
144(55.0)
|
97,000,149(49.0)
|
96,286,096(49.0)
|
714,053(49.4)
|
Semi-urgent
|
10,051(32.3)
|
10,034(32.6)
|
17(6.5)
|
65,085,335(32.9)
|
64,950,854(33.0)
|
134,480(9.3)
|
Non-urgent
|
1,784(5.7)
|
1,773(5.8)
|
11(4.2)
|
11,046,598(5.6)
|
10,931,909(5.6)
|
114,689(7.9)
|
Hospital Admission
|
5,852(13.7)
|
5,695(13.4)
|
157(42.8)
|
36,388,538(13.1)
|
35,517,254(12.8)
|
871,284(40.2)
|
<0.001
|
ICU
|
698(1.6)
|
669(1.6)
|
29(7.9)
|
4,647,353(1.7)
|
4,506,861(1.6)
|
140,492(6.5)
|
<0.001
|
In hospital death
|
201(0.5)
|
192(0.5)
|
9(2.5)
|
1,342,510(0.5)
|
1,298,220(0.5)
|
44,290(2.0)
|
<0.001
|
Left before/after triage
|
1,085(2.5)
|
1,076(2.5)
|
9(2.5)
|
6,792,175(2.4)
|
6,722,799(2.4)
|
69,376(3.2)
|
0.9212
|
Blood test
|
21,958(51.3)
|
21,654(51.0)
|
304(82.8)
|
142,656,097(51.2)
|
140,833,111(50.9)
|
1,822,986(84.1)
|
<0.001
|
Any image
|
21,950(51.2)
|
21,709(51.1)
|
241(65.7)
|
144,824,612(52.0)
|
143,375,099(51.8)
|
1,449,513(66.9)
|
<0.001
|
X-ray
|
15,099(35.3)
|
14,894(35.1)
|
205(55.9)
|
99,429,274(35.7)
|
98,179,495(35.5)
|
1,249,778(57.6)
|
<0.001
|
CT
|
8,414(19.6)
|
8,338(19.6)
|
76(20.7)
|
54,986,804(19.7)
|
54,559,942(19.7)
|
426,863(19.7)
|
0.6063
|
Ultrasound
|
2,218(5.2)
|
2,205(5.2)
|
13(3.5)
|
14,936,538(5.4)
|
14,833,060(5.4)
|
103,478(4.8)
|
0.1554
|
MRI
|
446(1.0)
|
438(1.0)
|
8(2.2)
|
2,831,626(1.0)
|
2,791,440(1.0)
|
40,186(1.9)
|
0.0309
|
Other Imaging
|
604(1.4)
|
595(1.4)
|
9(2.5)
|
4,297,097(1.5)
|
4,239,282(1.5)
|
57,815(2.7)
|
0.0890
|
Procedure
|
21,021(49.1)
|
20,807(49.0)
|
214(58.3)
|
133,801,012(48.0)
|
132,620,938(48.0)
|
1,180,074(54.4)
|
0.0011
|
Waiting time (minutes, MEANS (95% CI))
|
41.1(40.3-41.8)
|
41.0(40.3-41.8)
|
45.2(37.7-52.7)
|
39.9(39.2-40.6)
|
39.9(39.1-40.6)
|
46.5(38.8-54.1)
|
0.7500
|
Length of visit (minutes, MEANS (95% CI))
|
245.6(241.6-249.6)
|
244.1(240.1-248.1)
|
422.7(339.2-506.3)
|
230.2(226.7-233.8)
|
228.7(225.2-232.2)
|
450.3(358.0-542.5)
|
<.0001
|
Notes: Waiting time: time from arrival to seeing the physician. Length of visit: time from arrival to discharge.
Table 4. Odds Ratio of Emergency Severity Index, Hospital admission, ICU admission, Medical Resources Utilization for ESRD vs. Non-ESRD Patients, NHAMCS 2014–2016
|
Crude Odds Ratio
|
Adjusted for
|
|
Demographics
|
+ Social economic
|
+ Visiting & Clinical
|
ESI Score: Immediate or Emergent vs. Semi- or Non-Urgent
|
10.07(6.58-15.41)
|
6.98(4.53-10.74)
|
6.74(4.37-10.38)
|
4.72(3.00-7.41)
|
ESI Score: Urgent vs. Semi- or Non-Urgent
|
3.98(2.65-5.96)
|
3.33(2.22-5.01)
|
3.24(2.15-4.87)
|
2.46(1.62-3.74)
|
Hospital Admission
|
4.83(3.92-5.95)
|
3.32(2.67-4.13)
|
3.30(2.65-4.11)
|
2.70(2.13-3.41)
|
ICU
|
5.36(3.64-7.90)
|
3.25(2.20-4.82)
|
3.07(2.06-4.58)
|
2.21(1.45-3.38)
|
Death
|
5.54(2.81-10.89)
|
3.03(1.53-6.01)
|
2.65(1.33-5.30)
|
1.64(0.76-3.55)
|
Left
|
0.97(0.50-1.88)
|
1.23(0.63-2.40)
|
1.08(0.55-2.11)
|
0.93(0.47-1.82)
|
Blood test
|
4.64(3.53-6.09)
|
3.60(2.73-4.74)
|
3.41(2.59-4.49)
|
2.54(1.89-3.40)
|
Any imaging
|
1.83(1.47-2.27)
|
1.36(1.09-1.70)
|
1.36(1.09-1.70)
|
1.37(1.09-1.72)
|
X-ray
|
2.34(1.90-2.88)
|
1.73(1.40-2.14)
|
1.69(1.36-2.09)
|
1.79(1.43-2.24)
|
CT
|
1.07(0.83-1.38)
|
0.80(0.62-1.03)
|
0.81(0.63-1.05)
|
0.80(0.61-1.05)
|
Ultrasound
|
0.67(0.39-1.17)
|
0.86(0.49-1.51)
|
0.88(0.50-1.55)
|
0.84(0.47-1.48)
|
MRI
|
2.14(1.06-4.34)
|
1.58(0.78-3.22)
|
1.66(0.81-3.39)
|
1.92(0.93-4.00)
|
Procedure
|
1.33(1.08-1.63)
|
1.24(1.01-1.52)
|
1.24(1.01-1.52)
|
1.20(0.97-1.47)
|
Note: *+ Demographics include: gender, age group, race/ethnicity; +Social economic: residence type, insurance type, census region; + Visiting & Clinical: year, week of day, arrive by ambulance, seen within last 72 hours, pain level, temperature, heart rate, dialytic blood pressure, injury status, reason for visit.
The associations between ED patients’ demographic, socioeconomic, and clinical characteristics and their ESRD status are outlined in Supplement Table 1. Male ED patients were 34% more likely to have ESRD than were female patients (aOR: 1.34; 95% CI: 1.09 –1.66). Among ED patients, non-Hispanic Blacks were 2.55 times more likely than whites to have ESRD (aOR: 2.55; 95% CI: 1.97 – 3.30); Hispanics were 2.68 times more likely than whites to have ESRD (95% CI: 1.95–3.69); and Asians were 2.90 times more likely than whites to have ESRD (95% CI: 1.53–5.50).
Compared to ED patients inhabiting a private residence, those who were living in nursing homes were 1.53 times more likely to be ESRD patients (95% CI: 1.00–2.34). Compared to ED patients with private insurance, those with Medicare and Medicaid or CHIP were 4.23 and 2.05 times more likely to have ESRD (95% CI: 2.89-6.19, CI: 1.35-3.12, respectively).
Regarding vital signs, compared to patients with a DBP of 60-80, ED patients with DBP lower than 60 were 1.92 times to be ESRD patients (95% CI: 1.44–2.56). Compared to patients who arrived at the ED by other means, patients who arrived by ambulance were 1.58 times more likely to have ESRD (95% CI: 1.24–2.01). Meanwhile, ED patients who presented with an adverse effect of medical/surgical treatment were 6.58 times more likely to have ESRD than those presenting with injury or trauma (95% CI: 4.07–10.64).