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Epidemiology of epistaxis in the emergency department of a southern European tertiary care hospital
Acta Otorrinolaringol Esp. 2018;69(6):331---338
www.elsevier.es/otorrino
ORIGINAL ARTICLE
Epidemiology of epistaxis in the emergency department of a southern European tertiary care hospital夽 Luis Roque Reis ∗ , Filipe Correia, Luis Castelhano, Pedro Escada Department of Otolaryngology of Egas Moniz Hospital, Centro Hospitalar de Lisboa Ocidental (CHLO), NOVA Medical School Faculdade de Ciências Médicas, Lisbon, Portugal Received 28 May 2017; accepted 7 November 2017 Available online 5 May 2018
KEYWORDS Epistaxis; Epidemiology; Emergency
Abstract Objective: Epistaxis is the most common rhinological emergency seen in the emergency department. The purpose of this study was to evaluate epidemiological data of epistaxis in a southern European tertiary care hospital. Methods: A retrospective study was conducted during the period between January 2009 and December 2015. We analyzed the distribution by cross-referencing the demographic variables, destination after medical discharge, inpatient characteristics (major comorbid diseases, medication, bleeding localization and treatment) and health-care costs with the disease. Results: Epistaxis accounted for approximately 1 in 30 visits to the ED and 77 out of a population of 100,000 was served by that ED. Overall, 71,624 patients were treated and 2371 patients presented with epistaxis (3.31%). One-thousand three-hundred and twenty-seven cases were male and 1044 female (p <.001). The mean age was 56 years (±26). Age distribution was bimodal, with peaks among those <10 years and >70 (p <.001). Epistaxis was more common in the winter months (p < 0.001). The main referral destinations (6.8%) included outpatient (2.9%) and inpatient (1.9%) services. Hospitalization was more frequent between the ages of 60 and 80 years (p =.029), and the major comorbidity was hypertension (47.8%). Medication interfering with haemostasis was documented in 30.4%. Most inpatient epistaxis was managed in a noninterventional manner and only. 5% of patients needed surgery. The mean total health-care cost was 69.8 D per episode.
Abbreviations: ED, emergency department; ICD-9-CM, International Classification of Diseases, 9th revision, Clinical Modification. Egas Moniz Hospital, Centro Hospitalar de Lisboa Ocidental (CHLO), NOVA Medical School - Faculdade de Ciências Médicas. ∗ Corresponding author. Department of Otolaryngology of Egas Moniz Hospital, Centro Hospitalar de Lisboa Ocidental (CHLO), NOVA Medical School, Junqueira Street 126, 1340-019 Lisbon, Portugal. TEL.: +351 91886251. E-mail address: [email protected] (L.R. Reis). 夽
https://doi.org/10.1016/j.otorri.2017.11.002 0001-6519/© 2018 Sociedad Espa˜ nola de Otorrinolaringolog´ıa y Cirug´ıa de Cabeza y Cuello. Published by Elsevier Espa˜ na, S.L.U. All rights 2173-5735 reserved.
332
L.R. Reis et al. Conclusion: Emergency epistaxis was more frequent in men, the elderly, patients with underlying comorbidities, during the winter months, and showed a higher risk of referral and hospitalization with increasing age (as a result of an aging population in western countries). The main hospital expenses for epistaxis are related to hospitalization and health care costs. © 2018 Sociedad Espa˜ nola de Otorrinolaringolog´ıa y Cirug´ıa de Cabeza y Cuello. Published by Elsevier Espa˜ na, S.L.U. All rights reserved.
PALABRAS CLAVE Epistaxis; Epidemiología; Urgencia
Epidemiología de la epistaxis en el servicio de urgencias de un hospital de atención terciaria del sur de Europa Resumen Objetivo: La epistaxis es la urgencia rinológica más comúnmente observada en el servicio de urgencias (SU). El objetivo de este estudio es evaluar los datos epidemiológicos de la epistaxis en un hospital de atención terciaria del sur de Europa. Métodos: Se realizó un estudio retrospectivo durante el periodo comprendido entre enero de 2009 y diciembre de 2015. Analizamos la distribución entrecruzando las variables demográficas, el destino tras el alta médica, las características hospitalarias (enfermedades comórbidas mayores, medicación, localización del sangrado y tratamiento) y los costes sanitarios con la enfermedad. Resultados: La presentación con epistaxis supuso aproximadamente una de 30 visitas al SU, donde se atendió a una población de 77 de cada 100.000 habitantes. En general se trataron 71.624 pacientes, de los cuales 2.371 se presentaron con epistaxis (3,31%). Mil trescientos veintisiete casos eran varones y 1.044 mujeres (p < 0,001). La edad media fue de 56 a˜ nos (± 26). La distribución de la edad fue bimodal, con valores máximos entre ellos < 10 a˜ nos y > 70 (p < 0,001). La epistaxis fue más común durante los meses invernales (p < 0,001). Los principales destinos de derivación (6,8%) incluyeron los servicios ambulatorios (2,9%) y hospitalarios (1,9%). Las hospitalizaciones fueron más frecuentes entre los 60 y 80 a˜ nos (p = 0,029), siendo la hipertensión la mayor comorbilidad (47,8%). La medicación que interfirió con la hemostasia se documentó en el 30,4%. A la mayoría de pacientes hospitalarios con epistaxis se les trató de manera no intervencionista, y únicamente el 0,5% de los casos precisó cirugía. Los costes sanitarios totales medios fueron del 69,8 D por episodio. Conclusión: La epistaxis de urgencia fue más frecuente en varones, personas mayores, pacientes con comorbilidades subyacentes, durante los meses invernales, y reflejó un mayor riesgo de derivación y hospitalización con el incremento de la edad (como resultado del envejecimiento de la población en los países occidentales). Los principales gastos hospitalarios en los casos de epistaxis guardan relación con la hospitalización y los costes de la atención sanitaria. © 2018 Sociedad Espa˜ nola de Otorrinolaringolog´ıa y Cirug´ıa de Cabeza y Cuello. Publicado por Elsevier Espa˜ na, S.L.U. Todos los derechos reservados.
Introduction Epistaxis is a common clinical problem that is estimated to occur in 60% of people worldwide during their lifetime.1 It is difficult to precisely determine their frequency because most episodes resolve spontaneously or with self-treatment. However, data suggest that epistaxis presentation accounts for approximately 1 in 200 visits to the emergency department (ED) and 100 visits per 100,000 population served by the ED.2,3 The increasing demand for emergency services in hospitals must be meticulously analyzed, taking epidemiological trends into account. Understanding epistaxis epidemiological data during emergency services will allow better clinical decisions to be made and improve patients’ medical treatment. In Southern Europe and particularly in Portugal, the epistaxis epidemiology for ED visits is unknown. The purpose of
this study is to evaluate seven years of epistaxis epidemiological data in the ED of a tertiary care hospital. We analyzed the distribution by age, gender, season, year, cross-over of demographic variables (age and gender, year and gender, and year, season and gender), destination after medical discharge, inpatient characteristics (major comorbid diseases, medication, bleeding location, treatment), cost estimate and expenses with the disease in the hospital.
Methods Procedures The SSTI-Servic ¸o de Sistemas e Tecnologias de Informac ¸ão (Information Systems and Technologies Service) of the West Lisbon Central Hospital (CHLO), EPE (a public corporation) was used to search the otolaryngology emergency database.
Epidemiology of epistaxis All code numbers associated with the diagnosis of epistaxis (484.7) of the ICD-9-CM (International Classification of Diseases, 9th revision, Clinical Modification) were selected for this study. This classification does not have isolated codes for anterior and posterior epistaxis. The criteria for hospitalization were judged by clinical evaluation and included severe bleeding unresponsive to pressure, vasoconstrictor appliance, cauterization or nasal packing. All patients who attended the otolaryngology ED between 1 January 2009 and 31 December 2015 (a seven-year period) were considered in the study. This department operates as an open service (without triage) and serves five parishes of the Lisbon Municipality (São Francisco Xavier, Santa Maria de Belém, Alcântara, Santo Condestável e Ajuda) in addition to the Municipalities of Oeiras and Cascais, providing medical care to a population of 439,944 (2011 census). The area of coverage is on the west coast of Portugal, and the population is mainly Caucasian (96,7%). Access to health care is universal, but patients are subject to payment of a small flat-rate user fee. The total period selected for the study was lengthened to seven years to enable better statistical accuracy and epidemiological analysis over this period. Distribution was studied for epistaxis cases and for the total number of cases presenting to the ED. Data was collected from the SSTI: 1) age; 2) gender; 3) date of attendance at ED (taken as the date of the epistaxis); 4) destination after medical discharge; 5) inpatient characteristics; and 6) patients referred for surgery. The data was organized and stratified by age (in ten year groups), gender, year, and season. The protocol for this study was evaluated and approved by the Health Ethics Committee (CES) of the West Lisbon Hospital Centre (CHLO), Lisbon, on 15/05/2017.
Statistical analysis The data were entered on a database, and a statistical study was performed using the Statistical Package for The Social Sciences (SPSS), 21.0 version for Windows. To evaluate sample distribution, the chi-squared test was used. We applied a significance level of 0.05 (5%) with a 95% confidence interval. We tested for statistically significant differences between year, distribution, gender, age, season, destination after medical discharge, and a cross-over evaluation of the several variables.
Results Presentation with epistaxis accounted for approximately 1 in 30 visits to the ED and 77 per 100,000 population served by that ED. Overall, 71,624 patients presented to the ED from 2009 to 2015. In 2371 patients, the cause was epistaxis (3.31%) (Table 1). Annual distribution of epistaxis varied from 427 cases (2009) to 258 cases (2015). In the same period, there was also a reduction in total annual number of emergencies (from 11,602 to 9507 cases). We used the adjusted chi-square test to verify the distribution of epistaxis numbers per year. The statistical analysis demonstrated significant differences between the years [2 (6) = 68.806; p <0.001].
333 One thousand three-hundred and twenty-seven epistaxis cases included in this study were male (56%), and 1044 were female (44%). We used the adjusted chi-square test to verify epistaxis distribution by gender (Table 1). There was a statistical significant difference between gender [2 (1) = 33.779; p <0.001]. The individuals included in this study had a mean age of 56 years (±26). Epistaxis was very frequent in patients <10 years (9.7% of admitted patients with epistaxis) (Figure 1). The number of cases decreased to a minimum in the fourth decade (3.8%) and then increased to reach a maximum in the seventh decade (22.7%). Nine-hundred and sixty-four (36.3%) of the total number of epistaxis cases occurred between 60 and 80 years, and more than half of the total number of epistaxis cases occurred between 60 and 90 years (1316 cases, 53.6%); the number of patients, however, who were between 80 and 90 years was lower. The statistical analysis by the adjusted chi-square test demonstrated significant differences between age groups [2 (10) = 1215.636; p <0.001]. Epistaxis was more frequent in females only for age groups 40---50 and 90---100 years. We used the chi-square test to verify the association between gender and age group (Table 2). It was found that in epistaxis there was a statistically significant relationship between gender and age group [2 (10) = 46.029; p < 0.001]. We used the adjusted chi-square test to verify gender differences for each age group. There were no statistically significant differences for the age groups 30---40, 70---80, 90---100, and 100---110 years (p >0.05). Epistaxis was more common in the winter months (754 cases, 31.8%). Epistaxis rates in the summer (453 cases, 19.1%) were the smallest during all the seasons (Table 3). We used the adjusted chi-square test to verify the epistaxis distribution per season. Statistical analysis demonstrated significant differences between the seasons [2 (3) = 82.336; p <0.001]. Statistical analysis by the chi-square test did not demonstrate any significant association between gender and season (p >0.056). Destination of patients after medical discharge was mainly for non-hospitalized, non-referral (2209 cases). Referral destinations included outpatient consultations (68 cases), hospitalizations (46 cases), and health centers (30 cases). The remaining destinations (17 cases) were rare and included another hospital (14 cases), day hospital (two cases), and discharge. The largest number of cases admitted to the hospital or referred for outpatient consultation services consisted of patients between 60 and 80 years (Table 4). We used the chi-square test to verify the association between outpatient consultation/hospitalization and age group. There was a statistically significant relationship between consultation/hospitalization and age group [2 (4) = 10.803; p = 0.029]. The patients admitted to the hospital had a mean age of 61 years (±17). A greater number of inpatient cases occurred in the group 70---80 years (26.1%), and patients between 60 and 80 years constituted 50% of the cases (Table 5). There were no cases of hospitalization in patients <20 years. Men outnumbered women in a ratio of 2:1. The chi-square test for association did not demonstrate any significant differences between age and gender (p >0.05). We used the adjusted chi-square test to verify the distribution of epistaxis number
334 Table 1 Year
2009 2010 2011 2012 2013 2014 2015 total
L.R. Reis et al. Annual distribution of epistaxis by year and gender. n total
Epistaxis
11602 11571 11625 9438 8827 9054 9507 71624
Male
Female
n
%
2
p
223 200 211 176 176 172 169 1327
204 181 174 162 131 103 89 1044
427 381 385 338 307 275 258 2371
3,68 3,29 3,31 3,58 3,48 3,04 2,71 3.31
.845 .948 3.556 .580 6.596 17.313 24.806
.358 .330 .059 .446 .010 <.001 <.001
300 266
250
273
229 191
188
200
164 149
139
150
108
100
64
57 43
50
99
98
91
Male Female
65 42 48 27 25 1 4
0 0-10
10-20
20-30
30-40
40-50
50-60
60-70
70-80
80-90
90-100 100-110
Age (years)
Figure 1
Epistaxis cases by age group. The average number of epistaxis cases between 2009 and 2015 by 10-year age groups.
Table 2 Distribution of epistaxis by age and gender. The number of epistaxis cases between 2009 and 2015 by 10-year age groups and gender. Age
Male
Female
Total
%
2
p
[0-10] [10-20] [20-30] [30-40] [40-50] [50-60] [60-70] [70-80] [80-90] [90-100] [100-110] Total
139 108 57 48 65 188 229 273 191 25 4 1327
92 64 42 42 98 99 164 266 149 27 1 1044
231 172 99 90 163 287 393 539 340 52 5 2371
9.7 7.3 4.2 3.8 6.9 12.1 16.6 22.7 14.3 2.2 0.2
9.563 11.256 2.273 .400 6.688 27.599 10.751 .091 5.188 .077 1.800
.002 .001 .132 .527 .010 <.001 <.001 .763 .023 .782 .180
per season in cases of hospitalization (Figure 2). Statistical analysis demonstrated no significant differences between the seasons [2 (3) = 5.130; p = 0.162]. Also, there were no statistically significant differences between the seasons for patients referred to outpatient consultation services [2 (3) = 6.471; p = 0.091]. In 69.6% (n = 32) of hospitalized patients, the epistaxis was posterior (19.6% was anterior and in the remaining cases was anterior and posterior). Most inpatient epistaxis cases were managed in a noninterventional manner (nasal packing
and local electrocauterization). Thirteen cases (0.55% of the total cases) out of the 46 inpatient cases (1.9% of the total cases) had to go to the operating room (five required endoscopic surgical ligature). In our study, we did not observe any cases of mortality. The mean length for hospital stays was 7.2 days. Hypertension, diabetes, and ischemic heart disease were the major comorbid diseases in these patients. Medication interfering with hemostasis was documented in 30.4% of patients and hypertension in 47.8% of patients (Table 6).
Epidemiology of epistaxis Table 3
335
Distribution of epistaxis by year, season and gender.
Year
Winter
Spring
Summer
Autumn
Total
2009 2010 2011 2012 2013 2014 2015 Total
133 122 130 120 82 87 80 754 31.8 438 33.0 316 30.3
102 104 97 94 81 71 72 621 26.2 328 24.7 293 28.1
75 72 70 71 70 48 47 453 19.1 270 20.3 183 17.5
117 83 88 53 74 69 59 543 22.9 291 21.9 252 24.1
427 381 385 338 307 275 258 2371
Male Female 2 p
Table 4
n % n % n % 7.551 .056
Distribution of epistaxis by age of the patients referred for outpatient or inpatient services.
Age
Outpatient consult.
[0-20] [20-40] [40-60] [60-80] [80-100]
Table 5
N
%
12 11 14 21 10
17.6 16.2 20.6 30.9 14.7
Hospitalization N
2
p
10.803
.029
%
7 10 23 6
15.2 21.7 50.0 13.0
Characteristics of patients admitted in hospitalization, by age and gender.
Age
[20-30] [30-40] [40-50] [50-60] [60-70] [70-80] [80-90] Total
1327 56 1044 44
Male
Female
Total
n
%
n
%
n
%
1 3 3 3 8 10 4 32
3.1 9.4 9.4 9.4 25.0 31.3 12.5
1 2 2 2 3 2 2 14
7.1 14.3 14.3 14.3 21.4 14.3 14.3
2 5 5 5 11 12 6 46
4.7 10.9 10.9 10.9 23.9 26.1 13
The mean total health-care costs with epistaxis was 69.8 D per episode. Total hospital charges related to epistaxis may represent 21.500 D to 28.500 D per year, and this represents an estimated total cost of 150.000 to 200.000 D (Table 7). The main hospital expenses are related to hospitalization and health care costs (the amount spent on the resources needed to care for patients).
2
p
2.16
.904
Discussion Over a seven-year period, a total of 71,624 patients presented to the ED, and in 2371 (3.71%) the cause was epistaxis. Presentation with epistaxis accounted for approximately 1 in 30 visits to the ED and 77 per 100,000 population served by that ED. Men (56%) and older people between 60 and 80 years (39.3%) were most often affected. Epistaxis was
336
L.R. Reis et al.
Total inpatient cases
16 14 12
8 Men
10
8
Women
8
13
6 4
7
3
5
2
2 0
Winter
Spring
Summer
Autumn
Season Figure 2
Table 6
Inpatient admission by season.
Associated comorbidities and medications of the hospitalized patients.
Comorbidities
n
%
Anticoagulants/Antiaggregants
n
%
Arterial Hypertension Diabetes mellitus CVD Heart failure COPD Rendu-Osler-Weber IHD Total
22 6 3 3 3 2 2 41
47.8 13 6.5 6.5 6.5 4.4 4.4 89.1
ASA ASA + Clopidogrel Warfarine No medication
8 2 4 32
17.4 4.3 8.7 69.6
14
30.4
CVD: cerebral vascular disease, COPD: chronic obstructive pulmonary disease, IHD: ischemic heart disease, ASA: acetylsalicylic acid.
Table 7
Estimated cost (D ), per episode and per year, of epistaxis episodes in the ER.
Disposable material (n=2371) Healthcare costs (n=2371) Hospitalization (n=46) Operating room (n=13) Embolization (n=7) Average costs (n=2371)
per episode
per year
Total
2.41 34.3 1614.1 249 124.5 69.8
816.3 11617.9 10606.9 462.4 124.5 23628.1
5714.1 81325.3 74248.6 3237 871.5 165396.5
more common in the winter months (31.8%). The number of hospitalizations was stable in different seasons, but they were also more frequent in males between 60 and 80 years (50%). The main referral destinations (6.8%) included outpatient (2.9%) and inpatient services (1.9%). A larger number of hospitalizations occurred between 60 and 80 years and in 0.5% of the cases, patients required surgery to control the bleeding. An association with medication interfering with hemostasis (30.4%) and hypertension (47.8%) was found. We found a mean total health-care costs with epistaxis of 69.8 D per episode. Our ED operates as an open service only for otolaryngology patients, so we had high numbers of patients presenting with epistaxis (1 in 30 visits and 77 per 100,000 population served by the ED) that should document a higher incidence of epistaxis in the general population.2,3 Previous studies suggested a lifetime prevalence of nasal hemorrhage of 60%,
with 10% of those seeking medical care and 10% of those requiring an otolaryngology referral.4---7 Age distribution of epistaxis was bimodal with peaks among those <10 years (3.2 per 1000 visits) and those older than 70 years (13.1 per 1000 visits). We found a greater occurrence in the elderly, an aspect that could be more prevalent in the future with the aging of the population in western countries. Similar results were found with the same peaks among patients younger than 10 years (4 per 1000 visits) and older than 70 years (12 per 1000 visits).8,9 Despite this early age peak, most cases of epistaxis occur in the elderly adult population.10---13 We found a gender predilection with approximately 60% of patients being male and 40% female, which has been reported with some variations.4,10,13,14 There is a theory that gender predilection may be partially due to estrogen’s protective effects, which locally fosters a healthy nasal
Epidemiology of epistaxis mucosa and systemically reduces the risk of cardiovascular disease.9,15 This theory is supported by the observation that gender differences associated with nasal hemorrhage incidences equalizes after menopause. Epistaxis was more common in the winter months (32 per 100 cases of epistaxis). Although a small set of studies have shown no significant differences, these results are in line with those that refer to seasonal variation in epistaxis rates in temperate climes and an increase in ED visits from December to March.4,12,13,16,17 This seasonal spike in occurrence has been attributed to a decrease in ambient humidity in addition to an increase in the frequency of comorbid upper respiratory infections.10,18 We had less number of epistaxis cases requiring inpatient admission and more inpatient stays, when compared with previous studies. This could mean greater effectiveness in controlling epistaxis in the ED, but the epistaxis patients who were admitted had more severe cases. Overall, 1.9% of patients presenting to the ED with nasal hemorrhage required admission. A higher rate (6%) was found in the literature, and the need for hospitalization increased with age and concomitant use of anticoagulant medications.2,8,19,20 The average inpatient stay was 7.2 days, which was longer than that reported in the literature.20,22 The major comorbidities associated with the epistaxis were hypertension (47.8%) and medications interfering with hemostasis (30.4%). A very small percent (0.55%) of the total cases required surgery. We did not have any not fatal cases, but epistaxis-associated mortality is rare (estimated case fatality rate is 0.1%, and it is usually due to complications of hypovolemia from severe hemorrhage or complications from underlying disease states).20,21 There is no mention in the literature of health costs related to epistaxis. We found a mean total health-care costs with epistaxis of 69.8 D per episode. Epistaxis may impair the quality of life and, through work loss and school absences, be responsible for lost productivity annually. Consequently, there are also non-quantified indirect charges related with epistaxis. Epistaxis is the most common rhinological emergency seen in the ED.17,23,24 Most are merely nuisances, some are intense, and only a few are life-threatening. Few studies have addressed the key epidemiologic questions for emergency physicians, especially regarding southern Europe. This work has limitations, however, mainly due to its retrospective design. Future studies should be based on prospective cohort studies.
Conclusions To our knowledge, this is the largest study to date examining epistaxis epidemiology in southern Europe and the first study that has analyzed those characteristics and health-care costs in the portuguese population. Epistaxis demonstrates specific epidemiological characteristics in an otolaryngology ED. We had high presentation numbers, less number of epistaxis cases requiring inpatient admission, longer inpatient stays for those who were admitted, and more intense epistaxis episodes in the elderly (an aspect that could be more prevalent in the future as the population in western countries ages). The typical profile of a patient admitted for
337 epistaxis was a middle-aged or older male. Patients were more frequently admitted during the winter months and had comorbities associated with epistaxis, and there was a higher risk of referral and hospitalization with increasing age. The mean total health-care costs with epistaxis was 69.8 D per episode and the main hospital expenses are related to hospitalization and health care costs.
Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Financial support Nothing to declare.
Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Conflict of interests None of the authors has potential conflicts of interest. None of the authors has or has had any affiliation with any organization with a financial interest, direct or indirect, in the subject matter or materials discussed in the manuscript that may affect the conduct of reporting of the work submitted. Conflict of interests: Nothing to declare.
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www.elsevier.es/otorrino
ORIGINAL ARTICLE
Epidemiology of epistaxis in the emergency department of a southern European tertiary care hospital夽 Luis Roque Reis ∗ , Filipe Correia, Luis Castelhano, Pedro Escada Department of Otolaryngology of Egas Moniz Hospital, Centro Hospitalar de Lisboa Ocidental (CHLO), NOVA Medical School Faculdade de Ciências Médicas, Lisbon, Portugal Received 28 May 2017; accepted 7 November 2017 Available online 5 May 2018
KEYWORDS Epistaxis; Epidemiology; Emergency
Abstract Objective: Epistaxis is the most common rhinological emergency seen in the emergency department. The purpose of this study was to evaluate epidemiological data of epistaxis in a southern European tertiary care hospital. Methods: A retrospective study was conducted during the period between January 2009 and December 2015. We analyzed the distribution by cross-referencing the demographic variables, destination after medical discharge, inpatient characteristics (major comorbid diseases, medication, bleeding localization and treatment) and health-care costs with the disease. Results: Epistaxis accounted for approximately 1 in 30 visits to the ED and 77 out of a population of 100,000 was served by that ED. Overall, 71,624 patients were treated and 2371 patients presented with epistaxis (3.31%). One-thousand three-hundred and twenty-seven cases were male and 1044 female (p <.001). The mean age was 56 years (±26). Age distribution was bimodal, with peaks among those <10 years and >70 (p <.001). Epistaxis was more common in the winter months (p < 0.001). The main referral destinations (6.8%) included outpatient (2.9%) and inpatient (1.9%) services. Hospitalization was more frequent between the ages of 60 and 80 years (p =.029), and the major comorbidity was hypertension (47.8%). Medication interfering with haemostasis was documented in 30.4%. Most inpatient epistaxis was managed in a noninterventional manner and only. 5% of patients needed surgery. The mean total health-care cost was 69.8 D per episode.
Abbreviations: ED, emergency department; ICD-9-CM, International Classification of Diseases, 9th revision, Clinical Modification. Egas Moniz Hospital, Centro Hospitalar de Lisboa Ocidental (CHLO), NOVA Medical School - Faculdade de Ciências Médicas. ∗ Corresponding author. Department of Otolaryngology of Egas Moniz Hospital, Centro Hospitalar de Lisboa Ocidental (CHLO), NOVA Medical School, Junqueira Street 126, 1340-019 Lisbon, Portugal. TEL.: +351 91886251. E-mail address: [email protected] (L.R. Reis). 夽
https://doi.org/10.1016/j.otorri.2017.11.002 0001-6519/© 2018 Sociedad Espa˜ nola de Otorrinolaringolog´ıa y Cirug´ıa de Cabeza y Cuello. Published by Elsevier Espa˜ na, S.L.U. All rights 2173-5735 reserved.
332
L.R. Reis et al. Conclusion: Emergency epistaxis was more frequent in men, the elderly, patients with underlying comorbidities, during the winter months, and showed a higher risk of referral and hospitalization with increasing age (as a result of an aging population in western countries). The main hospital expenses for epistaxis are related to hospitalization and health care costs. © 2018 Sociedad Espa˜ nola de Otorrinolaringolog´ıa y Cirug´ıa de Cabeza y Cuello. Published by Elsevier Espa˜ na, S.L.U. All rights reserved.
PALABRAS CLAVE Epistaxis; Epidemiología; Urgencia
Epidemiología de la epistaxis en el servicio de urgencias de un hospital de atención terciaria del sur de Europa Resumen Objetivo: La epistaxis es la urgencia rinológica más comúnmente observada en el servicio de urgencias (SU). El objetivo de este estudio es evaluar los datos epidemiológicos de la epistaxis en un hospital de atención terciaria del sur de Europa. Métodos: Se realizó un estudio retrospectivo durante el periodo comprendido entre enero de 2009 y diciembre de 2015. Analizamos la distribución entrecruzando las variables demográficas, el destino tras el alta médica, las características hospitalarias (enfermedades comórbidas mayores, medicación, localización del sangrado y tratamiento) y los costes sanitarios con la enfermedad. Resultados: La presentación con epistaxis supuso aproximadamente una de 30 visitas al SU, donde se atendió a una población de 77 de cada 100.000 habitantes. En general se trataron 71.624 pacientes, de los cuales 2.371 se presentaron con epistaxis (3,31%). Mil trescientos veintisiete casos eran varones y 1.044 mujeres (p < 0,001). La edad media fue de 56 a˜ nos (± 26). La distribución de la edad fue bimodal, con valores máximos entre ellos < 10 a˜ nos y > 70 (p < 0,001). La epistaxis fue más común durante los meses invernales (p < 0,001). Los principales destinos de derivación (6,8%) incluyeron los servicios ambulatorios (2,9%) y hospitalarios (1,9%). Las hospitalizaciones fueron más frecuentes entre los 60 y 80 a˜ nos (p = 0,029), siendo la hipertensión la mayor comorbilidad (47,8%). La medicación que interfirió con la hemostasia se documentó en el 30,4%. A la mayoría de pacientes hospitalarios con epistaxis se les trató de manera no intervencionista, y únicamente el 0,5% de los casos precisó cirugía. Los costes sanitarios totales medios fueron del 69,8 D por episodio. Conclusión: La epistaxis de urgencia fue más frecuente en varones, personas mayores, pacientes con comorbilidades subyacentes, durante los meses invernales, y reflejó un mayor riesgo de derivación y hospitalización con el incremento de la edad (como resultado del envejecimiento de la población en los países occidentales). Los principales gastos hospitalarios en los casos de epistaxis guardan relación con la hospitalización y los costes de la atención sanitaria. © 2018 Sociedad Espa˜ nola de Otorrinolaringolog´ıa y Cirug´ıa de Cabeza y Cuello. Publicado por Elsevier Espa˜ na, S.L.U. Todos los derechos reservados.
Introduction Epistaxis is a common clinical problem that is estimated to occur in 60% of people worldwide during their lifetime.1 It is difficult to precisely determine their frequency because most episodes resolve spontaneously or with self-treatment. However, data suggest that epistaxis presentation accounts for approximately 1 in 200 visits to the emergency department (ED) and 100 visits per 100,000 population served by the ED.2,3 The increasing demand for emergency services in hospitals must be meticulously analyzed, taking epidemiological trends into account. Understanding epistaxis epidemiological data during emergency services will allow better clinical decisions to be made and improve patients’ medical treatment. In Southern Europe and particularly in Portugal, the epistaxis epidemiology for ED visits is unknown. The purpose of
this study is to evaluate seven years of epistaxis epidemiological data in the ED of a tertiary care hospital. We analyzed the distribution by age, gender, season, year, cross-over of demographic variables (age and gender, year and gender, and year, season and gender), destination after medical discharge, inpatient characteristics (major comorbid diseases, medication, bleeding location, treatment), cost estimate and expenses with the disease in the hospital.
Methods Procedures The SSTI-Servic ¸o de Sistemas e Tecnologias de Informac ¸ão (Information Systems and Technologies Service) of the West Lisbon Central Hospital (CHLO), EPE (a public corporation) was used to search the otolaryngology emergency database.
Epidemiology of epistaxis All code numbers associated with the diagnosis of epistaxis (484.7) of the ICD-9-CM (International Classification of Diseases, 9th revision, Clinical Modification) were selected for this study. This classification does not have isolated codes for anterior and posterior epistaxis. The criteria for hospitalization were judged by clinical evaluation and included severe bleeding unresponsive to pressure, vasoconstrictor appliance, cauterization or nasal packing. All patients who attended the otolaryngology ED between 1 January 2009 and 31 December 2015 (a seven-year period) were considered in the study. This department operates as an open service (without triage) and serves five parishes of the Lisbon Municipality (São Francisco Xavier, Santa Maria de Belém, Alcântara, Santo Condestável e Ajuda) in addition to the Municipalities of Oeiras and Cascais, providing medical care to a population of 439,944 (2011 census). The area of coverage is on the west coast of Portugal, and the population is mainly Caucasian (96,7%). Access to health care is universal, but patients are subject to payment of a small flat-rate user fee. The total period selected for the study was lengthened to seven years to enable better statistical accuracy and epidemiological analysis over this period. Distribution was studied for epistaxis cases and for the total number of cases presenting to the ED. Data was collected from the SSTI: 1) age; 2) gender; 3) date of attendance at ED (taken as the date of the epistaxis); 4) destination after medical discharge; 5) inpatient characteristics; and 6) patients referred for surgery. The data was organized and stratified by age (in ten year groups), gender, year, and season. The protocol for this study was evaluated and approved by the Health Ethics Committee (CES) of the West Lisbon Hospital Centre (CHLO), Lisbon, on 15/05/2017.
Statistical analysis The data were entered on a database, and a statistical study was performed using the Statistical Package for The Social Sciences (SPSS), 21.0 version for Windows. To evaluate sample distribution, the chi-squared test was used. We applied a significance level of 0.05 (5%) with a 95% confidence interval. We tested for statistically significant differences between year, distribution, gender, age, season, destination after medical discharge, and a cross-over evaluation of the several variables.
Results Presentation with epistaxis accounted for approximately 1 in 30 visits to the ED and 77 per 100,000 population served by that ED. Overall, 71,624 patients presented to the ED from 2009 to 2015. In 2371 patients, the cause was epistaxis (3.31%) (Table 1). Annual distribution of epistaxis varied from 427 cases (2009) to 258 cases (2015). In the same period, there was also a reduction in total annual number of emergencies (from 11,602 to 9507 cases). We used the adjusted chi-square test to verify the distribution of epistaxis numbers per year. The statistical analysis demonstrated significant differences between the years [2 (6) = 68.806; p <0.001].
333 One thousand three-hundred and twenty-seven epistaxis cases included in this study were male (56%), and 1044 were female (44%). We used the adjusted chi-square test to verify epistaxis distribution by gender (Table 1). There was a statistical significant difference between gender [2 (1) = 33.779; p <0.001]. The individuals included in this study had a mean age of 56 years (±26). Epistaxis was very frequent in patients <10 years (9.7% of admitted patients with epistaxis) (Figure 1). The number of cases decreased to a minimum in the fourth decade (3.8%) and then increased to reach a maximum in the seventh decade (22.7%). Nine-hundred and sixty-four (36.3%) of the total number of epistaxis cases occurred between 60 and 80 years, and more than half of the total number of epistaxis cases occurred between 60 and 90 years (1316 cases, 53.6%); the number of patients, however, who were between 80 and 90 years was lower. The statistical analysis by the adjusted chi-square test demonstrated significant differences between age groups [2 (10) = 1215.636; p <0.001]. Epistaxis was more frequent in females only for age groups 40---50 and 90---100 years. We used the chi-square test to verify the association between gender and age group (Table 2). It was found that in epistaxis there was a statistically significant relationship between gender and age group [2 (10) = 46.029; p < 0.001]. We used the adjusted chi-square test to verify gender differences for each age group. There were no statistically significant differences for the age groups 30---40, 70---80, 90---100, and 100---110 years (p >0.05). Epistaxis was more common in the winter months (754 cases, 31.8%). Epistaxis rates in the summer (453 cases, 19.1%) were the smallest during all the seasons (Table 3). We used the adjusted chi-square test to verify the epistaxis distribution per season. Statistical analysis demonstrated significant differences between the seasons [2 (3) = 82.336; p <0.001]. Statistical analysis by the chi-square test did not demonstrate any significant association between gender and season (p >0.056). Destination of patients after medical discharge was mainly for non-hospitalized, non-referral (2209 cases). Referral destinations included outpatient consultations (68 cases), hospitalizations (46 cases), and health centers (30 cases). The remaining destinations (17 cases) were rare and included another hospital (14 cases), day hospital (two cases), and discharge. The largest number of cases admitted to the hospital or referred for outpatient consultation services consisted of patients between 60 and 80 years (Table 4). We used the chi-square test to verify the association between outpatient consultation/hospitalization and age group. There was a statistically significant relationship between consultation/hospitalization and age group [2 (4) = 10.803; p = 0.029]. The patients admitted to the hospital had a mean age of 61 years (±17). A greater number of inpatient cases occurred in the group 70---80 years (26.1%), and patients between 60 and 80 years constituted 50% of the cases (Table 5). There were no cases of hospitalization in patients <20 years. Men outnumbered women in a ratio of 2:1. The chi-square test for association did not demonstrate any significant differences between age and gender (p >0.05). We used the adjusted chi-square test to verify the distribution of epistaxis number
334 Table 1 Year
2009 2010 2011 2012 2013 2014 2015 total
L.R. Reis et al. Annual distribution of epistaxis by year and gender. n total
Epistaxis
11602 11571 11625 9438 8827 9054 9507 71624
Male
Female
n
%
2
p
223 200 211 176 176 172 169 1327
204 181 174 162 131 103 89 1044
427 381 385 338 307 275 258 2371
3,68 3,29 3,31 3,58 3,48 3,04 2,71 3.31
.845 .948 3.556 .580 6.596 17.313 24.806
.358 .330 .059 .446 .010 <.001 <.001
300 266
250
273
229 191
188
200
164 149
139
150
108
100
64
57 43
50
99
98
91
Male Female
65 42 48 27 25 1 4
0 0-10
10-20
20-30
30-40
40-50
50-60
60-70
70-80
80-90
90-100 100-110
Age (years)
Figure 1
Epistaxis cases by age group. The average number of epistaxis cases between 2009 and 2015 by 10-year age groups.
Table 2 Distribution of epistaxis by age and gender. The number of epistaxis cases between 2009 and 2015 by 10-year age groups and gender. Age
Male
Female
Total
%
2
p
[0-10] [10-20] [20-30] [30-40] [40-50] [50-60] [60-70] [70-80] [80-90] [90-100] [100-110] Total
139 108 57 48 65 188 229 273 191 25 4 1327
92 64 42 42 98 99 164 266 149 27 1 1044
231 172 99 90 163 287 393 539 340 52 5 2371
9.7 7.3 4.2 3.8 6.9 12.1 16.6 22.7 14.3 2.2 0.2
9.563 11.256 2.273 .400 6.688 27.599 10.751 .091 5.188 .077 1.800
.002 .001 .132 .527 .010 <.001 <.001 .763 .023 .782 .180
per season in cases of hospitalization (Figure 2). Statistical analysis demonstrated no significant differences between the seasons [2 (3) = 5.130; p = 0.162]. Also, there were no statistically significant differences between the seasons for patients referred to outpatient consultation services [2 (3) = 6.471; p = 0.091]. In 69.6% (n = 32) of hospitalized patients, the epistaxis was posterior (19.6% was anterior and in the remaining cases was anterior and posterior). Most inpatient epistaxis cases were managed in a noninterventional manner (nasal packing
and local electrocauterization). Thirteen cases (0.55% of the total cases) out of the 46 inpatient cases (1.9% of the total cases) had to go to the operating room (five required endoscopic surgical ligature). In our study, we did not observe any cases of mortality. The mean length for hospital stays was 7.2 days. Hypertension, diabetes, and ischemic heart disease were the major comorbid diseases in these patients. Medication interfering with hemostasis was documented in 30.4% of patients and hypertension in 47.8% of patients (Table 6).
Epidemiology of epistaxis Table 3
335
Distribution of epistaxis by year, season and gender.
Year
Winter
Spring
Summer
Autumn
Total
2009 2010 2011 2012 2013 2014 2015 Total
133 122 130 120 82 87 80 754 31.8 438 33.0 316 30.3
102 104 97 94 81 71 72 621 26.2 328 24.7 293 28.1
75 72 70 71 70 48 47 453 19.1 270 20.3 183 17.5
117 83 88 53 74 69 59 543 22.9 291 21.9 252 24.1
427 381 385 338 307 275 258 2371
Male Female 2 p
Table 4
n % n % n % 7.551 .056
Distribution of epistaxis by age of the patients referred for outpatient or inpatient services.
Age
Outpatient consult.
[0-20] [20-40] [40-60] [60-80] [80-100]
Table 5
N
%
12 11 14 21 10
17.6 16.2 20.6 30.9 14.7
Hospitalization N
2
p
10.803
.029
%
7 10 23 6
15.2 21.7 50.0 13.0
Characteristics of patients admitted in hospitalization, by age and gender.
Age
[20-30] [30-40] [40-50] [50-60] [60-70] [70-80] [80-90] Total
1327 56 1044 44
Male
Female
Total
n
%
n
%
n
%
1 3 3 3 8 10 4 32
3.1 9.4 9.4 9.4 25.0 31.3 12.5
1 2 2 2 3 2 2 14
7.1 14.3 14.3 14.3 21.4 14.3 14.3
2 5 5 5 11 12 6 46
4.7 10.9 10.9 10.9 23.9 26.1 13
The mean total health-care costs with epistaxis was 69.8 D per episode. Total hospital charges related to epistaxis may represent 21.500 D to 28.500 D per year, and this represents an estimated total cost of 150.000 to 200.000 D (Table 7). The main hospital expenses are related to hospitalization and health care costs (the amount spent on the resources needed to care for patients).
2
p
2.16
.904
Discussion Over a seven-year period, a total of 71,624 patients presented to the ED, and in 2371 (3.71%) the cause was epistaxis. Presentation with epistaxis accounted for approximately 1 in 30 visits to the ED and 77 per 100,000 population served by that ED. Men (56%) and older people between 60 and 80 years (39.3%) were most often affected. Epistaxis was
336
L.R. Reis et al.
Total inpatient cases
16 14 12
8 Men
10
8
Women
8
13
6 4
7
3
5
2
2 0
Winter
Spring
Summer
Autumn
Season Figure 2
Table 6
Inpatient admission by season.
Associated comorbidities and medications of the hospitalized patients.
Comorbidities
n
%
Anticoagulants/Antiaggregants
n
%
Arterial Hypertension Diabetes mellitus CVD Heart failure COPD Rendu-Osler-Weber IHD Total
22 6 3 3 3 2 2 41
47.8 13 6.5 6.5 6.5 4.4 4.4 89.1
ASA ASA + Clopidogrel Warfarine No medication
8 2 4 32
17.4 4.3 8.7 69.6
14
30.4
CVD: cerebral vascular disease, COPD: chronic obstructive pulmonary disease, IHD: ischemic heart disease, ASA: acetylsalicylic acid.
Table 7
Estimated cost (D ), per episode and per year, of epistaxis episodes in the ER.
Disposable material (n=2371) Healthcare costs (n=2371) Hospitalization (n=46) Operating room (n=13) Embolization (n=7) Average costs (n=2371)
per episode
per year
Total
2.41 34.3 1614.1 249 124.5 69.8
816.3 11617.9 10606.9 462.4 124.5 23628.1
5714.1 81325.3 74248.6 3237 871.5 165396.5
more common in the winter months (31.8%). The number of hospitalizations was stable in different seasons, but they were also more frequent in males between 60 and 80 years (50%). The main referral destinations (6.8%) included outpatient (2.9%) and inpatient services (1.9%). A larger number of hospitalizations occurred between 60 and 80 years and in 0.5% of the cases, patients required surgery to control the bleeding. An association with medication interfering with hemostasis (30.4%) and hypertension (47.8%) was found. We found a mean total health-care costs with epistaxis of 69.8 D per episode. Our ED operates as an open service only for otolaryngology patients, so we had high numbers of patients presenting with epistaxis (1 in 30 visits and 77 per 100,000 population served by the ED) that should document a higher incidence of epistaxis in the general population.2,3 Previous studies suggested a lifetime prevalence of nasal hemorrhage of 60%,
with 10% of those seeking medical care and 10% of those requiring an otolaryngology referral.4---7 Age distribution of epistaxis was bimodal with peaks among those <10 years (3.2 per 1000 visits) and those older than 70 years (13.1 per 1000 visits). We found a greater occurrence in the elderly, an aspect that could be more prevalent in the future with the aging of the population in western countries. Similar results were found with the same peaks among patients younger than 10 years (4 per 1000 visits) and older than 70 years (12 per 1000 visits).8,9 Despite this early age peak, most cases of epistaxis occur in the elderly adult population.10---13 We found a gender predilection with approximately 60% of patients being male and 40% female, which has been reported with some variations.4,10,13,14 There is a theory that gender predilection may be partially due to estrogen’s protective effects, which locally fosters a healthy nasal
Epidemiology of epistaxis mucosa and systemically reduces the risk of cardiovascular disease.9,15 This theory is supported by the observation that gender differences associated with nasal hemorrhage incidences equalizes after menopause. Epistaxis was more common in the winter months (32 per 100 cases of epistaxis). Although a small set of studies have shown no significant differences, these results are in line with those that refer to seasonal variation in epistaxis rates in temperate climes and an increase in ED visits from December to March.4,12,13,16,17 This seasonal spike in occurrence has been attributed to a decrease in ambient humidity in addition to an increase in the frequency of comorbid upper respiratory infections.10,18 We had less number of epistaxis cases requiring inpatient admission and more inpatient stays, when compared with previous studies. This could mean greater effectiveness in controlling epistaxis in the ED, but the epistaxis patients who were admitted had more severe cases. Overall, 1.9% of patients presenting to the ED with nasal hemorrhage required admission. A higher rate (6%) was found in the literature, and the need for hospitalization increased with age and concomitant use of anticoagulant medications.2,8,19,20 The average inpatient stay was 7.2 days, which was longer than that reported in the literature.20,22 The major comorbidities associated with the epistaxis were hypertension (47.8%) and medications interfering with hemostasis (30.4%). A very small percent (0.55%) of the total cases required surgery. We did not have any not fatal cases, but epistaxis-associated mortality is rare (estimated case fatality rate is 0.1%, and it is usually due to complications of hypovolemia from severe hemorrhage or complications from underlying disease states).20,21 There is no mention in the literature of health costs related to epistaxis. We found a mean total health-care costs with epistaxis of 69.8 D per episode. Epistaxis may impair the quality of life and, through work loss and school absences, be responsible for lost productivity annually. Consequently, there are also non-quantified indirect charges related with epistaxis. Epistaxis is the most common rhinological emergency seen in the ED.17,23,24 Most are merely nuisances, some are intense, and only a few are life-threatening. Few studies have addressed the key epidemiologic questions for emergency physicians, especially regarding southern Europe. This work has limitations, however, mainly due to its retrospective design. Future studies should be based on prospective cohort studies.
Conclusions To our knowledge, this is the largest study to date examining epistaxis epidemiology in southern Europe and the first study that has analyzed those characteristics and health-care costs in the portuguese population. Epistaxis demonstrates specific epidemiological characteristics in an otolaryngology ED. We had high presentation numbers, less number of epistaxis cases requiring inpatient admission, longer inpatient stays for those who were admitted, and more intense epistaxis episodes in the elderly (an aspect that could be more prevalent in the future as the population in western countries ages). The typical profile of a patient admitted for
337 epistaxis was a middle-aged or older male. Patients were more frequently admitted during the winter months and had comorbities associated with epistaxis, and there was a higher risk of referral and hospitalization with increasing age. The mean total health-care costs with epistaxis was 69.8 D per episode and the main hospital expenses are related to hospitalization and health care costs.
Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Financial support Nothing to declare.
Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Conflict of interests None of the authors has potential conflicts of interest. None of the authors has or has had any affiliation with any organization with a financial interest, direct or indirect, in the subject matter or materials discussed in the manuscript that may affect the conduct of reporting of the work submitted. Conflict of interests: Nothing to declare.
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