Health resource utilization of the emergency department headache "repeater".

Maizels M.

Department of Family Practice, Kaiser Permanente, Woodland Hills, Calif 91367, USA.

OBJECTIVE: To document the health resource utilization of patients who repeatedly use emergency department services for headache care. BACKGROUND: Patients with headache who frequently use emergency department services may differ from patients with more typical, episodic migraine. Previous studies of health resource utilization have often failed to distinguish the high utilizer as a specific subset of the migraine population. DESIGN: Retrospective review of urgent care/emergency department charts, clinic charts, and pharmacy rosters. PATIENTS AND METHODS: Patients who made three or more visits for headache to an urgent care/emergency department (UC/ED) facility for headache over a 6-month study period were identified and designated as "repeaters" for this study. Pharmacy profiles and appointment histories of 52 of the 54 repeaters whose records were available were reviewed for the 12 months prior to the study period. RESULTS: Over the 6-month study period, 518 patients visited the UC/ED 1004 times for primary headache complaints. Fifty-four (10%) repeaters made 502 visits (50% of total visits; mean 9.3, range 3-50). In the 12 months prior to the study period, 52 of these repeaters made 1832 visits to the UC/ED or clinic (mean 35.2, range 0-178): 1458 (79.6%) were headache related, and 1271 (69.4%) of all visits were to the UC/ED. An estimated 12-month cost for all visits was $183,760. Pharmacy rosters showed use of narcotics in 41 of the 52 patients (annual mean +/- SD, 613 +/- 670 tablets), benzodiazepines in 30 patients (500 +/- 486 tablets), and butalbital products in 27 patients (395 +/- 590 tablets). Mean daily use of all symptomatic medications combined was 3.9 +/- 3.2 doses/day. CONCLUSION: Health resource utilization of emergency department headache repeaters is predominantly headache-related acute care. Associated medication overuse is frequently present. Efforts to improve care for patients with headache will benefit from distinguishing the high utilizer as a subset of the migraine population.

Source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=&dopt=Abstract butalbital fioricet barbiturate




Health care utilization in patients with migraine: demographics and patterns of care in the ambulatory setting.

Gibbs TS, Fleischer AB Jr, Feldman SR, Sam MC, O'Donovan CA.

Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.

BACKGROUND: Migraine affects people of all races and both sexes. Migraineurs suffer both financial losses and impaired quality of life. Recent progress in the treatment of migraine has not been made readily available to all who suffer the condition. OBJECTIVE: To assess outpatient health care delivery patterns for migraine sufferers in the United States. METHODS: National Ambulatory Medical Care Survey data from 1990 to 1998 was used to assess the demographics of patients seen with a diagnosis of migraine, the types of physicians they saw, and the medications used to treat migraine. RESULTS: Women accounted for 79% of visits for migraines and whites for 91% of the visits. There was a dramatic increase in the number of migraine visits during the study period, from 9.4 visits per 1000 people in 1990 to 18 visits per 1000 in 1998. Primary care physicians saw the majority of patients (72.2%). Butalbital/aspirin/caffeine was the drug most commonly prescribed for migraine treatment, followed by acetaminophen/dichloralphenazone/isometheptene mucate, propranolol, and sumatriptan. CONCLUSION: Perhaps in part due to newer treatment options, the number of visits for the treatment of migraine doubled over the study interval. Even so, most patients with migraine continue to be treated with older and presumably less effective medications.

Source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=&dopt=Abstract butalbital fioricet barbiturate




Comparison of the serum barbiturate fluorescence polarization immunoassay by the COBAS INTEGRA to a GC/MS method.

Cannon RD, Wong SH, Gock SB, Jentzen JJ.

Office of the Milwaukee County Medical Examiner and the Department of Pathology, Medical College of Wisconsin, 53233, USA.

The authors evaluated a new Cassette Serum Barbiturates fluorescence polarization immunoassay (FPIA) on the COBAS INTEGRA. The assay was calibrated with secobarbital standards at 0, 0.5, and 4.0 microg/mL. The assay range was 0.030 to 80 microg/mL using an automatic 1/20 postdilution feature. Precision was established for two COBAS INTEGRA instruments for ten days by assaying secobarbital target concentrations ranging from 0.125 to 2.2 microg/mL. The coefficients of variation (CV) for the above target concentrations for the first instrument ranged from 2.7% to 8.3%, and for a second instrument, 3.8 to 8.3%. Seven clinically elevated bilirubin samples were spiked with 0.46 and 1.77 microg/mL secobarbital. Bilirubin interference was less than 10.9 and less than 7.9%, respectively. The average recovery ranged from 85% to 94%. The mean difference in recovery in serum versus plasma was < or = 3%. Fifty-two clinical samples were analyzed for butalbital, pentobarbital, secobarbital, and phenobarbital by GC/MS, and the results were compared to the new Cassette Serum Barbiturates FPIA. The diagnostic sensitivity and specificity were 95% and 100%, respectively. Both FPIA and GC/MS assays are clinically efficacious for monitoring serum barbiturates.

Source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=&dopt=Abstract butalbital fioricet barbiturate




Distribution of butalbital in postmortem tissues and fluids from non-overdose cases.

Lewis RJ, Johnson RD, Southern TL, Canfield DV.

Civil Aerospace Medical Institute, Federal Aviation Administration, Toxicology and Accident Research Laboratory, AAM-610, PO Box 25082, Oklahoma City, Oklahoma 73125, USA.

During the investigation of fatal aviation accidents, postmortem samples from the pilots/co-pilots are submitted to the Federal Aviation Administration's (FAA) Civil Aerospace Medical Institute (CAMI) for toxicological analysis. Although therapeutic levels for most drugs are typically reported in the scientific literature for blood and plasma, blood specimens are received in only approximately 70% of our cases. Therefore, it is imperative for an accident investigator and forensic toxicologist to be able to estimate drug concentrations in an aviation accident victim's blood from available tissue drug concentrations. This is exemplified by a recent aviation fatality in which butalbital was identified in the muscle tissue of a pilot. In this case, no blood was available for analysis, but investigators needed to know the approximate butalbital concentration expected in the victim's blood. Certain side effects of butalbital, such as drowsiness, sedation, dizziness, and a feeling of intoxication, could affect pilot performance and become a significant factor in an aviation accident. Thus, our laboratory determined the distribution of butalbital in various postmortem tissues and fluids. The distribution coefficients for butalbital, expressed as specimen/blood ratios, were found to be as follows: 0.66 +/- 0.09 (muscle, n = 4), 0.98 +/- 0.09 (kidney, n = 4), 0.87 +/- 0.06 (lung, n = 4), 0.75 +/- 0.03 (spleen, n = 4), 0.96 +/- 0.07 (brain, n = 3), 2.22 +/- 0.04 (liver, n = 4), and 0.91 +/- 0.17 (heart, n = 2). The results obtained from our limited number of cases suggest that muscle, kidney, lung, spleen, brain, liver, and heart could be used, in a cautious and conservative fashion, to estimate butalbital blood concentrations.

Source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=&dopt=Abstract butalbital fioricet barbiturate




Application of atmospheric pressure chemical ionisation mass spectrometry in the analysis of barbiturates by high-speed analytical countercurrent chromatography.

Jones JJ, Kidwell H, Games DE.

Mass Spectrometry Research Unit, University of Wales Swansea, Grove Building, Singleton Park, Swansea SA2 8PP, Wales, UK. 147437 swan.ac.uk

Four barbiturates (barbital, allobarbital, phenobarbital and butalbital) were analysed using high-speed analytical countercurrent chromatography (HSACCC) and high-performance liquid chromatography (HPLC) interfaced with mass spectrometry, using negative mode atmospheric pressure chemical ionisation (APCI). The polar biphasic solvent system of butyronitrile/acetonitrile/water (1:1:1) was used, in the upper-stationary, lower-mobile mode of operation, at a flow rate of 1 mL/min and a rotational speed of 1200 rpm, equating to an applied "g"-field of 177 g. The fractional stationary phase retention (S(F)) was 0.58. Representative mass spectral data are presented from the HPLC and the HSACCC analyses. Structural information was obtained using source-induced fragmentation at increased source block voltages. The effect of increasing g-field on chromatographic resolution is illustrated using the binary base system of butyronitrile/water (1:1), under electrospray ionisation. Copyright 2003 John Wiley & Sons, Ltd.

Source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=&dopt=Abstract butalbital fioricet barbiturate