Multiple sclerosis (MS) affects approximately. Triaging Patients with Multiple Sclerosis in the Emergency Department. Room for Improvement

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1 Systemtic Review of Tools for Anxiety in MS MS CARE DELIVERY: CHALLENGES AND INVATIONS Triging Ptients with Multiple Sclerosis in the Emergency Deprtment Room for Improvement Heshm Abboud, MD, PhD; Krin Mente, MD; Megn Sey, DO; Jeffrey Kim, MD; Ashhr Ali, DO; Robert Bermel, MD; Mry A. Willis, MD Bckground: Ptients with multiple sclerosis (MS) present to the emergency deprtment (ED) for vrious resons. Although true relpse is rrely the underlying culprit, ED visits commonly result in new mgnetic resonnce imging (MRI) nd neurology dmissions. We studied ED visits in ptients with MS nd evluted decision mking regrding dignostic/therpeutic interventions nd visit outcomes. We identified potentil res for improvement nd used the dt to propose triging lgorithm for ptients with MS in the ED. Methods: We reviewed the medicl records from 176 ED visits for ptients with MS in Results: Ninety-seven visits in 75 ptients were MS relted (66.6% femle; men ± SD ge, 52.6 ± 13.8 yers; men ± SD disese durtion, 18.5 ± 10.5 yers). Thirty-three visits were for new neurologic symptoms (ctegory 1), 29 for worsening preexisting symptoms (ctegory 2), nd 35 for MS-relted complictions (ctegory 3). Eighty-nine visits (91.8%) resulted in hospitl dmission (42.7% to neurology). Only 39% of ordered MRIs showed rdiogrphic ctivity. New relpses were determined in 27.8% of the visits nd were more prevlent in ctegory 1 compred with ctegory 2 (P =.003); however, the two ctegories hd similr rtes of ordered MRIs nd neurology dmissions. Conclusions: New relpse is rre cuse of ED visits in MS. Unnecessry MRIs nd neurology dmissions cn be voided by developing triging system for ptients with MS bsed on symptom strtifiction. Int J MS Cre. 2017;19: Multiple sclerosis (MS) ffects pproximtely 350,000 people in the United Sttes, with pproximtely 12,000 new dignoses ech yer. 1 The high cost of tretment, disbility, nd loss of productivity throughout the disese course is gret burden to society. 2 A cross-sectionl study of ptients with MS in the North Americn Reserch Committee From the Mellen Center for Multiple Sclerosis Tretment nd Reserch (HA, RB, MAW) nd Deprtment of Neurology (KM, MS, AA), Clevelnd Clinic, Clevelnd, OH, USA; Cse Western Reserve University, University Hospitls Multiple Sclerosis nd Neuroimmunology Progrm, Clevelnd, OH, USA (HA); Deprtment of Neurology, Alexndri University, Alexndri, Egypt (HA); Ntionl Institutes of Helth, Bethesd, MD, USA (KM); nd Torrnce Memoril Physicin Network Neurology, Torrnce, CA, USA (JK). Correspondence: Heshm Abboud, MD, PhD, Cse Western Reserve University, School of Medicine, Euclid Ave., Clevelnd, OH 44106; e-mil: heshm.bboud@uhhospitls.org. DOI: / Consortium of Multiple Sclerosis Centers. 290 on Multiple Sclerosis (NARCOMS) Registry estimted tht the verge nnul cost per ptient ws greter thn $47, A study using the Ntionwide Inptient Smple looked t overll trends of MS hospitl dmissions from 1993 through Over the 14-yer period, the percentge of ptients with MS dmitted from the emergency deprtment (ED) incresed from 19.4% to 60.0%. The verge cost per dmission incresed from $7965 in 1993 to $20,076 in 2006, with totl MS popultion cost of $445 million. 4 In ddition to the cost of disese-modifying therpy (DMT) nd imging, it is known tht hospitl dmissions lso contribute considerbly to the cost of mnging MS. 5,6 Although hospitliztion my be necessry in severe cute excerbtions, most ptients with less severe relpses nd those with pseudorelpses cn be treted s outptients. When ptients re hospitlized for mngement of cute excerbtions, the cost increses pproximtely six times compred with ptients who re treted s outptients.

2 MS Emergency Deprtment Visits Ptients dmitted from the ED compred with those dmitted by their outptient physicins hd even higher dmission costs. 7 Ptients with MS visit the ED for vrious resons, including relpses, pseudorelpses (temporry worsening of preexisting deficits), medicl complictions, nd tretment-relted dverse effects. 8,9 In the bsence of cler guidelines on triging ptients with MS in the ED, there is gret vribility in the course of ction tken t ech hospitl, which results in lrge number of unnecessry tests, consulttions/dmissions, nd tretments nd, ultimtely, dds to the high economic burden of this chronic disese. Estblishing triging system nd cler guidelines on hndling ptients with MS in the ED cn trnslte into better ptient cre by voiding tretment delys nd promoting fster ptient dischrge while lso reducing the cost of medicl services. 10 This process requires creful evlution of common shortcomings nd prevlent ptterns of improper strtifiction of ptients with MS in the ED. This study imed to identify potentil res of improvement when hndling ptients with MS in the ED so tht comprehensive triging system nd preliminry guidelines for MS hospitl dmissions cn be developed. Methods Ptient Serch nd Visit Ctegoriztion Clevelnd Clinic Helth System electronic medicl records were serched for ptients with n MS dignosis who hd ED visits from Jnury 1, 2014, through December 31, Visits tht were clerly unrelted to MS were excluded from further nlysis, for exmple, ptients with comorbid conditions presenting with cute coronry syndrome, dibetic complictions, chronic obstructive pulmonry disese excerbtions, nd postopertive complictions unrelted to MS. We clssified the remining visits into three ctegories: ctegory 1, visits for new neurologic symptoms; ctegory 2, visits for worsening of preexisting neurologic symptoms; nd ctegory 3, visits for nonneurologic MS-relted complictions. Ctegory 1 ws defined s involvement of new body prt never ffected by n MS ttck previously or involvement of new neurologic system in previously ffected body prt (eg, new motor wekness of limb previously ffected by sensory deficit). Ptients with new neurologic symptoms were included in this ctegory even if the new neurologic symptoms were not typicl of MS, such s seizures, pinless vision loss, or cognitive decline. Ctegory 2 ws defined s worsening of the sme neurologic system in previously ffected body prt (eg, worsening limb wekness in wek limb from previous relpse, worsening vision in n eye with history of optic neuritis). Ctegory 3 includes vrious MS-relted nonneurologic complictions, such s flls/trum secondry to wekness or txi, deep vein thrombosis (DVT) from immobility, urinry trct infections (UTIs) or urosepsis secondry to bldder dysfunction, nd spirtion pneumoni secondry to bulbr dysfunction. Medicl records were crefully reviewed to differentite visits unrelted to MS (nd, therefore, excluded from further nlysis) from those directly or indirectly relted to MS even for the sme ptient. For exmple, visit for immobility-relted DVT ws included s ctegory 3, wheres visit for ngin in ptient with vsculr risk fctors ws considered unrelted to MS nd thus ws not nlyzed. Moreover, ctegoriztion ws strictly bsed on the presenting symptom nd not on the finl dignosis; for exmple, visit with new UTI ws ctegorized s ctegory 2 if the ptient presented with worsening wekness/numbness or s ctegory 3 if the ptient presented with fever nd dysuri. For ech ctegory, the following vribles were nlyzed: ptient demogrphics, outptient tem contct before ED presenttion, ED/hospitl interventions (imging, corticosteroids), visit outcome (dischrge, neurology dmission, or other dmission), presence of UTI or other infection, nd presence of new MS relpse. Sttisticl Anlysis Anlysis of vrince ws used to compre differences mong the three ctegories. In ddition, we used t nd χ 2 tests to compre ctegories 1 nd 2 seprtely becuse these two ctegories re substntilly different from ctegory 3 nd differentiting the two is more cliniclly chllenging in the ED setting. We lso compred ptients in whom new MS relpse ws determined t the end of the ED visit or hospitl dmission (s determined by the neurology tem) with those in whom new relpse ws excluded or not considered regrdless of the visit ctegory. The dt were used to identify potentil res of improvement. This study ws pproved for review exemption by the Clevelnd Clinic s institutionl review bord. Results Overview A totl of 176 ED visits pertining to 94 ptients with MS in 2014 were identified nd reviewed. Seventynine visits were unrelted to MS nd were thus excluded. The remining 97 visits pertining to 75 ptients with 291

3 Abboud et l. MS were further nlyzed. See Tble 1 for ptients demogrphic chrcteristics. In totl, new brin or spine mgnetic resonnce imging (MRI) ws obtined in 38 visits (39.2%), of which only 15 (39.5%) showed evidence of rdiogrphic disese ctivity. Eighty-nine visits (91.8%) resulted in hospitl dmission, of which 38 (42.7%) were to neurology. Corticosteroids were given in 24 visits (24.7%). A new relpse ws determined in 27 visits (27.8%), nd UTIs were found in 30 (30.9%). Telephone clls to the outptient tretment tem or the nurse/resident on cll before ED presenttion were infrequent (8.2%). Visit Ctegories Ctegory 1: New Neurologic Symptoms There were 33 ED visits for new neurologic symptoms, with new MRI ordered in 21 (63.6%), of which only 11 (52.4%) showed evidence of rdiologic ctivity. Twenty visits (60.6%) resulted in dmission to neurology, ten in dmission to other services, nd three in dischrge from the ED. A new relpse ws determined in 20 visits (60.6%), nd other cuses were found in 13 (39.4%). These other cuses included UTI (eight visits) (mostly presenting with new sensory symptoms) nd septic emboli, seizure secondry to subdurl hemtom, dementi, vitreous hemorrhge (presenting with pinless vision loss), nd conversion disorder (one visit ech). Corticosteroid tretment ws given in 17 visits (51.5%). Ctegory 2: Worsening Neurologic Symptoms There were 29 ED visits for worsening preexisting neurologic symptoms. Fourteen new MRIs (48.3%) were ordered in this ctegory, but only four (28.6%) showed evidence of rdiogrphic ctivity. Most visits in this ctegory (n = 27) resulted in hospitl dmission, of which 13 (48.1%) were to neurology. A true relpse ws determined in seven visits (24.1%), nd in ll of them Tble 1. Demogrphic chrcteristics of the 75 study ptients Chrcteristic Vlue Femle sex, No. (%) 50 (66.6) Age, men ± SD, y 52.6 ± 13.8 Disese durtion, men ± SD, y 18.5 ± 10.5 Not receiving DMT, No. (%) 58 (77.3) MS type, No. (%) RRMS 24 (32) SPMS 28 (37.3) PPMS 23 (30.7) Abbrevitions: DMT, disese-modifying therpy; MS, multiple sclerosis; PPMS, primry progressive MS; RRMS, relpsing-remitting MS; SPMS, secondry progressive MS. there ws substntil quntittive chnge in the degree of the previously documented deficit from the ltest vilble neurologic exmintion on record. Other cuses of worsening preexisting symptoms included UTI (ten cses; 34.5%), other infections (three; 10.3%), ileus/constiption/stool impction (three; 10.3%), nd others (one ech): worsening tonic spsms, trigeminl neurlgi relpse, bclofen pump overdose, functionl/somtoform symptoms, migrine, nd drenl insufficiency. Corticosteroids were given in seven visits (24.1%). Ctegory 3: Nonneurologic Symptoms We identified 35 visits for nonneurologic MS-relted complictions: urinry symptoms secondry to UTI (n = 12), fll/frcture/subdurl hemtom (n = 6), spirtion pneumoni (n = 4), bck/hip pin from immobility (n = 3), MS mediction dverse effects (n = 2), constiption/ percutneous endoscopic gstrostomy tube mlfunction (n = 2), fever/sepsis (n = 2), infected pressure ulcer (n = 1), immobility-relted DVT (n = 1), hemorrhge fter thrombolytic therpy for DVT (n = 1), nd wrist swelling fter flexor spsm (n = 1). Three MRIs were performed in this ctegory looking for intrcrnil pthology fter flls or seizures. Five visits resulted in neurology dmission (14.3%), wheres most dmissions were to other services (77.1%). No corticosteroid tretments were given in this visit ctegory. Sttisticl Anlysis Tble 2 shows the results of nlysis of vrince mong the three visit ctegories. Expectedly, the three ctegories hd sttisticlly significnt between-group differences in ge, disese durtion, DMT use, nurse on cll contct, MRI ordered, MRI positivity, corticosteroid tretment, ED visit outcome, nd prevlence of new relpses. There ws no sttisticlly significnt difference between groups in sex, MS type, presence of UTI, or presence of ny infection. Tble 3 shows the results of χ 2 tests compring ctegories 1 nd 2 in reltion to severl ctegoricl vribles. As expected, ctegory 1 visits were more likely to result from true relpse compred with visits from ctegory 2 visits (P =.0033) nd, therefore, were more likely to be treted with corticosteroids (P =.025). Ptients in ctegory 1 were lso more likely to be femle compred with those in ctegory 2 (P =.043). There ws no sttisticlly significnt difference between the two ctegories in MS type, DMT use, presenting neurologic symptoms, number of MRIs ordered, presence of UTI, visit outcome, or use of nurse on cll services before ED presenttion. Ctegory 1 visits hd higher percentge 292

4 Tble 2. Ptient chrcteristics nd visit outcomes by visit ctegory Vrible Ctegory 1 Ctegory 2 Ctegory 3 MS Emergency Deprtment Visits F rtio or likelihood rtio P vlue Age, men, y Disese durtion, men, y Mle sex, % RRMS, % DMT, % MRI ordered, % <.0001 Positive MRI findings, % <.0001 Any infection, % UTI, % Visit outcome of dmission to neurology, % Nurse on cll contct, % Corticosteroids, % <.0001 New relpse, % <.0001 Abbrevitions: DMT, disese-modifying therpy; MRI, mgnetic resonnce imging; RRMS, relpsing-remitting multiple sclerosis; UTI, urinry trct infection. Sttisticlly significnt. Tble 3. χ 2 test compring ctegories 1 nd 2 Vrible Ctegory 1 Ctegory 2 χ 2 P vlue Mle sex, % MS type, % DMT, % Motor symptoms, % Sensory symptoms, % Visul symptoms, % Coordintion symptoms, % Sphincter symptoms, % MRI ordered, % Positive MRI results, % Any infection, % UTI, % Visit outcome of dmission to neurology, % Nurse on cll contct, % Corticosteroids, % True relpse, % Abbrevitions: DMT, disese-modifying therpy; MRI, mgnetic resonnce imging; MS, multiple sclerosis; UTI, urinry trct infection. Sttisticlly significnt. Discussion We studied ED visits of ptients with MS over 1 yer. We strtified ED visits bsed on the presenting symptoms into three ctegories: new neurologic, worsening of preexisting neurologic, nd nonneurologic symptoms (ctegories 1, 2, nd 3, respectively). The strtified ctof positive MRI findings (33.3% of ll ctegory 1 visits nd 52% of MRIs performed in this ctegory) compred with ctegory 2 (13.7% of ll ctegory 2 visits nd 28% of MRIs performed in this ctegory). However, the difference between the two groups in MRI positivity ws not sttisticlly significnt. There were 27 visits in which new relpse ws determined (20 in ctegory 1, seven in ctegory 2, nd zero in ctegory 3) nd 70 visits in which new relpse ws excluded or not considered (13 in ctegory 1, 22 in ctegory 2, nd 35 in ctegory 3). Tbles 4 nd 5 show the results of t nd χ 2 tests, respectively, compring visits in which new MS relpse ws determined (regrdless of the visit ctegory) with those in which new relpse ws excluded (ED visits tht were initilly determined to be unrelted to MS were not included in this nlysis). Visits with new relpse were more likely to occur in younger ptients with short disese durtion, femle ptients, those with relpsing-remitting MS, nd ctegory 1 ptients, especilly those with new motor, sensory, or coordintion deficits. They were more likely to undergo new MRI, to hve positive findings on MRI, nd to receive corticosteroids. They were less likely to hve n ssocited infection. There ws no sttisticlly significnt difference between the two groups in DMT use, visul or sphincteric presenttion, nd presence of UTI. Tble 4. T test for continuous numericl vribles by new relpse versus no relpse Vrible True relpse No relpse F rtio P vlue Age, men, y Disese durtion, men, y Sttisticlly significnt

5 Abboud et l. Tble 5. χ 2 Test for ctegoricl vribles by new relpse versus no relpse Vrible True relpse No relpse Likelihood rtio P vlue Mle sex, % RRMS, % No DMT, % Motor symptoms, % Sensory symptoms, % <.0001 Visul symptoms, % Coordintion symptoms, % Sphincteric symptoms, % Ctegory 1, % <.0001 MRI ordered, % Positive MRI results, % <.0001 Any infection, % UTI, % Corticosteroids, % <.0001 Abbrevitions: DMT, disese-modifying therpy; MRI, mgnetic resonnce imging; RRMS, relpsing-remitting multiple sclerosis; UTI, urinry trct infection. Sttisticlly significnt. egories differed significntly in the prevlence of new MS relpse, which ws significntly more prevlent in ptients in ctegory 1. When studying ptients with new MS relpse s group regrdless of the visit ctegory, they were more likely to be younger femles with erly relpsingremitting disese. Indeed, they were more likely to belong to ctegory 1, with new neurologic symptoms, especilly motor, sensory, or coordintion dysfunction, wheres visul nd sphincteric symptoms were less specific for true relpse. The commonness of Uhthoff s phenomenon 11 nd UTIs in MS cn probbly explin why visul nd sphincteric symptoms were less indictive of true relpse. 12,13 Although we expected sensory symptoms to lso be less specific, the present dt did not support this. The rtes of DMT use nd presence of UTIs were not different between visits with nd without true relpses. We found tht more thn one-third of ptients presenting with new neurologic symptoms do not hve new MS relpse; rther, their new neurologic symptoms were ttributed to vriety of other cuses. Symptoms tht re typicl for MS (seizures, pinless vision loss, profound cognitive decline, etc.) should rise suspicion for lterntive etiologies. Creful clinicl exmintion of ptients with MS presenting with typicl neurologic symptoms cn reduce the number of unnecessry interventions (eg, vitreous hemorrhge on fundus exmintion, dermtologic mnifesttions of septic emboli). In ddition, lrge number of ptients presenting with new neurologic symptoms were found to hve UTIs. Most of these ptients presented with new sensory chnges tht were probbly the result of previous symptomtic relpses unmsked by UTIs. This possibility is supported by the bsence of rdiogrphic ctivity on MRI, the bsence of other neurologic symptoms, nd the improvement fter ntibiotic drug tretment seen in those ptients. This reinforces the common prctices of not treting pure sensory relpses in MS nd checking urine in ptients with new sensory symptoms even in the bsence of urinry symptoms. However, it is importnt to note tht visits with true relpse did not differ significntly from visits without true relpse in the prevlence of UTIs, nd, therefore, positive urinlysis finding in itself should not be considered predictor of pseudorelpse, nd ech cse should be evluted individully. The yield of obtining new MRI in ptients with new neurologic symptoms ws surprisingly low becuse only pproximtely 50% of MRIs ordered in this ctegory showed evidence of rdiogrphic disese ctivity. This underlines the importnce of considering the ptient s overll clinicl findings before proceeding to MRI (eg, ptients with new but mild sensory symptoms nd positive urinlysis results should not undergo imging). Note, however, tht spinl MRI ws not performed in every cse, nd, therefore, some rdiologic ctivity my hve been missed in this cohort. Moreover, most MRI studies were performed using conventionl 1.5-T mgnet, which hs low sensitivity to smll nd corticl lesions. In ctegory 2, ptients who presented with worsening of preexisting neurologic symptoms hd significntly lower rte of true relpse with n expectedly low yield of new MRI compred with ptients in ctegory 1. Despite tht, these ctegories did not differ in the number of MRIs ordered nd the rte of neurology dmissions; therefore, this group represents the highest need for qulity improvement in ED triging. Secondry cuses should be presumed unless there is quntifible worsening in neurologic exmintion findings compred with previous documenttions. A thorough serch for secondry cuses is crucil, nd new neurologic dignostic nd therpeutic interventions should be kept to minimum nd for few selected cses. In ctegory 3, ptients with nonneurologic presenttions were older, with longer disese durtion nd less use of DMTs. These visits were often hndled ppropritely without unnecessry interventions except for smll number of unnecessry neurology dmissions. 294

6 It is importnt to note tht the Clevelnd Clinic is high-volume center for ptients with MS. 14 The ED physicins nd neurologists re well experienced with MS; therefore, the rtes of unnecessry interventions presented in this study cnnot be generlized to other centers. The true rtes of unnecessry MRIs, corticosteroid tretments, nd neurology dmissions in the community my be substntilly different from the numbers presented herein. This underlines the importnce of estblishing unified triging system for ptients with MS in the ED becuse even in well-experienced highvolume centers, the rte of unnecessry interventions is Ptient eduction, encourge telephone clls to report symptoms Is the new symptom pure sensory or minor nd tolerble? HOME ED Ctegory 1: New neurologic symptoms Is the neurologic symptom disbling? (Requires rehbilittion, swllow evlution, etc.) Admit to neurology, updte MRI, IV corticosteroids s n inptient if indicted, rehbilittion evlution, etc. Is ptient mediclly stble? * My order MRI in the ED to document brekthrough disese, IV corticosteroids in the ED nd then s n outptient if indicted Recommend evlution in ED Ctegory 2: Worsening of preexisting neurologic symptoms Is there significnt nd quntifible chnge in neurologic exmintion results from bseline? Is ptient ble to tke cre of himself or herself t home? Figure 1. Algorithm for pproprite mngement of ptients with multiple sclerosis (MS) with new symptoms ED, emergency deprtment; IV, intrvenous. *If there is significnt nd quntifible chnge in neurologic exmintion results, urinlysis (UA) nd infectious work-up should be ordered, but further neurologic evlution, including mgnetic resonnce imging (MRI), should lso be pursued regrdless of the results of the lbortory tests. UA, infectious work-up, evlute common MS medicl complictions 295 MS Emergency Deprtment Visits still reltively high, t lest in certin visit ctegories. In ddition, there ws very low rte of telephone clls to the outptient tem or the nurse/resident on cll before ED presenttion in ll visit ctegories. This highlights the importnce of educting ptients nd providing them with esy ccessibility to the treting tem. Most ptients who hd no hospitl needs nd were, therefore, dischrged from the ED could hve been hndled entirely over the telephone. The dt cptured in this study do not represent the ptients who do cll their outptient tem to report new symptoms/problems. Those ptients, in our experience, rrely end up in the ED. A well-implemented triging system cn Outptient mngement: UA, outptient IV corticosteroids, etc. Ctegory 3: MS-relted medicl complictions, no neurologic symptoms Admit to pproprite service or send home with outptient follow-up, void unnecessry MRIs, neurology consults, dmissions, nd corticosteroids reduce the cost of ED visits nd subsequent hospitl dmissions significntly. In study by Lery nd collegues, 10 implementing proctive cse mngement system of ptients with MS including generl guidelines to the ED reduced hospitl bed use by pproximtely 90%. Their study highlighted the strong effect of proper triging of ptients with MS on improving cute mngement. The role of MS nurse specilists in triging ptients seems to be pivotl in tht process nd should be used on lrger scle. 15 Ares for Improvement nd Estblishing Triging System The following potentil res of improvement were identified for ech group: for ctegory 1 (new neurologic symptoms), there ws moderte number of unnecessry MRIs ordered; for ctegory 2 (worsening

7 Abboud et l. neurologic symptoms), there ws significnt number of unnecessry MRIs nd neurology dmissions; for ctegory 3 (nonneurologic symptoms), there ws smll number of unnecessry neurology dmissions; nd for ll visit ctegories, there were few telephone clls mde to the outptient tem before ED presenttion. Bsed on these potentil res of improvement, we propose simple triging system for ptients with MS t home nd in the ED (Figure 1). Study Limittions There re severl limittions to this study. First, the triging system is bsed on ptterns of mishndling ptients in the ED, but it hs not been tested for its utility or benefit. As next step, we pln to gther postimplementtion dt to compre with the dt presented herein to test whether the triging system trnsltes into prctice improvement. Second, we did not nlyze the ctul cost of ED visits nd subsequent hospitl dmissions. However, this study ws ment to identify unnecessry interventions tht cn be eliminted when hndling ptients with MS in the ED nd ws not ment to be comprehensive economic study. Studying the economic spects of the ED triging system is n importnt re for future reserch. Third, this study ws bsed on medicl record review, with its inherent documenttion nd reporting bises, which might hve confounded the results. Conclusion A lrge number of unnecessry investigtions nd hospitl dmissions cn be voided in MS visits to the PrcticePoints Educting ptients with MS nd encourging communiction with the outptient tretment tem cn reduce unnecessry visits to the emergency deprtment (ED). A triging system bsed on symptom strtifiction my reduce unnecessry interventions nd hospitl dmissions. Ptients presenting with new neurologic symptoms re more likely to hve new relpse thn ptients presenting with worsening of preexisting symptoms. The prevlence of urinry trct infection (UTI) is the sme in ptients presenting with new relpse nd those without true relpse; therefore, the presence of UTI in itself should not determine the course of ction tken in the ED. ED. A well-implemented triging system for ptients with MS in the ED bsed on symptom strtifiction hs the potentil for improving ptient cre nd reducing unnecessry costs. This should be combined with efforts to reduce ED visits by encourging telephone clls to the outptient tretment tem before ED presenttion. o Finncil Disclosures: Dr. Abboud receives honorri from Genzyme Corp. Dr. Bermel receives fees s pid consultnt, speker, or member of n dvisory committee for Biogen Idec Inc, Genentech Inc, Genzyme Corp, Medscpe, nd Novrtis Interntionl AG; nd receives or hs the right to receive roylty pyments for inventions or discoveries commercilized through Biogen Idec Inc. Dr. Willis receives fees s pid consultnt, speker, or member of n dvisory committee for Biogen Idec Inc nd Genzyme Corp. The other uthors hve no conflicts of interest to disclose. References 1. Prescott JD, Fctor S, Pill M, et l. Descriptive nlysis of the direct medicl costs of multiple sclerosis in 2004 using dministrtive clims in lrge ntionwide dtbse. J Mng Cre Phrm. 2007;13: Mroney M, Hunter SF. Implictions for multiple sclerosis in the er of the Affordble Cre Act: clinicl overview. Am J Mng Cre. 2014;20(suppl 11):S220 S Kobelt G, Berg J, Atherly D, Hdjimichel O. Costs nd qulity of life in multiple sclerosis: cross-sectionl study in the United Sttes. Neurology. 2006;66: Ld SP, Chpmn CH, Vninetti M, et l. Socioeconomic trends in hospitliztion for multiple sclerosis. Neuroepidemiology. 2010;35: Whetten-Goldstein K, Slon FA, Goldstein LB, Kuls ED. A comprehensive ssessment of the cost of multiple sclerosis in the United Sttes. 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