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Keywords:

  • emergency department visit;
  • gastric emptying study;
  • hospitalization;
  • knowledge;
  • resource utilization

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Funding
  9. Disclosure
  10. Author Contributions
  11. References
  12. Supporting Information

Background  Recent reports provide a conflicting picture with a stable prevalence of gastroparesis (GP) in a population-based study, but a more than doubling in hospitalizations for gastroparesis within the last 10 years. We hypothesized that this apparent discrepancy is due to changes in disease recognition and coding rather than prevalence.

Methods  Using data from the Nationwide Inpatient Sample, Healthcare cost and utilization project, Agency for Healthcare Research and Quality, we examined time trends of resource utilization for GP and related disorders.

Key Results  Between 1994 and 2009, annual hospitalizations for gastroparesis as primary diagnosis increased more than 18-fold from 918 to 16 736. In the same time frame, hospitalizations for not otherwise specified functional disorders of the stomach decreased by nearly 50% from 13 430 to 6480 per year.

Conclusions & Inferences  Although hospitalizations rates and emergency encounters for gastroparesis have increased dramatically within the last 2 decades, there was a concomitant decrease in resource utilization for other functional disorders of the stomach, suggesting that increased awareness contributed to this trend, which represents a shift in diagnoses rather than a true difference in the incidence and/or prevalence of these illnesses.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Funding
  9. Disclosure
  10. Author Contributions
  11. References
  12. Supporting Information

Gastroparesis (GP) is characterized by chronic upper gastrointestinal symptoms and documented delay in gastric emptying in the absence of mechanical obstruction.1 Most clinicians experience the care of patients with gastroparesis as difficult and frustrating. Difficult control of symptoms and nutritional and metabolic consequences may require prolonged hospitalizations, perhaps leading to the perception of an increasingly common problem. By modeling the likelihood of gastroparesis based on symptoms in the general population, a recent study supports such a view by suggesting a high prevalence of gastroparesis in the general population with up to 2% potentially being affected.2 Consistent with this epidemiologic study, an earlier investigation demonstrated a significant increase in the number of hospitalizations for gastroparesis.3 Although these data suggest that gastroparesis is on the rise, only one study addressed the prevalence of confirmed cases in a defined geographic area. Using the Rochester Epidemiology Project, Jung et al.4 identified persons with proven or possible GP in Olmsted County and did not see significant changes in incidence of prevalence within a 10-year time frame. Interestingly, the time period largely overlaps with that showing a more than 150% increase in hospitalizations for this disorder.3

How can we reconcile this apparent discrepancy? Symptoms of gastroparesis significantly overlap with other disorders. Compared to patients with functional dyspepsia, symptomatic individuals with delayed gastric emptying have similar symptoms, but are more likely to experience more significant nausea and vomiting.5,6 A recent large multicenter study showed that most patients with gastroparesis meet criteria for functional dyspepsia.7 Considering this overlap, we hypothesized that the significant rise in hospitalizations for gastroparesis is due to changes in disease recognition and/or classification rather than prevalence.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Funding
  9. Disclosure
  10. Author Contributions
  11. References
  12. Supporting Information

We examined national trends of gastroparesis-related hospitalization during 1994–2009, using the Nationwide Inpatient Sample (NIS) of the Agency for Healthcare Research and Quality (AHRQ) database. For each year, AHRQ provides projected and weighted national estimates of number of hospitalization, listed as primary or as one of the secondary diagnoses. International Classification of Diseases, Clinical Modification (ICD-9-CM) code 536.3 was used to extract hospitalization due to gastroparesis. Similarly, Nationwide Emergency Department Sample (NEDS) of the AHRQ was used to analyze number of emergency room encounters. As the data are only available for a more recent time frame, we examined encounters from GP from 2006 to 2008. In addition, we used ICD-9 code 536.8 and 536.9 to identify number of hospitalizations and emergency room visits for functional dyspepsia and otherwise not specified functional disorders of the stomach. Demographic information (age and sex distribution), type of primary insurance (Medicare, Medicaid, private, self-pay, and uninsured), length of hospital stay, total charges, and transfer to nursing homes or long-term care facilities and inpatient deaths were abstracted and recorded.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Funding
  9. Disclosure
  10. Author Contributions
  11. References
  12. Supporting Information

Time trends in hospitalizations/emergency encounters

Reviewing time trends based on the NIS data, overall hospitalizations for gastroparesis increased from 11 120 in 1994 to 231 140, amounting to an increase of 207.8% (Fig. 1A). Hospitalizations listing gastroparesis as the primary diagnosis similarly rose about 18-fold from 918 in 1994 to 16 736 in 2009 (Fig. 1B). During the same time period, the total number of hospital discharges increased by only 14.9% from 34 314 247 to 39 434 956, showing the disproportionate increase in hospitalization for this disorder. Although there was a significant rise in the number of hospital admissions due to gastroparesis, inpatient treatment for not otherwise specified functional disorders of the stomach dropped by nearly 40% from 150 935 to 93 935 (Fig. 1).

image

Figure 1.  The line graph shows annual rates of hospitalizations for gastroparesis (white circles) or the two diagnostic codes for functional dyspepsia (black symbols) for the time period between 1994 and 2009. In panel (A), all admissions with gastroparesis or otherwise unspecified functional disorder of the stomach are plotted, whereas panel (B) only includes admissions with these diagnoses coded as primary diagnosis.

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To account for an increasing shift toward outpatient treatment in patients with functional diseases of the gastrointestinal tract, we examined the trends in emergency room visits. Although available data on emergency encounters covered a significantly shorter time frame, the NEDS sample showed an ongoing increase of emergency room encounters due to gastroparesis from 163 149 to 227 075, an increase of nearly 40% within a 4-year time period, while emergency room visits for functional dyspepsia decreased slightly from 180 395 to 177 080 (Fig. 2).

image

Figure 2.  Emergency room visits for gastroparesis (black circles) or functional dyspepsia (white circles) are plotted for the time period between 2006 and 2009.

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Time trends in demographics

To assess changes in sex and age distribution in hospitalized gastroparesis patients, we focused on the period between 1997 and 2009 to minimize variability due to the smaller patient sample size in prior years. Consistent with published case series, there was a consistent female predominance of about 70% for patients with gastroparesis listed as the primary diagnosis, compared with about 65% for the entire group of inpatients admissions with the diagnosis of gastroparesis. As shown in Fig. 3A, there was a slight shift in the age distribution with an increase in the younger age cohorts. A similar pattern was seen in patients hospitalized for functional stomach disorders not otherwise specified; the gender distribution showed less of a female predominance with about 60%. Although the cohort of elderly individuals over the age of 65 years was larger compared with gastroparesis patients, there was a shift over time to younger age cohorts (Fig. 3B).

image

Figure 3.  The relative age distribution of patients hospitalized for gastroparesis (A) or functional dyspepsia (B) is plotted for the time period between 1997 and 2009.

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In parallel with the shift in age cohorts, there was a decrease in primary insurance coverage for the hospitalization. Medicare coverage dropped from 43.8% to 36.1%; interestingly, there was no corresponding change in private insurance coverage, which accounted for about 35% of the hospitalizations. In contrast, the percentage of hospital stays supported by Medicaid rose from 9.9% to 17.6% (Fig. 4). Considering similar age changes over time, a comparable shift was seen in patient with functional dyspepsia.

image

Figure 4.  The distribution of insurance coverage for hospitalizations due to gastroparesis (A) or functional dyspepsia (B) is plotted for the time period between 1997 and 2009.

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Hospital stays and charges

Patients with gastroparesis spent more than twice as many days as inpatients per hospitalization compared with patients diagnosed with not otherwise specified functional disorders of the stomach (Fig. 5A). The mean charges per admission were accordingly higher in gastroparesis (Fig. 5B). During the time period examined, there was a slight decrease in hospital days per admission for gastroparesis compared with an increase in patients with functional dyspepsia. We related these time trends to the recorded length of stay and charges in all patients with gastroduodenal disorders other than hemorrhage and saw stable inpatient days and similar rises in cost.

image

Figure 5.  Length of stay (A) and average charges per hospitalization (B) are plotted for gastroparesis (black circles), functional dyspepsia (white circles), and all gastroduodenal disorders except for those with hemorrhages (white squares) are plotted for the time period between 1997 and 2009.

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Outcome

Data on inpatient mortality were only available for 2002–2009. No patient discharged with the primary diagnosis of functional stomach disorders not otherwise specified died. The total number of deaths remained stable during this time period. However, the significant increase in hospitalization led to a decrease in inpatient mortality rate from 0.83% to 0.13% per annual hospitalizations. As shown in Fig. 6, the fraction of patients discharged to nursing homes or transitional care facilities remained relatively stable over time for gastroparesis and was significantly higher than for patients with functional dyspepsia.

image

Figure 6.  The fraction of admissions resulting in nursing home discharges is plotted for gastroparesis (black circles) and functional dyspepsia (white circles) covering the time period between 1997 and 2009.

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Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Funding
  9. Disclosure
  10. Author Contributions
  11. References
  12. Supporting Information

Using the same large national data bank Wang et al.3 examined, we certainly confirmed the previously reported increase in hospitalization for gastroparesis. Considering the puzzling discrepancy between the rise in admissions for gastroparesis and stable hospitalization rates of individuals with gastroparesis within a predefined geographic area,4 we expanded the time frame of our analysis, noticing an even more dramatic change with an 18-fold increase in admission for gastroparesis as the primary diagnosis between 1993 and 2009. Such a change of nearly endemic proportion within a relatively short time period suggests a shift in diagnostic criteria or approaches with increased recognition, a phenomenon that has been well documented in patients with reflux symptoms and Barrett’s metaplasia.8 The increasing use of endoscopy as diagnostic test in patient with upper gastrointestinal symptoms was associated with a 30-fold increase in the incidence of Barrett’s esophagus over a period of 30 years. Although we were not able to assess the use of gastric emptying studies using this data repository, several points show a parallel development. The principles of scintigraphic assessment of gastric emptying, the current diagnostic test of choice, were introduced more than 40 years.9 However, more cost-effective, standardized and reproducible approaches became available about 2-decades later, with then increasingly widespread use in clinical practice.10,11 Considering the similarity in symptoms between gastroparesis and functional dyspepsia5–7,12 the gradual adoption of gastric emptying tests in clinical practice may well account for the opposing time trends we noted when comparing functional dyspepsia and gastroparesis. The decline in admissions for functional dyspepsia differs from the overall trend of increasing hospitalization frequency, which was not only seen in gastroparesis but was also present for diagnoses based on symptom coding (nausea with or without vomiting), which overlaps with the clinical presentation of gastroparesis and functional dyspepsia (Figure S1, supporting information). Even if the opposing time trends support our interpretation, no study has directly addressed changes in the use of gastric emptying studies over time. As gastric emptying studies do not have a separate ICD-9 code, but are grouped with other assessments under ‘gastrointestinal scan and isotope function’ (ICD-9 code 9204), we could not directly examine time trends in test utilization. It thus remains unclear whether the apparent shift in diagnoses is due to a true increase in cases of gastroparesis caused by more testing of patients (confirmed gastroparesis) or rising awareness about the disorder and its presentation, leading to more diagnoses based on clinical grounds only (possible gastroparesis).

The NIS data do not differentiate between multiple admissions of single individuals and single admissions of multiple individuals. We have previously shown that about 5% of patients account for nearly half of the hospitalizations for gastroparesis.13 Consistent with these results, others estimated that about 10% of patients with gastroparesis fail to respond to conventional medical therapy, often requiring repeated admissions to control symptoms or provide nutritional support.14 Consistent with these results, longitudinal studies suggest that only between 25% and 40% of patients do not require hospitalizations for gastroparesis.4,13 It is thus likely that repeated admissions account for a significant number of the hospitalizations captured in the Nationwide Inpatients Sample, not allowing us to make reliable conclusions about the incidence or prevalence of gastroparesis based on these data. Nonetheless, our analysis points at the influence of recognition and diagnostic coding as key factors in the dramatic rise of hospitalizations for gastroparesis.

The data provide some additional important information that complements case series mostly published based on patients seen in tertiary referral centers. As is true for these defined patient populations, the NIS data show a clear female predominance.4,7,13,15–17 Although these case series demonstrate a wide age range of affected individuals, the NIS data show a relatively high fraction of patients 65 years and older, accounting for nearly 20% of the patients. Considering the increasing prevalence of comorbidities, the common use of multiple medications with potential for adverse effects and the limited information about gastric motility in geriatric patients, it remains unclear whether this discrepancy is due to differences between the more select populations seen in tertiary referral centers and those captured by the NIS data repository. As these administrative data rely on diagnostic coding rather than symptoms and/or test results, we cannot determine the validity of the coded diagnoses. In the absence of data on test utilization, we may extrapolate from prior investigations, which suggest that in tertiary care environments, the diagnosis of gastroparesis is based on clinical suspicion without confirmatory tests in about 40% of cases.4,13 It is certainly unknown whether such a pattern is also seen in other healthcare settings.

The NIS or other large data banks provide rich sources of information about relatively rare disorders, such as gastroparesis. However, the data shed limited or no insight into details of clinical presentation, the basis of a clinical diagnosis and the underlying etiology. Interestingly, we found a more than 10-fold difference between annual hospitalizations for gastroparesis as primary or secondary diagnosis. This discrepancy points at gastroparesis as confounder in other disorders, such as diabetes mellitus, systemic sclerosis, or Parkinson’s disease. Considering differences in the prevalence of these disorders, diabetes will almost certainly be the most common reason for listing gastroparesis as secondary diagnosis, which is consistent with several studies showing that diabetes and poor metabolic control are important risk factors for repeated hospitalizations of patients with gastroparesis.13,18,19 However, the dramatic increase in hospitalizations for gastroparesis as primary or secondary diagnosis cannot be explained by similar trends in hospitalizations for diabetes and its complications. Between 1994 and 2009, admissions with diabetes as the primary diagnosis rose by about 25%, certainly substantially less than seen for gastroparesis (Figure S1).

The insurance coverage for the hospitalizations provides an indirect glimpse at the social context. Consistent with results obtained in North Carolina,20 Medicare and Medicaid were the primary payers accounting for about two-third of the billed admissions. With the shift in age distribution to younger patients, the relative fraction of Medicare payments dropped. Interestingly, there was a parallel increase in uninsured admissions and Medicaid coverage, while the proportion of privately insured admissions fell. These data do not allow conclusions about the economic impact of this chronic disorder. However, they are consistent with our own experience showing that less than one-third of patients with gastroparesis were employed and 60% had an annual household income of less than $40 000.17 Although a larger sample of patients recruited by a consortium sponsored by the National Institute of Diabetes, Digestive and Kidney Diseases (NIDDK) suggested higher median incomes for patients with idiopathic gastroparesis, less than half of the individuals with diabetic gastroparesis had annual incomes of $50 000 or more.21 Consistent with this income picture, only 35% of diabetic patients and 50% of patients with idiopathic gastroparesis were employed.22 Considering a mean age in the early 40s, the aggregate points at the significant economic toll that is associated with or even caused by gastroparesis.

We have little information about the prognosis of gastroparesis. Data from tertiary referral centers report mortality in 4–12% of their cases.13,15,19 The only population-based study demonstrated an increased mortality compared with the general population, which was largely due to cardiovascular complications of diabetes, which often coincide with the development of gastroparesis in this subgroup.4 The NIS data show that a low likelihood of death as outcome for all hospitalizations with gastroparesis as the primary diagnosis, consistent with results reported for hospitalization during a single year (1998) in North Carolina.20 Although the data cover admissions and not individual patients and may thus underestimate the overall likelihood of death, the results still argue against a significant excess mortality caused by gastroparesis.

Even if the impact on life expectancy may not be quite as grim as reported, gastroparesis takes a significant toll. During a follow-up period of 5 years, about 25% of the patients with gastroparesis require at least one hospitalization.4 The duration of these hospital stays has not changed significantly over the last 10 years and constitutes a significant economic burden for individuals and society as evidenced by charges of about $25 000 per hospitalization.3,18

Using an administrative data bank based on hospital charges has advantages and limitations. The NIS contains data from approximately 1000 hospitals on more than 7 million hospital stays each year and was designed to approximate a 20% stratified sample of US. The large sample size allows analyses of rare diseases and provides information that is not skewed by the referral patterns of tertiary care centers. As data were collected over nearly 2 decades, we can extract time trends as described in this article. As hospitalizations and not individual patients are captured in the NIS data, we cannot make inferences about incidence or prevalence. More importantly, diagnostic criteria for gastroparesis are not known and likely vary tremendously from hospital to hospital and over time. This phenomenon likely is the primary reason for the apparent increase in the gastroparesis-associated hospitalizations we noted and others described in the past.3 Despite these shortcomings, the data demonstrate that gastroparesis has a significant impact. It leads to often long hospitalizations. Patients may not only suffer from a chronic illness but also experience the indirect economic impact with loss of productivity, perhaps employment and insurance coverage. The one reassuring piece of information is the relatively low morbidity, which should make us reluctant to pursue overly aggressive strategies.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Funding
  9. Disclosure
  10. Author Contributions
  11. References
  12. Supporting Information

We would like to thank Healthcare cost and utilization project, Agency for Healthcare Research and Quality for allowing us to use their data base.

Author Contributions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Funding
  9. Disclosure
  10. Author Contributions
  11. References
  12. Supporting Information

SN and KB authors contributed to the study design and data analysis. They discussed the results and commented on the manuscript at all stages.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Funding
  9. Disclosure
  10. Author Contributions
  11. References
  12. Supporting Information
  • 1
    Parkman HP, Hasler WL, Fisher RS. American Gastroenterological Association technical review on the diagnosis and treatment of gastroparesis. Gastroenterology 2004; 127: 1592622.
  • 2
    Rey E, Choung RS, Schleck CD, Zinsmeister AR, Talley NJ, Locke GR III. Prevalence of hidden gastroparesis in the community: the gastroparesis “iceberg”. J Neurogastroenterol Motil 2012; 18: 3442.
  • 3
    Wang YR, Fisher RS, Parkman HP. Gastroparesis-related hospitalizations in the United States: trends, characteristics, and outcomes, 1995–2004. Am J Gastroenterol 2008; 103: 31322.
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    Jung H-K, Choung RS, Locke GR III et al. The incidence, prevalence, and outcomes of patients with gastroparesis in Olmsted County, Minnesota, from 1996 to 2006. Gastroenterology 2009; 136: 122533.
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    Fischler B, Tack J, De Gucht V et al. Heterogeneity of symptom pattern, psychosocial factors, and pathophysiological mechanisms in severe functional dyspepsia. Gastroenterology 2003; 124: 90310.
  • 6
    Sarnelli G, Caenepeel P, Geypens B, Janssens J, Tack J. Symptoms associated with impaired gastric emptying of solids and liquids in functional dyspepsia. Am J Gastroenterol 2003; 98: 7838.
    Direct Link:
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    Hasler WL, Parkman HP, Wilson LA et al. Psychological dysfunction is associated with symptom severity but not disease etiology or degree of gastric retention in patients with gastroparesis. Am J Gastroenterol 2010; 105: 235767.
  • 8
    Jung K, Talley N, Romero Y et al. Epidemiology and natural history of intestinal metaplasia of the gastroesophageal junction and Barrett’s esophagus: a population-based study. Am J Gastroenterol 2011; 106: 144755.
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    Shields R, Griffith G, Owen G. Gastric emptying in health and disease. Gastroenterology 1968; 54: 12078.
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    Wright R, Krinsky S. The use of a single gamma camera in radionuclide assessment of gastric emptying. Am J Gastroenterol 1982; 77: 8901.
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    Hasler W, Wilson L, Parkman H et al. Bloating in gastroparesis: severity, impact, and associated factors. Am J Gastroenterol 2011; 106: 1492502.
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    Dudekula A, O’Connell M, K B. Hospitalizations and testing in gastroparesis. J Gastroenterol Hepatol 2011; 26: 127582.
  • 14
    Cutts TF, Luo J, Starkebaum W, Rashed H, Abell TL. Is gastric electrical stimulation superior to standard pharmacologic therapy in improving GI symptoms, healthcare resources, and long-term health care benefits? Neurogastroenterol Motil 2005; 17: 3543.
  • 15
    Soykan I, Sivri B, Sarosiek I, Kiernan B, McCallum RW. Demography, clinical characteristics, psychological and abuse profiles, treatment, and long-term follow-up of patients with gastroparesis. Dig Dis Sci 1998; 43: 2398404.
  • 16
    Anaparthy R, Pehlivanov N, Grady J, Yimei H, Pasricha PJ. Gastroparesis and gastroparesis-like syndrome: response to therapy and its predictors. Dig Dis Sci 2009; 54: 100310.
  • 17
    Bielefeldt K, Raza N, Zickmund SL. Different faces of gastroparesis. World J Gastroenterol 2009; 15: 605260.
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    Uppalapati SS, Ramzan Z, Fisher RS, Parkman HP. Factors contributing to hospitalization for gastroparesis exacerbations. Dig Dis Sci 2009; 54: 24049.
  • 19
    McCallum RW, Lin Z, Forster J, Roeser K, Hou Q, Sarosiek I. Gastric electrical stimulation improves outcomes of patients with gastroparesis for up to 10 years. Clin Gastroenterol Hepatol 2011; 9: 3159.
  • 20
    Bell RA, Jones-Vessey K, Summerson JH. Hospitalizations and outcomes for diabetic gastroparesis in North Carolina. South Med J 2002; 95: 12979.
  • 21
    Parkman HP, Yates K, Hasler WL et al. Clinical features of idiopathic gastroparesis vary with sex, body mass, symptom onset, delay in gastric emptying, and gastroparesis severity. Gastroenterology 2011; 140: 1015.
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    Parkman HP, Yates K, Hasler WL et al. Similarities and differences between diabetic and idiopathic gastroparesis. Clin Gastroenterol Hepatol 2011; 9: 105664.

Supporting Information

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Funding
  9. Disclosure
  10. Author Contributions
  11. References
  12. Supporting Information

Figure S1. Hospitalizations secondary to diabetes (white squares), gastroparesis (black circles), vomiting (white triangles), and all admission (white circle) are plotted for the time period between 1994 and 2009.

FilenameFormatSizeDescription
NMO_2002_sm_figS1.TIF2625KSupporting info item

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