scholarly journals Responsivity of Utilization Rates to the Intensity of Case Management over Time Among High-Utilizing Adults with Sickle Cell Disease

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 5803-5803
Author(s):  
Wally R Smith ◽  
Daniel Sop ◽  
Shirley Johnson ◽  
Thokozeni Lipato ◽  
Sarah Hartigan
Keyword(s):  
Sickle Cell Disease ◽  
Case Management ◽  
Sickle Cell ◽  
Medical Center ◽  
Academic Medical Center ◽  
Fiscal Year ◽  
Cell Disease ◽  
Outpatient Visits ◽  
Academic Medical ◽  
Over Time

Background: Case management (CM) and community health workers (CHWs) are two evidence-based health management strategies that can help reduce health risks, reduce readmission rates, and improve patient-provider relationships, all of which may be suboptimal in adults with sickle cell disease (SCD). In Fiscal Year (FY) 2016, the actual average vs. expected average length of stay (ALOS) among SCD adults at Virginia Commonwealth University Medical Center (VCU), an urban academic medical center, was 6.7 days vs 4.2 days. The 30-day readmission rate was 33.7%. We have previously presented results of a year-long pilot CM and CHW intervention for five of VCU's highest adult SCD utilizers, measured by calendar year (CY) 2015 VCU charges (Sop, et al., Blood 2017). Comparing CYs 2015 and 2016, there were numeric improvements in inpatient discharges, 30-day readmissions, 3-Day Emergency Department (ED) returns, ED discharges, outpatient visits, inpatient days, and total VCU charges. Herein, we show results of an extension of the pilot to evaluate responsivity to change over time: whether these improvements were lost among these same patients in the subsequent year (CY 2017) with diminished CM due to loss of funding, and whether they recurred in CY 2018, when CM was more robust as a result of new, more stable funding. Methods: Using the VCU charge and utilization database, we compared the above utilization variables for the five highest CY 2015 utilizers in CYs 2018, 2017, 2016 and 2015. The five original patients included 2 males and 3 females aged between 25-31 years old. One of the females passed away in 2016. Results: There was a trend toward numerically lower utilization during the two CM and CHW years (2016 and 2018), compared to the two diminished CM years (2015 and 2017). Inpatient discharges, inpatient days, and total charges see-sawed according to the intensity of intervention, going down during the year of the initial intervention, rising during the year after intervention, and going down again with resumption of intervention. However, there were notable exceptions: 30-day re-admissions were the lowest in 2017 a diminished intervention year; 3-day ED returns were flat throughout; ED discharges declined throughout, and; outpatient visits rose throughout. Conclusions: These pilot results must be interpreted with caution, since the sample was very small, and interventions were not standardized or randomized, so that secondary trends could be excluded. We found that, after diminution in 2017 of an initial CM and CHW intervention in 2016, several of the initial 2015-to-2016 improvements in academic medical center utilization for five high-utilizing adult SCD patients deteriorated. Subsequently, these improvements recurred when CM and CHWs were reapplied in 2018. We also found that other utilization improvements were sustained despite diminution or resumption of the intervention. This pilot result lays the groundwork for larger, more rigorous CM and CHW Table Disclosures Smith: Novartis: Consultancy, Honoraria. Lipato:Novartis: Honoraria.

scholarly journals Impact of the COVID19 Pandemic on Admissions and Emergency Department Visits of Adults with Sickle Cell Disease

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 37-38
Author(s):  
Alice J. Cohen
Keyword(s):  
Emergency Department ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Medical Center ◽  
Cell Disease ◽  
Face To Face ◽  
Outpatient Visits ◽  
Pain Medications ◽  
Time Period ◽  
Ed Visits

Background: The most common complication of sickle cell disease (SCD) in adults is vaso-occlusive crisis that is characterized by severe pain. These events can often be managed at home with oral analgesics, but if the pain is not controlled or the patient develops other associated problems, they seek care in an emergency department (ED). In the ED, they receive initial treatment with pain medications and are assessed for other complications such as infection and acute chest syndrome. If an individual's pain is not controlled in a short period of time, the majority of these patients are admitted to the hospital for inpatient management or placed in an observation unit (OBs) for 6-47 hours. The COVID-19 pandemic affected the Greater Newark community starting in mid March with the majority of all inpatient admissions (Ads) being COVID related through the end of May. It has been observed both at our medical center and nationally that during this time period and even afterwards, the number of ED visits and Ads had significantly fallen. The reasons for this finding may include fear of contracting COVID infection at the hospital, regular telemedicine (TM) calls to facilitate outpatient management, and an increase in the number of prescriptions of home pain medications. The purpose of this analysis was to examine patterns of ED visits, Ads, outpatient visits, prescription renewals and nurse (RN) and social worker (MSW) calls in order to determine the impact of COVID-19 infection on the local SCD community. Methodology: A retrospective review was undertaken of billing data and the EMR of all patients with SCD treated at Newark Beth Israel Medical Center (a 450 bed community-based academic tertiary care medical center) between January 2020 and June 2020. Data collected included the number of and reason for ED and OBs, Ads, the number of TM and outpatient visits, and MSW and RN telephone contacts. All patients 18 years of age and older were included. Overall, 100 adults with SCD received care between January and June. Results: Peak hospital COVID Ads, ED and OBs for all patients (SCD and non-SCD) occurred during the weeks between March 25 and May 24, 2020 with a daily inpatient census over 200 between April 7 and 24. SCD Ads at peak COVID (April-May) were significantly lower at 26±2/month compared to 64±11/month pre-COVID (January-February) (p= 0.04). ED and OBs were unchanged. During the peak of COVID, 10/93 (11%) SCD Ads (1 death) were COVID related with 80/96 (86%) for uncomplicated pain crises. MSW and RN called all patients proactively to offer support at onset of COVID pandemic. During this same time period, the number of MSW telephone contacts increased from 138±37/month pre-COVID to 372±21/month during COVID (p=0.02). RN contacts with SCD patients were stable and mostly were for pain prescription renewals. TM was initiated in March 2020 and an increase in these visits correlated with a fall in face to face physician visits: 83.5±11/month pre-COVID to 39.5±8/month peak COVID (p= 0.04), and TM 0/month pre-COVID and 31±4/month peak COVID (0.01). Conclusion: The outbreak of COVID-19 in the community reduced the number of Ads for patients with SCD without an increase in ED and OBs visits. MD face-to-face encounters were reduced but outpatient care continued with the initiation of TM, regular RN contact with maintenance of pain medication prescriptions and a greater numbers of MSW calls for psychosocial support. Further investigation and understanding of the use of Ads for SCD care, and the reduction during COVID, may have implications for current SCD management. Disclosures Cohen: GBT: Speakers Bureau.

scholarly journals Diagnosis patterns of sickle cell disease in Ghana: a secondary analysis

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Alexandra M. Sims ◽  
Kwaku Osei Bonsu ◽  
Rebekah Urbonya ◽  
Fatimah Farooq ◽  
Fitz Tavernier ◽  
...  
Keyword(s):  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Screening Program ◽  
Medical Center ◽  
Academic Medical Center ◽  
Sub Saharan Africa ◽  
Cell Disease ◽  
Mortality And Morbidity ◽  
Pain Crisis ◽  
First Pain

Abstract Background Despite having the highest prevalence of sickle cell disease (SCD) in the world, no country in Sub-Saharan Africa has a universal screening program for the disease. We sought to capture the diagnosis patterns of SCD (age at SCD diagnosis, method of SCD diagnosis, and age of first pain crisis) in Accra, Ghana. Methods We administered an in-person, voluntary survey to parents of offspring with SCD between 2009 and 2013 in Accra as a part of a larger study and conducted a secondary data analysis to determine diagnosis patterns. This was conducted at a single site: a large academic medical center in the region. Univariate analyses were performed on diagnosis patterns; bivariate analyses were conducted to determine whether patterns differed by participant’s age (children: those < 18 years old whose parents completed a survey about them, compared to adults: those > = 18 years old whose parents completed a survey about them), or their disease severity based on SCD genotype. Pearson’s chi-squared were calculated. Results Data was collected on 354 unique participants from parents. Few were diagnosed via SCD testing in the newborn period. Only 44% were diagnosed with SCD by age four; 46% had experienced a pain crisis by the same age. Most (66%) were diagnosed during pain crisis, either in acute (49%) or primary care (17%) settings. Children were diagnosed with SCD at an earlier age (74% by four years old); among the adults, parents reflected that 30% were diagnosed by four years old (p < 0.001). Half with severe forms of SCD were diagnosed by age four, compared to 31% with mild forms of the disease (p = 0.009). Conclusions The lack of a robust newborn screening program for SCD in Accra, Ghana, leaves children at risk for disease complications and death. People in our sample were diagnosed with SCD in the acute care setting, and in their toddler or school-age years or thereafter, meaning they are likely being excluded from important preventive care. Understanding current SCD diagnosis patterns in the region can inform efforts to improve the timeliness of SCD diagnosis, and improve the mortality and morbidity caused by the disease in this high prevalence population.

scholarly journals Implementation of a Community Hospital-Based Fast Track Pathway for the Treatment of Acute Pain Episodes in Adults with Sickle Cell Disease

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 4854-4854 ◽  
Author(s):  
Richard Lottenberg ◽  
Robert Krywicki ◽  
Gurinder Doad ◽  
Witemba Kabange ◽  
Monisola Modupe ◽  
...  
Keyword(s):  
Sickle Cell ◽  
Fast Track ◽  
Community Hospital ◽  
Medical Center ◽  
Academic Medical Center ◽  
Cell Disease ◽  
Observation Unit ◽  
Academic Medical ◽  
The Mean

Abstract Background: A growing number of adult patients with sickle cell disease (SCD) receive care in a community setting and often lack access to physicians with sickle cell expertise. To address this healthcare disparity we are testing a co-management medical home model with Hematology/Oncology (H/O) and Family Medicine (FM) physicians to facilitate evidence-based acute and chronic care. An Emergency Department (ED) Observation Unit based pathway for treatment of sickle cell pain developed at an academic medical center with a Comprehensive Sickle Cell Center (CSCC) has been adopted and modified to fit the needs of a community multi-specialty hospital with an unopposed FM residency program. The hospital serves a large sickle cell population in a predominantly rural setting with the closest CSCC 180 miles away. Methods: Pathway development was facilitated by having a formal meeting for the community hospital physicians and staff at the academic medical center and sickle cell experts providing ongoing on site consultation at the community hospital. Protocols for the community hospital were produced with input from physicians, nurses, advanced practice providers, and support services at multiple meetings. Adult patients with SCD presenting to the ED with pain are triaged at Emergency Severity Index Level 2 for evaluation by the ED physician. The ED protocol uses specific criteria to identify patients with uncomplicated pain. Patients presenting with abnormal vital signs (other than mild tachycardia), fever, pregnancy, or apparent other sickle cell-related complications are excluded. Patients qualifying for the pathway are directly admitted to the SCD unit (a hospital room with 4 infusion chairs on the H/O floor exclusively designated for care of sickle cell patients). Following intake evaluation by the nurse, a clinician is notified to evaluate the patient and provide orders for intravenous fluids and opioid patient controlled analgesia (PCA) which is administered according to hospital guidelines. PCA by the subcutaneous route is used if intravenous access is not readily available. A CBC is obtained whereas other laboratory testing and imaging studies are ordered based on clinical indications. H/O physicians and nurse practitioners cover the unit weekdays 8:00am-5:00pm and FM residents cover nights and weekends with back up by the on call H/O physician. Patients can be treated in the SCD unit up to 23 hours. For patients discharged home a follow up phone call by an H/O nurse will be placed within 3 days and an outpatient clinic appointment is scheduled to be within 7 days. Monthly quality assurance meetings are attended by H/O, FM, and ED physicians as well as nursing, pharmacy and administrative staff from the ED and H/O inpatient service to review process issues and patient outcomes. Consultation is provided by academic physicians with sickle cell expertise (H/O and ED) who attend each meeting in person or by conference call. Results: From March 5-June 30, 2014, 67 patients accounted for 271 visits to the SCD unit. The mean time in the unit was 13.6 hours. The mean pain score on admission was 8.7/10 and reduced to 4.9 upon discharge. PCA drug, pump setting, and dosage are recorded to be used for future visits. Over the 4 months 91.1% of the patients were discharged home from the unit. Six patients accounted for 31% (84) of the visits with only 4 hospital admissions. Conclusions: A fast track pathway for the treatment of acute sickle cell pain coordinated between ED, H/O, and FM physicians has been implemented at a community hospital using an Observation Unit based treatment program. During the entire initial experience the majority of patients have been discharged home with adequate pain relief. In the future the impact of the program will be evaluated including effect on frequency of hospitalizations, outpatient follow up, patient satisfaction, and cost effectiveness. The pathway can be adapted to other community hospital settings where sickle cell expertise is not locally available. Disclosures Kutlar: NIH/NIMHD: Research Funding.

Growth and Management of Repaired Complete Tracheal Rings after Slide Tracheoplasty

2019 ◽  
Vol 161 (1) ◽  
pp. 164-170 ◽  
Author(s):  
Lyndy J. Wilcox ◽  
Claudia Schweiger ◽  
Catherine K. Hart ◽  
Alessandro de Alarcon ◽  
Nithin S. Peddireddy ◽  
...  
Keyword(s):  
Medical Center ◽  
Academic Medical Center ◽  
Balloon Dilation ◽  
Case Series ◽  
Slide Tracheoplasty ◽  
Time Period ◽  
Academic Medical ◽  
Operative Notes ◽  
Over Time

ObjectiveThis study documents the growth and course of repaired complete tracheal rings over time after slide tracheoplasty.Study DesignCase series with review.SettingTertiary pediatric academic medical center.Subjects/MethodsMedical records of pediatric patients with confirmed tracheal rings on bronchoscopy who underwent slide tracheoplasty between January 2001 and December 2015 were reviewed. Patients who had operative notes documenting tracheal sizing over time were included. Exclusion criteria included tracheal stenosis not caused by complete tracheal rings, surgical repair prior to presentation at our institution, or lack of adequate sizing information. The postoperative follow-up was examined and airway growth over time documented.ResultsOf 197 slide tracheoplasties performed during the study time period, 139 were for complete tracheal rings, and 40 of those children met inclusion criteria. The median age at time of surgery was 7 months, and the median initial airway size was 3.9 mm (n = 34). The median growth postoperatively was 1.9 mm over a median follow-up period of 57 months (0.42 mm/year), which is similar to growth rates of unrepaired complete tracheal rings ( P = .53). Children underwent a median of 10 postoperative endoscopies, with time between endoscopies increasing further out from surgery. The most commonly performed adjunctive procedure was balloon dilation.ConclusionsThis is the first study documenting continued growth of repaired complete tracheal rings after slide tracheoplasty. Postoperative endoscopic surveillance ensures adequate growth. Intervals between airway endoscopies can be increased as the child gets older, as the airway increases in size, and as long as symptoms are minimal.

Clinical Transformation in Care for Patients With Sickle Cell Disease at an Urban Academic Medical Center

2019 ◽  
Vol 35 (3) ◽  
pp. 236-241
Author(s):  
Sanaa Rizk ◽  
David Axelrod ◽  
Gaye Riddick-Burden ◽  
Elisabeth Congdon-Martin ◽  
Steven McKenzie ◽  
...  
Keyword(s):  
Sickle Cell Disease ◽  
Case Studies ◽  
Sickle Cell ◽  
Academic Medical Center ◽  
Thomas Jefferson ◽  
Cell Disease ◽  
Observation Unit ◽  
Quantitative Analyses ◽  
Clinical Transformation ◽  
The Impact

This article demonstrates effects on utilization of a clinical transformation: changing locus of care from a dedicated sickle cell day unit to an approach that “fast-tracks” patients through the emergency department (ED) into an observation unit with 24/7 access. Retrospective quantitative analyses of claims and Epic electronic medical record data for patients with sickle cell disease treated at Thomas Jefferson University (inpatient and ED) assessed effects of the clinical transformation. Additionally, case studies were conducted to confirm and deepen the quantitative analyses. This study was approved by the Thomas Jefferson University Institutional Review Board. The quantitative analyses show significant decreases in ED and inpatient utilization following the transformation. These effects likely were facilitated by increased observation stays. This study demonstrated the impact on utilization of transformation in care (from dedicated day unit to an approach that fast-tracks patients into an observation unit). Additional case studies support the quantitative findings.

scholarly journals Improved survival of children and adolescents with sickle cell disease

Blood ◽  
2010 ◽  
Vol 115 (17) ◽  
pp. 3447-3452 ◽  
Author(s):  
Charles T. Quinn ◽  
Zora R. Rogers ◽  
Timothy L. McCavit ◽  
George R. Buchanan
Keyword(s):  
Sickle Cell Disease ◽  
Young Children ◽  
Medical Care ◽  
Children And Adolescents ◽  
Sickle Cell ◽  
Care Quality ◽  
Transition To Adult Care ◽  
Cell Disease ◽  
Over Time

Abstract The survival of young children with sickle cell disease (SCD) has improved, but less is known about older children and adolescents. We studied the Dallas Newborn Cohort (DNC) to estimate contemporary 18-year survival for newborns with SCD and document changes in the causes and ages of death over time. We also explored whether improvements in the quality of medical care were temporally associated with survival. The DNC now includes 940 subjects with 8857 patient-years of follow-up. Most children with sickle cell anemia (93.9%) and nearly all children with milder forms of SCD (98.4%) now live to become adults. The incidence of death and the pattern of mortality changed over the duration of the cohort. Sepsis is no longer the leading cause of death. All the recent deaths in the cohort occurred in patients 18 years or older, most shortly after the transition to adult care. Quality of care in the DNC has improved over time, with significantly more timely initial visits and preventive interventions for young children. In summary, most children with SCD now survive the childhood years, but young adults who transition to adult medical care are at high risk for early death.

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