Optimizing the Economic Impact of Sickle Cell Hospitalization By Effective Care Plans

Background: Adults with sickle cell disease (SCD) vaso-occlusive crisis (VOC) frequently seek care in the emergency department (ED) which often results in hospital admissions. The Hematology-Oncology at Ellis Fischel Cancer Center collaborated with organization's ED to develop and implement individualized care plans for adults with SCD presenting to the ED with the goal of adequate outpatient management, reduction in hospital admissions and optimizing the economic impact of sickle cell hospitalization. Methods: Baseline data was collected from November 2014 through June 2018. Medical Director, Oncology Unit Manager, and Performance Improvement Professional (PIP) collaborated with the ED Medical Director and representatives to develop a disease-specific individualized acute care plan for our adult SCD patient population. 100% case were reviewed by PIP and bi-monthly aggregate case review were done by the Medical Director/Unit Manager. The care plan include pathways for lab collection, pain medication regimens, prescription opioid refill policies, a timeline for outpatient follow-up, and criteria for hospital admission. These care pathways were then transitioned to order sets within the organization's electronic medical record. Results: Implementation of the SCD care plans resulted in significant improvement of length of stay(LOS) index indicating better management during the hospital stay, resulting in reduction of the inpatient pharmacy cost per encounter in half as mentioned in Table 1. Admissions per patient did not change significantly, but ED visits per patient went down and clinic visits per patient went up pointing to better management outside of acute care as shown in Table 2. Last 4 quarters of this study showed marked decrease in cost per patient as indicated in Table 3. Conclusions: This study clearly demonstrates that collaboration with the ED and development of care plans can improve the overall patient care for this population resulting in better outpatient management. Implementing this protocol has not only improved the patient experience but also has decreased the financial toxicity for the patient and the institution. We would encourage other institutions to implement such protocol in the ED and in the outpatient setting to meet the patient needs. Table 3 Disclosures No relevant conflicts of interest to declare.

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Role of effective care plans in reducing admissions for sickle cell patients.

Journal of Clinical Oncology ◽

10.1200/jco.2018.36.30_suppl.156 ◽

2018 ◽

Vol 36 (30_suppl) ◽

pp. 156-156

Author(s):

Bilawal Ahmed ◽

Tami Day ◽

Cara Hirner ◽

Michael Trendle ◽

Jonathan Heidt ◽

...

Keyword(s):

Length Of Stay ◽

Sickle Cell ◽

Patient Population ◽

Hospital Admissions ◽

Average Length ◽

Medical Director ◽

Care Plan ◽

Care Plans ◽

Average Length Of Stay ◽

Individualized Care

156 Background: Adults with sickle cell disease (SCD) vaso-occlusive crisis (VOC) frequently seek care in the emergency department (ED) which often results in hospital admissions. The Hematology-Oncology at Ellis Fischel Cancer Center collaborated with organization’s ED to develop and implement individualized care plans for adults with SCD presenting to the ED with the goal of adequate outpatient management and a reduction in hospital admissions. Methods: Baseline data collected from November 2014 through December 2016 indicated that 108 SCD patients accounted for 195 inpatient hospital admissions, and 40% of all 30-day readmissions for the Hematology-Oncology service line. Further, the average length of stay for patients admitted for SCD crisis was 6.8 days per stay. Medical Director, Oncology Unit Manager, and Performance Improvement Professional collaborated with the ED Medical Director and representatives to develop a disease-specific acute care plan for our adult SCD patient population. The care plan include pathways for lab collection, pain medication regimens, prescription opioid refill policies, a timeline for outpatient follow-up, and criteria for hospital admission. These care pathways were then transitioned to order sets in within the organization’s electronic medical record. Results: Implementation of the SCD care plans resulted in significant improvement in the 30-day readmission rate among the SCD patient population, from 40% to 3%. Further, use the SCD care plans helped reduce the average length of stay for patients admitted with SCD crisis from 6.8 days to 3 days. More importantly, we have been able to sustain this improvement over time. Conclusions: This study clearly demonstrates that collaboration with the ED and development of care plans are key to reducing ED and hospital utilization among patients with SCD, and reducing the average length of stay for SCD patients who require hospitalization for disease management.

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Survivorship care plan: Use of the ‘Oncology History’ (OncHx) feature of the Epic electronic health record (EHR).

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.5_suppl.51 ◽

2017 ◽

Vol 35 (5_suppl) ◽

pp. 51-51

Author(s):

Kelly Bugos ◽

Jessica Foran ◽

Janis M. Petree ◽

Katrina Pose Sabati ◽

Mary Bruels ◽

...

Keyword(s):

Hospital Admissions ◽

Disease Status ◽

Marrow Transplant ◽

Care Plan ◽

Survivorship Care Plan ◽

Problem List ◽

Survivorship Care ◽

Care Plans ◽

Blood And Marrow Transplant ◽

Treatment Summary

51 Background: Survivorship care plans, including a cancer treatment summary, are a standard of cancer survivorship care. At Stanford Health Care (SHC), OncHx, a component of the Beacon module in Epic version 2012, became available May 2, 2013. The OncHx, linked to the problem list and visible to all SHC users, can be inserted in all encounter documentation and provides a chronological treatment summary. OncHx can be updated at any time. Events are categorized as: diagnosis, surgery, chemotherapy, radiation, blood and marrow transplant, anti-hormone therapy, clinical research, disease status, procedures, hospital admissions and adverse reactions. Each event is auto-sorted by date. We measured OncHx use at SHC between 5/1/13-5/1/16. Aim: Our objective is to measure the frequency OncHx is populated as a treatment summary. Methods: Our cohort was unique cancer diagnosis in the problem list and >1 visit to SHC during the analytical period. Cohort patients with >1 event recorded in OncHx at analytic period end was counted as having a populated OncHx. Results: The number of documented cancer diagnoses in the problem list increased over time. The frequency of populated OncHx increased from 5.6 to 16.5% reached a steady state of 15%. Five survivorship APPs populated 12% of all OncHx (#653). Nurses have edit privileges and populated < 1% of all OncHx events. Conclusions: The OncHx contains an organized, date ordered and refreshable treatment summary and is useful in generation of the survivorship care plan. Initial adoption by SHC advanced practice providers (APPs) and physicians has been slow, except Survivorship APPs. Use increased after more providers were given edit privileges in May, 2014. Near future enhancements are auto-population of chemotherapy administered and report of OncHx usage in Epic generated survivorship care plan template. There is an opportunity for nurses to populate OncHx and use it for their documentation.

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Proactive, multidisciplinary approach to supportive medicine: Improving health outcomes and care utilization.

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.15_suppl.6537 ◽

2019 ◽

Vol 37 (15_suppl) ◽

pp. 6537-6537

Author(s):

Brooke Worster ◽

Valerie P Csik ◽

Jared Minetola ◽

Gregory D. Garber ◽

Alison Petok ◽

...

Keyword(s):

Quality Of Life ◽

Palliative Care ◽

Cancer Patients ◽

Hospital Admissions ◽

Care Plan ◽

Cancer Center ◽

Care Plans ◽

Oncology Care ◽

The Impact

6537 Background: Evidence suggests that cancer patients who receive palliative care early in their disease have improved quality of life, decreased emergency department (ED) visits, and less aggressive end-of-life care. In 2017, the Sidney Kimmel Cancer Center at Jefferson established the Neu Center for Supportive Medicine and Cancer Survivorship (NCSMCS) as a model for integrated care in the outpatient setting for all cancer patients. A multidisciplinary team consisting of palliative care physicians, social work, psychology, and navigation conducts biopsychosocial screening and initiates a personalized care plan for each patient to clarify treatment goals and offer assistance. Objectives: To use biopsychosocial screening at specified time points to identify needs and evaluate the impact of supportive care as part of standardized oncology care regardless of stage. Methods: This assessment utilized Oncology Care Model (OCM) data for Jefferson Medicare patients between 7/1/16 to 7/31/18. Incidence of ED admits ED/Observation and admissions were evaluated as well as ICU utilization and advanced care planning. Poisson regression was used to generate incidence rate ratios (IRR) and 95% confidence intervals (CI) to facilitate the comparison of post- vs. pre- incidence rates of hospitalization. Results: The post-intervention hospital admissions decreased by 31% in NCSMCS (IRR 0.69; 95% CI 0.48-0.98) and by 10% in Non-NCSMCS (IRR 0.90; 0.84-0.96) and advanced care plans were more likely to be on file for NCSMCS (9.0% vs. 4.9%). The intensive care unit (ICU) admissions were decreased by 17% among Non-NCSMCS (IRR 0.83; 95% CI 0.74-0.93). The utilization rates for ED admissions were not statistically different among both the groups. Conclusions: The preliminary data is promising and impact will be monitored as the intervention is expanded. Reducing admissions has benefits from both a cost savings as well as quality of life perspective. Future analyses will consider the impact of the intervention on a patient’s quality of life.

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A Multidisciplinary Care Management Program for Patients with Sickle Cell Syndromes Significantly Reduces Health Care Resource Utilization.

Blood ◽

10.1182/blood.v106.11.1339.1339 ◽

2005 ◽

Vol 106 (11) ◽

pp. 1339-1339

Author(s):

William S. Jonas ◽

Matthew Hogan ◽

Allan F. Platt ◽

Melanie Jacob ◽

JoAnn A. Beasley ◽

...

Keyword(s):

Health Care ◽

Acute Care ◽

Sickle Cell ◽

Care Management ◽

Hospital Admissions ◽

Care Program ◽

Multidisciplinary Care ◽

Management Program ◽

Care Management Program ◽

Disease Specific

Abstract The Georgia Comprehensive Sickle Cell Center at Grady Memorial Hospital was established in 1985 to provide primary care and 24 hour acute care to patients with sickle cell syndromes with the goals of providing better patient care. The Center is equipped with an acute care center with 12 observation beds, a clinic area with 6 exam rooms, a waiting room, a multimedia teaching center for patients, and support offices. The initial experience showed very high outpatient and inpatient utilization by a small number of patients. In 1990, to address this problem, a comprehensive care program was instituted. The multidisciplinary care management program involving physicians, nurses, physician assistants, nurse practitioners, clinic assistants, social workers, psychologists, secretarial support and a psychiatric clinical nurse specialist addresses patients’ medical, social, psychological and vocational needs. Outcome analysis of the impact of this program is based on demographics, disease-specific characteristics, outpatient visit frequency, and admission data contained in a clinical database. This analysis shows that the program significantly reduced acute care visits and hospital admissions. In the five year period from 1985–1989, prior to the multidisciplinary program, there were 1152 acute care visits per 100 patients/year and 137 admissions per 100 patients/year. In the five year period following institution of the multidisciplinary management program, acute care visits were reduced to 355 acute care visits per 100 patients/year and 61 hospital admissions per 100 patients/year. These results were durable for the next decade (Table 1). Major factors in this reduction were departure of 24 patients with greater than 52 visits a year and a similar reduction in acute visits and hospitalizations in 166 patients that continued as active patients. A care facility dedicated to acute and ongoing management of patients with sickle cell syndromes is necessary, but not sufficient to improve their health outcomes. A multidisciplinary care program that addresses the medical, social and psychological needs of these patients is required to reduce health care utilization. In conclusion, this data demonstrates a dramatic decrease in hospital health resource utilization with the establishment of a multidisciplinary care management approach in a disease-specific comprehensive center. This model is effective for sickle cell syndromes; a chronic disease characterized by acute exacerbations, and could be considered in other similar diseases such as asthma, diabetes, and chest pain. Table 1. Georgia Comprehensive Sickle Cell Center - Clinical Activity 1985–1989 1990–1994 1995–1999 2000–2004 *Active patient = one or more visits every two years. **Mean ± SD Average active adult Pt/year* 414 ± 52** 545 ± 85 648 ± 125 1055 ± 113 Average F/U clinic appts/year 1362 ± 26 1879 ± 58 2128 ± 134 3190 ± 313 Acute care visits 100 Pt/years 1152 ± 129 355 ± 92 371 ± 36 348 ± 64 Admissions/100 Pt years 137 ± 19 61 ± 15 72 ± 11 53 ± 6

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Temperature and Humidity Effects on Acute Vaso-Occlusive Pain Episodes in Sickle Cell Disease

Blood ◽

10.1182/blood.v126.23.992.992 ◽

2015 ◽

Vol 126 (23) ◽

pp. 992-992

Author(s):

Fuad El Rassi ◽

Eldrida Randall ◽

Sidney F. Stein ◽

Hanna Jean Khoury ◽

James R. Eckman ◽

...

Keyword(s):

Sickle Cell Disease ◽

Hospital Admission ◽

Acute Care ◽

Sickle Cell ◽

Hospital Admissions ◽

Admission Rate ◽

Emergency Department Visits ◽

Cell Disease ◽

Temperature And Humidity ◽

The City

Abstract Background: Sickle cell patients suffer from painful vaso-occlusive episodes (VOE) that interrupt patients' lives and productivity and lead to emergency department visits and hospitalizations and, on occasion, death. The VOE in sickle cell disease (SCD) accounts for 90% of hospital admissions for patients with SCD and constitute a financial burden on both patients and hospitals. Efforts to prevent pain crises have failed to establish a causal relationship in about 40% of reported cases. The remaining 60% of known causes of VOE are related to dehydration, febrile illness, and infections. The Emory University Sickle Cell Center at Grady Memorial hospital has been providing specialized services for SCD patients for 30 years. The center includes a 24/7 acute care unit (ACU) that is staffed by SCD providers who specialize in the management of VOE. The patients are started on intravenous narcotics and fluids within 30 minutes of presenting to the ACC. After eight hours of management, the patient is then either discharged home if the VOE is controlled or admitted to the hospital for continued management. Annually, around 3000 ACU visits are recorded with a 17% hospital admission rate. When patients are questioned on the reason for their presentation, “weather change” is frequently reported as the trigger of the VOE. A review of the literature reveals scant data to support the hypothesis that weather-related changes trigger sickle cell pain crises. Methods: In a retrospective evaluation of patient visits over the last 4 years, we identified temperature and humidity measurements for that period of time and attempted to correlate them with the frequency of ACU visits. We used the “weatherspark” website that records weather changes for the city of Atlanta because > 90% of our patients reside in the city. Results: The four-year review of weather data and ACU visits did not show a direct correlation between graphs of temperature and humidity, and the number of ACU visits. The annual number of visits to the ACU was 2930, 2467, 3195 and 3370 for the years 2011, 2012, 2013 and 2014 respectively. The average admission rate was 16.6% overall, and the admission rate in the years 2011, 2012, 2013 and 2014 was 12.4%, 14.9%, 19.6% and 19.6% respectively. The attached figure has an example of the year 2013 charts for temperature, humidity, sickle cell acute care visits and hospital admission graphs. Conclusion: The retrospective analysis does not reflect a direct correlation between the temperature and humidity graphs and the number of ACU visits and hospital admissions. Given the volume of data analyzed, it is unlikely that there is any correlation between temperature and humidity variations and either acute care visits or admissions. Atlanta, GA- ACU visits, Hospital admissions, Temperature and Humidity Charts for 2013: DATA from weatherspark.com Figure 1. Figure 1. Figure 2. Figure 2. Figure 3. Figure 3. Disclosures No relevant conflicts of interest to declare.

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Characteristics of Sickle Cell Clinic Visits and Hospital Admissions in a Large Urban Academic Hospital

Blood ◽

10.1182/blood-2019-131133 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 5857-5857

Author(s):

Levani Odikadze ◽

Morgan L. McLemore ◽

Neli Stoyanova ◽

Fuad A El Rassi

Keyword(s):

Sickle Cell Disease ◽

Emergency Room ◽

Acute Care ◽

Sickle Cell ◽

Hospital Admissions ◽

Disease Patient ◽

Admission Rate ◽

Cell Disease ◽

The Mean ◽

Clinic Visits

Introduction: Although high rates of emergency department (ED) visits by sickle cell disease patient population is a significant health-care system burden, there are limited studies available that explore outpatient/ED visit patterns. The purpose of this study was to evaluate the pattern of medical care utilization including clinic visits and hospital admission in adults with sickle cell disease in a large urban academic center with a dedicated 24 hour/7 day a week sickle cell emergency room. Methods: Patients seen in the Acute Care at Grady Memorial Hospital Comprehensive Sickle Cell Center (GMHSCC) over a three years from January 2015 to December 2017 where analyzed. The Acute Care center at GRMHSCC is a unique 24 hour 7 day a week dedicated emergency room for sickle cell patients. Patient demographics, specialized sickle cell clinic visits and hospital admissions were analyzed descriptively. Independent samples t-test was used for comparison of hospitalization and acute care visits between males/females and phenotype groups. Results: The total of 1,277 patients were included in analysis representing 12,129 acute care visits. 683 (53.5%) females and 593 males (46.5%). Mean age was 32.9 years. Genotypes where similar to known expected distributions, 878 patients had Hb SS (68.8%), 301 had SC (23.6%), 23 had SB0TH (1.8%) and 74 had SB+TH (5.8%). The mean number of acute care visits over 3 years for SS phenotype was 9.71, SC phenotype 9.74, SB+Th phenotype 5.73 and SB0TH phenotype 10.48. Overall admission rate was 16%. There was a significant statistical difference between the mean number of admissions among SS and SC phenotype patients (p=0.009). Rate of hospitalization per clinic visit for SS phenotype was 18.19% , for SC phenotype 10.78% , SB+TH phenotype was 15.58% and SB0TH phenotype 9.55%; Conclusions and future objectives: We have demonstrated that a dedicated Sickle Cell emergency room is able to achieve a significantly lower admission rate than standard Emergency rooms. Preliminary analysis shows that the distribution of acute care visits is distributed across the genotypes at the known distribution. In addition there is no difference in mean number of sickle cell acute visits between patients with SS and SC phenotype. This is interesting as Hgb SC is considered a less severe form of the disease. There was a statistically significant higher admission rate for SS patients compared to SC patients. Future analyses will look at additional parameters associated with acute care visits and admission. Disclosures No relevant conflicts of interest to declare.

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Impact of a Dedicated Sickle Cell Acute Care Observation Unit on Rate of Hospital Admission for Acute Pain Crisis

Blood ◽

10.1182/blood.v126.23.4584.4584 ◽

2015 ◽

Vol 126 (23) ◽

pp. 4584-4584

Author(s):

Michel Gowhari ◽

Laura Kavoliunaite ◽

Johnson Bonnye ◽

Stephen Brown ◽

Robert E. Molokie ◽

...

Keyword(s):

Hospital Admission ◽

Acute Care ◽

Sickle Cell ◽

Hospital Admissions ◽

Conflicts Of Interest ◽

Observation Unit ◽

Admission Rates ◽

Inpatient Hospitalizations ◽

The Hours ◽

Painful Episode

Abstract Introduction: Pain is the top concern of individuals with sickle cell disease (SCD). Acute painful vaso-occlusive episodes are the leading cause of emergency department (ED) encounters and frequent hospital admissions. There are well-documented disparities for patients with SCD, including significant delays in starting therapy and under treatment of pain in the ED. An acute care observation unit (ACOU) staffed with SCD specialists can help to address these disparities. Here we study the service impact of increasing the hours of operation of a dedicated sickle cell ACOU on utilization and hospital admissions at the University of Illinois at Chicago (UIC), a regional sickle cell resource. We hypothesized that increased hours of operations will lead to decreased ED utilization and inpatient hospitalizations. Methods: The outcomes of individuals >16 years of age presenting with an acute painful episode to the sickle cell ACOU at UIC were assessed for the 12 months before and the 12 months after increasing the hours of operation from 9 hours/day to 15 hours/day Monday through Friday in February 2014. The outcomes of SCD patients presenting to the ED during the 12-month period following expanding hours in the ACOU were also assessed. The main outcome measures were ACOU and ED utilization and hospital admission rates. Results: There were 344 encounters in the sickle cell ACOU in the 12 months before expansion of service hours compared to 796 in the 12 months after expanding the hours, an increase of 131%. This represents 0.15 patients treated per hour before increasing the hours versus 0.2 per hour after increasing the hours. Seventy-two percent of the patients treated at the sickle cell ACOU were discharged home in the 12 months prior to expanding hours versus 75% after. During the comparative 12-month period following expansion of hours in the ACOU, there were 1074 encounters for SCD acute painful episodes in our ED, representing 0.12 patients treated per hour of operation. Only 35% of SCD patients treated in the ED for an acute painful episode were discharged home. Conclusion: The sickle cell ACOU at UIC more than doubled its patient volume following the expansion of operation from 9 to 15 hours/day during weekdays. Based on the hours of operation, during a comparative 12-month period the sickle cell ACOU treated twice as many SCD patients with an acute painful compared to the ED while discharging rather than hospitalizing twice as often. These observations suggest that allocating resources to a dedicated sickle cell ACOU can decrease ED utilization and subsequent inpatient hospitalizations. Disclosures No relevant conflicts of interest to declare.

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Hemgolobin S-C Disease at the Emory University Georgia Comprehensive Sickle Cell Center at Grady Health System

Blood ◽

10.1182/blood.v128.22.4873.4873 ◽

2016 ◽

Vol 128 (22) ◽

pp. 4873-4873

Author(s):

Anthony Hunter ◽

Ross M. Fasano ◽

James R. Eckman ◽

Morgan L. McLemore ◽

Fuad El Rassi

Keyword(s):

Steady State ◽

Acute Care ◽

Sickle Cell ◽

Subgroup Analysis ◽

Hospital Admissions ◽

Acute Chest Syndrome ◽

P Value ◽

Opiate Use ◽

Laboratory Values ◽

Pain Crisis

Abstract Introduction Unlike sickle cell anemia (HbSS disease), little research has been devoted specifically to Hemoglobin SC (HbSC) disease. Though distinct, the disease is often treated simply as a milder form of HbSS disease. As a result, its associated manifestations are less well defined which leads to mismanagement of these patients in the medical community. The aim of this study was to further define HbSC disease and its manifestations, as well as evaluate the burden of chronic opiate use and healthcare utilization in this population. Design and Methods A retrospective chart review was performed utilizing patients from one of the largest sickle cell clinics in North America. Patients with hemoglobin electrophoresis confirmed HbSC disease that had been to the center between 2010 and 2016 were identified. Clinical data relating to baseline laboratory values, HbSC disease-related complications and acute care visits was then abstracted from patient's medical records and analyzed to further define this population. IRB approval was granted for this retrospective review. Results A total of 210 patients were included in the study. The cohort had a median age of 35 years (mean of 37.2 years, range of 18 to 81 years) and 57.1% were female while 42.9% were male. Steady state laboratory values included an average hemoglobin (HGB) concentration of 11.67 mg/dL. The incidence of chronic complications including chronic opiate use, avascular necrosis (AVN), retinopathy and pulmonary hypertension were 34.76%, 23.33 %, 65.22% (in those with a documented fundoscopic exam) and 2.38% respectively. The incidence of acute complications during the study period including venous thromboembolism, stroke, and acute chest syndrome were 7.62%, 0% and 1.9% respectively. A total of 183 patients (87.1%) had an acute care visit for vaso-occlusive pain crisis during the study period of 6 years (average of 3.51 visits/patient/year) while 113 patients (53.8%) required hospital admission for a vaso-occlusive pain crisis (average of 0.43 admissions/patient/year with an average length of stay of 3.91 nights). Subgroup analysis comparing those with and without chronic opiate use (more than 3 months chronic pain) revealed similar baseline demographics with median ages of 38 and 33 (average age of 38.5 vs. 36.5, p-value 0.31), respectively. The two groups were also similar in steady state laboratory values (Hemoglobin concentration of 11.69 mg/dL versus 11.65 mg/dL, p-value 0.86) and incidence of AVN (28.77% versus 20.44%, p-value 0.17). However, chronic opiate users did have a significantly higher number of acute care unit visits per year (average of 6.15 versus 1.35, p-value 0.0001) and hospital admissions per year (0.84 versus 0.22, p-value of 0.0001), with chronic opiate users (34.8% of the study population) accounting for 74% of all acute care visits and 71.2% of all hospital admissions. Conclusions This cohort helps to further define HbSC disease as a distinct entity from HbSS disease and demonstrates that, though often thought of as mild, this disease places a significant burden on the healthcare system. As expected, the degree of anemia was quite mild compared to that seen in HbSS disease and there were significantly less episodes of stroke and acute chest. However, the incidence of AVN was similar to that seen in HbSS disease and in those with a documented fundoscopic exam the degree of retinopathy was higher, demonstrating one of the characteristics that makes this disease unique. Subgroup analysis of those with chronic opiate use reveals a population with a propensity toward high health care utilization. These distinctions help to identify risks of morbid complications in this population as well as areas to focus efforts in screening and prevention. Disclosures No relevant conflicts of interest to declare.

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Patients with Sickle Cell Disease and Venous Thromboembolism Experience Increased Frequency of Vasoocclusive Events

Blood ◽

10.1182/blood-2019-122199 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 999-999

Author(s):

Romy Carmen Lawrence ◽

Sarah L Khan ◽

Vishal Gupta ◽

Brittany Scarpato ◽

Rachel Strykowski ◽

...

Keyword(s):

Venous Thromboembolism ◽

Sickle Cell Disease ◽

Acute Care ◽

Sickle Cell ◽

Hospital Admissions ◽

Care Utilization ◽

Cell Disease ◽

History Of ◽

Acute Care Utilization ◽

Ed Visits

Introduction Patients with sickle cell disease (SCD) are at increased risk for venous thromboembolism (VTE). By age 40, 11-12% of SCD patients have experienced a VTE. VTE confers nearly a three-fold increase in mortality risk for individuals with SCD. We hypothesized that VTE increases subsequent SCD severity which may increase acute care utilization. We investigated the association between VTE and rates of vaso-occlusive events (VOE) and acute care utilization for individuals with SCD. Methods We performed a retrospective longitudinal chart review of 239 adults with SCD who received care at our institution between 2003 and 2018. VTE was defined as deep venous thrombosis (DVT) diagnosed by Duplex ultrasound or pulmonary embolism (PE) diagnosed by either ventilation-perfusion scanning or computed tomography angiography. Medical histories, laboratories and medication use for all subjects were obtained. For VTE patients, clinical data for 1- and 5- years post-VTE were obtained and compared to 1 year prior to the VTE. For non-VTE patients, data were obtained at baseline and compared to five years later. We evaluated all acute care visits for the presence of a SCD-related problem, specifically assessing if a VOE or acute chest syndrome (ACS) occurred. We calculated rates of VOE, ACS, Emergency Department (ED) visits and hospitalizations prior to and subsequent to a VTE and compared these to occurrence rates among those without VTE. Data were analyzed using Stata 14.2. Results In our cohort of 239 individuals with SCD, 153 (64%) were HbSS/HbSβ0 and 127(53%) were female. Fifty-six individuals (23%) had a history of VTE; 20 had a DVT (36%), 33 had a PE (59%), and 3 had both (5%). Patients with VTE had a higher frequency of prior history of ACS (p<0.001), stroke (p=0.013), splenectomy (p=0.033), and avascular necrosis (p<0.001) than those without a VTE. Prior to their VTE, these patients had higher white blood cell (11.8 x103 [9-15 x 103] vs 9.7 x103 [7-12 x 103], p=0.047) and platelet counts (378 x 103 [272-485 x 103] vs 322 x 103 [244-400 x 103], p=0.007) than those without a VTE. During five years of follow-up after a VTE, these patients had 6.32 (SD 14.97) ED visits per year compared to 2.84 (SD 5.93, p<0.03) ED visits per year in those without a VTE. Ninety two percent of these ED visits were SCD-related; 73% were for VOE and 4% for ACS. Additionally, SCD patients with a VTE had an increase in all-cause hospital admissions (2.84 [SD 3.26] vs 1.43 [SD 2.86], p=0.003) and SCD-related hospital admissions (2.61 [SD 3.13] vs 1.23 [SD 2.74], p=0.001) per year compared to those without VTE. Conclusion VTE is a frequent complication in patients with SCD. Our study suggests that patients who experience a VTE have greater SCD severity as evidenced by increased VOE, ED and hospital utilization. These data suggest that VTE is not merely an isolated event in SCD patients and that it may either serve as an indicator of disease severity or contribute to overall disease pathophysiology. Disclosures Sloan: Abbvie: Other: Endpoint Review Committee; Stemline: Consultancy; Merck: Other: endpoint review commitee.

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Exploring the impact of pharmacist comprehensive annual care plans on perceived quality of chronic illness care by patients in Alberta, Canada

Canadian Pharmacists Journal / Revue des Pharmaciens du Canada ◽

10.1177/17151635211020340 ◽

2021 ◽

pp. 171516352110203

Author(s):

Candace Necyk ◽

Jeffrey A. Johnson ◽

Ross T. Tsuyuki ◽

Dean T. Eurich

Keyword(s):

Quality Of Care ◽

Chronic Illness ◽

Care Plan ◽

Short Version ◽

Chronic Illness Care ◽

Online Questionnaire ◽

Care Plans ◽

Funding Program ◽

The Impact

Background: In 2012, the Government of Alberta introduced a funding program to remunerate pharmacists to develop a comprehensive annual care plan (CACP) for patients with complex needs. The objective of this study is to explore patients’ perceptions of the care they received through the pharmacist CACP program in Alberta. Methods: We invited 3442 patients who received a pharmacist-billed CACP within the previous 3 months and 6888 matched controls across Alberta to complete an online questionnaire. The questionnaire consisted of the short version Patient Assessment of Chronic Illness Care (PACIC-11), with 3 additional pharmacy-specific assessment questions added. Additional questions related to health status and demographics were also included. Results: Overall, most patients indicated a low level of chronic illness care by pharmacists, with few differences noted between CACP patients and non-CACP controls. Of note, controls reported higher quality of care for 5 domains within the adapted PACIC-like tool compared with CACP patients ( p < 0.05 for all). Interestingly, only 79 (44%) of CACP patients reported that they had received a CACP, whereas only 192 (66%) of control patients reported that they did not receive a care plan. In a sensitivity analysis including only these respondents, individuals who received a CACP perceived a significantly higher quality of chronic illness care across all PACIC domains. Conclusion: Overall, chronic illness care incentivized by the pharmacist CACP program in Alberta is perceived to be moderate to low. When limited to respondents who explicitly recognized receiving the service or not, the perceptions of quality of care were more positive. This suggests that better implementation of CACP by pharmacists may be associated with improved quality of care and that some redesign is needed to engage patients more. Can Pharm J (Ott) 2021;154:xx-xx.

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