Impact of an Infusion Center on the Utilization of Hospital Based Care in Sickle Cell Disease

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 6-7
Author(s):  
Jonathan B Hurst ◽  
Richard Gentry Wilkerson
Keyword(s):  
Sickle Cell Disease ◽  
Acute Care ◽  
Hospital Admissions ◽  
Hospital Utilization ◽  
Cell Disease ◽  
High Utilizers ◽  
Significant Difference ◽  
Opioid Administration ◽  
Before And After ◽  
Ed Visits

Background: Sickle cell disease (SCD) consists of a group of hemoglobinopathies inherited in an autosomal recessive pattern whereby a single point mutation results in the formation of a hemoglobin protein with altered structure. Many of the complications of SCD and their end organ manifestations are the result of a vaso-occlusive process. These include acute chest syndrome, dactylitis, myocardial infarction, stroke, venous thromboemboli, avascular necrosis, and acute vaso-occlusive episodes (VOEs). VOEs are the most common reason for a patient with SCD to seek medical attention. This care is often provided at an emergency department (ED). It has been well documented that the management of VOEs are often delayed and fail to follow published guidelines. Numerous efforts have been undertaken to ensure appropriate and timely analgesic administration to patients with SCD who are experiencing a VOE. One such intervention is the creation of an infusion center (IC) that has the capability to administer parenteral opioids while avoiding the delays associated with an ED visit. Objectives: This study aims to evaluate the impact of a dedicated IC that was established for the treatment of SCD VOEs. The goal of the IC is to provide timely and appropriate pain management in an effort to reduce ED visits and hospital admissions related to treatment of VOEs in patients with SCD. The IC was available to adult patients with SCD who regularly sought care at our hospital and who did not have a care plan that excluded the administration of parenteral opioids. Methods: This is an observational, retrospective study comparing the rates of hospital utilization before and after the opening of a dedicated IC for patients treated for SCD VOE at a single, urban medical center that regularly provides care for approximately 150 adult patients with SCD. We compared the rates of ED visits, hospital admissions, and length of stay for six months prior and four months following the opening of the IC. Hospital utilization was standardized before and after the intervention using 30-day rates. Additionally, opioid usage, measured in Morphine Equivalent Dose (MED) was compared between the ED and the IC. Results: A total of 12 patients (Table 1) utilized the IC during the 4 months after its opening (6/20/19 - 10/16/19). During this time there were 92 total visits to the IC. Four patients were noted to be high utilizers accounting for 77 (83.7%) of the 92 visits (median = 20 visits, range 12 - 25). The other 8 patients were low utilizers and accounted for 15 (16.3%) of the visits (median = 2, range 1 - 4). Following implementation of the IC, there was found to be a statistically significant decrease in ED visits (pre- = 3.97/30d vs post- = 2.40/30d; p = 0.04) (Table 2, Fig. 1). No significant difference was found in hospital admissions (pre- = 1.47/30d vs post- = 1.17/30d; p = 0.18) or inpatient days (pre- = 6.47/30d vs post- = 5.47/30d; p = 0.23). The total number of acute care visits (sum of ED and IC visits) was found to increase after the opening of the IC, although the change was not statistically significant (pre- = 3.97/30d vs post- = 5.47/30d; p = 0.07). The change in acute care visits was largely driven by an increase in visits from the high utilizers (pre- = 2.00/30d vs post- = 3.53/30d; p = 0.05). In terms of parenteral opioid administration, there was a statistically significant decrease in amount of opioids given in the IC compared to the ED (ED = 251.64 MED vs IC = 177.17 MED; p = 0.04), although this was only seen in the low utilizer group (Table 3, Fig. 2). There was no significant difference in opioid doses received for the high utilizers (ED = 256.31 MED vs IC = 272.12 MED; p = 0.24) and for the group as a whole (ED = 253.34 MED vs IC = 208.84 MED; p = 0.10). Conclusion: The introduction of an IC for the management of SCD VOE led to a significant decrease ED visits but also led to an increase in overall acute care visits, although this was not statistically significant. This increase was largely driven by a subset of this population considered high utilizers. Additionally, the use of the IC was not associated with a decrease in the total amount of parenteral opioids that were administered. However, for the low utilizer group there was a decrease in parenteral opioid administration. The IC did not reduce admissions and duration of hospitalization in this population. Overall, the IC had variable success and further refinement of how it is used should be undertaken to ensure quality care for patients with SCD. Disclosures No relevant conflicts of interest to declare.

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

Blood ◽  
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.

scholarly journals Impact of the COVID-19 Pandemic on Acute Care Visits for Patients with Sickle Cell Disease

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 3097-3097
Author(s):  
Dennis Orkoulas-Razis ◽  
Nicholas Bishop ◽  
Ellen Dupont ◽  
Maria R. Baer ◽  
Richard Gentry Wilkerson ◽  
...  
Keyword(s):  
Sickle Cell Disease ◽  
Acute Care ◽  
Sickle Cell ◽  
Care Utilization ◽  
Cell Disease ◽  
Presenting Symptoms ◽  
Significant Difference ◽  
Acute Care Utilization ◽  
Ed Visits ◽  
Disease Specific

Abstract Introduction: The COVID-19 pandemic significantly impacted emergency department (ED) and overall hospital utilization, with a substantial decline in non-COVID-19-related medical presentations. In the weeks following the declaration of a national health emergency, ED visits declined by 42%. Patients with sickle cell disease (SCD) are at risk for needing ED-based care and hospitalization due to disease-specific complications. We examined the impact of the COVID-19 pandemic on acute care utilization by patients with SCD at our institution. Methods: We performed a retrospective cohort study at our institution comparing the period of the first "stay at home" order in Baltimore, MD (3/30/2020-6/8/2020) to the same date range in 2019. We included all adult patients with SCD who either presented to the ED or were directly admitted to the hospital. All SCD genotypes were included (HbSS, HbSC, HbSβ +/0 thalassemia). Data collected included presenting symptoms, disposition for ED visits, admission length of stay (LOS), re-admission within 7 days, as well as frequency of sickle cell-specific complications during hospitalization. We collected data regarding the acuity of patients' initial presentation using the emergency severity index (ESI), a five-tiered grading tool utilized by triage nurses to indicate the acuity and resource-intensiveness of a patient's presenting symptoms (1= highest urgency, 5= least urgency). We performed statistical analyses using Pearson's chi square test, Fisher's exact test and the Mann-Whitney U test. Results: During the initial stay at home order in 2020, 77 patients presented to acute care services at our institution, compared to 163 patients during the same dates in 2019, a decrease of > 50%. Statistically significant demographic differences between 2020 and 2019 included gender (53% vs 34% male gender, p = 0.004) and hemoglobinopathy type (2020: SS (66%), SC (27%), Sβ-thal (6.5%) vs 2019: SS (48%), SC (42%), Sβ-thal (10%), p = 0.03), whereas there was no difference in severity on presentation measured by ESI (median score of 3: 88% vs 90%, p = 0.13) or age (30 vs 30 years old, p = 0.925). More patients in 2020 presented with dyspnea (22% vs 11%, p = 0.02), and/or nausea or vomiting (22% vs 11%, p = 0.02), but more patients in 2019 presented with cough (7% vs 17%, p = 0.025). None of the patients tested positive for SARS-CoV-2. There was no statistically significant difference between the study periods in hospitalization rate (44% vs 37%, p = 0.32), LOS (60 vs 64 hrs, p = 0.73), admission to the ICU (3% vs 2.5%, p = 1.0) or step-down unit (0% vs 1%, p = 1.0), or death (0% vs 1%, p = 1.0). There was a difference in ED re-presentation within 7 days of the index visit (14% vs 47%, p < 0.001), but no difference in rate of readmission within 7 days (9% vs 15%, p = 0.225). Discussion: Although fewer patients with SCD presented for acute care in 2020, there was no significant difference in objective metrics, including admission rates, LOS, readmissions, and disease-specific complications. The decrease in ED return visits in 2020 may reflect patients' concerns regarding exposure to SARS-CoV-2 while in the ED. Our data demonstrate that although fewer patients with SCD presented for acute care utilization, they did not appear to be sicker. The data support more frequent management of uncomplicated pain crises outside of the ED, through optimization of outpatient services including infusion centers and telehealth. The advent of new care delivery models as a result of the Covid-19 pandemic may have a positive impact on frequency of ED utilization for patients with SCD. Disclosures No relevant conflicts of interest to declare.

scholarly journals Trends in Hospital Utilization for Acute Illness in a Large Population-Based Cohort of Children and Adolescents with Sickle Cell Disease (SCD): 2010–2017

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 3528-3528
Author(s):  
Kristina Lai ◽  
Sonia Anand ◽  
Maa-Ohui Quarmyne ◽  
Carlton Dampier ◽  
Peter A. Lane ◽  
...  
Keyword(s):  
Sickle Cell Disease ◽  
Acute Care ◽  
Sickle Cell ◽  
Large Population ◽  
Admission Rate ◽  
Acute Illness ◽  
Hospital Utilization ◽  
Acute Chest Syndrome ◽  
Cell Disease ◽  
Admission Rates

Abstract Disease severity and healthcare utilization varies widely among persons with sickle cell disease (SCD). Hydroxyurea (HU) has been demonstrated to reduce rates of pain and acute chest syndrome, the leading causes of inpatient utilization in patients with Hb SS and S β°-thalassemia in clinical trials. We recently reported that HU was clinically effective in reducing rates of pain and acute chest syndrome in patients who initiate treatment. Use of hydroxyurea in SS/S β°-thalassemia has increased markedly since 2010. Thus we sought to detemine trends of hospital utilization for acute illness during an 8 yr in which HU utilization increased markedly (2010-2017). Data from years 2010-201 were obtained from the SCD database and patient records at Children's Healthcare of Atlanta (CHOA). Utilization data were restricted to acute care admissions. Admissions for elective procedures, non-SCD related discharge diagnoses, rare SCD genotypes, and patients who had undergone bone marrow transplant were excluded. Patients were compared based on number of hospitalizations, age, sex, SCD genotype (SS/S β°-thalassemia vs Hb SC/S β+thalassemia), and discharge diagnosis. A total of 3,116 patients had at least one encounter between 2010 and 2017; 2,947 patients met inclusion criteria. From 2010-2017 the total number of active patients per year increased from 1,546 patients to 1,789 patients (+16%), while the total number acute care admissions increased from 1,295 admissions to 1,609 admissions (+24%). There were no significant differences in the proportion of patients with genotypes SS/S β° thalassemia genotypes (67.0% vs 63.9%, p=0.06). Overall patients with SS/S β° thalassemia had higher admission rates compared to SC/S β+ thalassemia patients (0.94 vs 0.57 admissions per patient per year). During the study period. overall admission rates in SCD (acute illness hospitalizations/patient/yr) increased from a low of 0.74 in 2011 to a high of 0.90 in 2017. The proportion of admissions attributed to SS/S β°-thalassemia patients decreased (79.2% in 2010 vs 72.3% in 2017, p<0.0001). However, admission rate in SC/S β+ thalassemia increased (0.53 to 0.69 admissions per patient per year). Overall, over 60% of patients were not admitted in any given year, and the proportion of patients with 0-1 admissions in a given year remained unchanged. However, the proportion of super high hospital utilizers (SHHU), patients with 8 or more admissions in a given year, increased by 185%. In 2001 this group made up 0.6% of all patients and accounted for 7.3% of admissions; in 2017 SHHU had increased 1.8% of patients and 24.3% of admissions. There was no difference in genotype or sex between SHHU and non-SHHU patients. SHHU were older (>90% of patients over age 8 years), and had greater percentages of admissions for pain and acute chest syndrome then non-SHHU. In conclusion, during a period in which HU utilization in SS/S β°-thalassemia increased significantly, hospital utilization for acute illness in SS/S β° thalassemia decreased as expected. However, during the same period there was an unexpected increase in overall hospital utilization for acute illness in SCD. This increase in hospital utilization was the result of 1) a marked increase in SHHU and 2) an overall increased utilization in SC/S β+ thalassemia. Disclosures Dampier: Pfizer: Research Funding.

Outcomes of Chronic Automated RBC Exchange Program in Omaha, Nebraska 2015-2020

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 21-22
Author(s):  
Aleh Bobr ◽  
Scott A Koepsell ◽  
Julie Eclov ◽  
Omar Abughanimeh ◽  
Steven Ebers ◽  
...  
Keyword(s):  
Sickle Cell Disease ◽  
Blood Cell ◽  
Iron Overload ◽  
Sickle Cell ◽  
Red Blood Cell ◽  
Beta Thalassemia ◽  
Acute Chest Syndrome ◽  
Cell Disease ◽  
Before And After ◽  
Ed Visits

Background: Red blood cell exchange (RBCX) is an effective therapy in the treatment of different hemoglobinopathies. The University of Nebraska Medical Center (UNMC) established a chronic RBCX program in November 2015, which took care of patients with multiple hemoglobinopathies. In this study, we aim to evaluate the outcomes of this program. Methods: This is a retrospective study. After an IRB approval, we reviewed the charts of patients who were enrolled in the chronic RBCX program between 11/2015-7/2020 at UNMC. Data was collected to evaluate indications of RBCX, types of hemoglobinopathies, hemoglobinopathies' complications before and after the enrollment in the program, and assessment of hospital visits before and after enrollment in the program. Results: In November 2015, the chronic RBCX program was established in Nebraska. Since the start, 24 patients came through the program and 20 patients are still actively enrolled and undergoing regular exchange transfusions. The four patients who left the program did it for the following reasons: moving out of state, stem cell transplant and change to different treatment modality. Four of 24 patients were beta thalassemia patients (two of them with combined HbE/beta thalassemia). Twenty patients had sickle cell disease with two of them having combined beta thalassemia and HbS and one with alpha thalassemia and HbS. The indications ranged from history of stroke, intracranial vascular stenosis, acute chest syndrome (ACS), iron overload, multiple vascular occlusive crises (VOC) and intolerance of medications with most of the patients having multiple indications from the list above (Figure 1). There are several positive outcomes from being on the program. In the patients who had been on the program for at least one year (n=11), nine started the program with iron overload and all of them had a significant decrease in serum ferritin (average 751 ng/mL) with three patients returning to normal range. In the patients who had been in the program at least six months (n=16), 13 patients started with iron overload with five returning to normal range and average decrease in ferritin of 585 ng/mL. Another positive outcome is the number of emergency department (ED) visits for pain crisis. We noted reduction in ED visits in all patients who were in the program for at least six months (n=14), with the exception of one patient where the visits were likely the part of drug seeking behavior. In fact 12 of 13 patients had one or no ED visits within one year after starting on the chronic exchange program having had from 2-11 visits a year prior. None of the patients in the program experienced more severe complications of sickle cell disease, like stroke and acute chest syndrome, while on the program. Due to high volumes of transfusion, there is a big concern about developing red blood cell antibodies in sickle cell disease patients who in general have higher red blood cell antibody burden. Out of 24 patients in the program, six had pre-existing antibodies. For the duration of the program, no new alloantibodies were discovered in the chronically exchanged patients despite high transfusion volumes (range 14L-30L/year). The transfused blood was matched for Rh and Kell antigens for the patients with no antibody history. The patients with previous antibody history had additional matching for the antigen to which antibody was directed. Conclusion:Automated chronic RBCX transfusion program is safe to perform. It leads to significant reduction in volume overload and ED visits. Performing high volume transfusions outside of acute sickle cell crisis and with Rh and Kell matched units prevents formation of RBC antibodies Disclosures Gundabolu: BioMarin:Consultancy;Bristol Myers Squibb pharmaceuticals:Consultancy.

High Resource Utilizers From The Multicenter Compact Study Of Complications In Patients With Sickle Cell Disease and Utilization Of Iron Chelation Therapy

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 982-982
Author(s):  
Lanetta B Jordan ◽  
Patricia Adams-Graves ◽  
Julie Kanter-Washko ◽  
Patricia A Oneal ◽  
Medha Sasane ◽  
...  
Keyword(s):  
Sickle Cell Disease ◽  
Research Funding ◽  
Chelation Therapy ◽  
Iron Chelation ◽  
Iron Chelation Therapy ◽  
Cell Disease ◽  
High Utilizers ◽  
Ed Visits ◽  
High Utilizer ◽  
High Utilization

Abstract Introduction While treating patients (pts) with sickle cell disease (SCD) can be costly, costs are not evenly distributed across pts; rather, a minority of pts accounts for a majority of costs. Identifying those pts who consume a disproportionately large share of healthcare resources can assist payers and providers in directing appropriate and targeted interventions to deliver better pt care with lower costs. The objective of this study was to understand characteristics of pts who have increased utilization of inpatient (IP) and emergency department (ED) resources in a population of SCD pts ≥16 years old. Method Medical records of 254 SCD pts ≥16 years old were retrospectively reviewed between 8/2011 and 7/2012 at three US tertiary care centers. The high utilization threshold was derived from the literature and defined as pts with ≥ 5 days of IP+ED care (assuming 1 day/ED visit) for SCD-related complications per year (high utilizer group). Pts were also classified into cohorts based on cumulative blood transfusion units and use iron chelation therapy (ICT): <15 units, no ICT (Cohort 1 [C1]), ≥15 units, no ICT (Cohort 2 [C2]), and ≥15 units, with ICT (Cohort 3 [C3]). SCD complication rates were expressed as the number of SCD complications per pt per year (PPPY); rate ratios (RRs) were used for cohort comparisons. A logistic regression was used to identify risk factors associated with high utilization of IP+ED care. Results Of the 254 pts (C1: 69, C2: 91, C3: 94), 30% (n =76) were classified as high utilizers (C1: 14 [18.4%], C2: 37 [48.7%], C3: 25 [32.9%]). Patients in the high utilizer group were younger (median [range] (21 years old [16-65], vs. 23 years old [16-59]) and had shorter follow-up (4.2 years [0.6-23.9], vs. 5.4 years [0.5-33.3]) compared to the rest of the sample. Those in the high utilizer group accounted for 68% of all SCD-related complications and over 88% of all IP+ED days for treatment of these complications. Similar to the rest of the sample, pain (81%) and infection (7%) were the two key complications seen in this high utilizer group. The rate of IP +ED days was significantly higher among the high utilizer group with 16.63 [16.28-16.99] IP+ED days PPPY compared to 0.89 [0.84-0.94] PPPY for other pts. Similarly, the high utilizer group had 4.58 [95% CI: 4.39-4.76] IP+ED visits PPPY, compared to 0.34 [0.31-0.37] visits PPPY for other pts (Table). Among regularly transfused pts (C2+C3) in the high utilizer group, those who received ICT had lower rates of IP+ED visits (C2 vs. C3 rate ratio [RR] [95% CI]: 1.31[1.20-1.44]), IP+ED days (C2 vs. C3 RR: 1.30 [1.24-1.36]), and readmission to IP+ED settings within 30 days (1.70 [1.49-1.93]) compared with those who did not (Table). History of infections (odds ratio: 7.45, p<0.0001) was associated with an increased risk of high utilization of IP+ED care. Conclusion Results from this study show that a relatively small fraction of SCD pts account for the majority of IP+ED visits. Moreover, among regularly transfused pts identified as high utilizers, those who received ICT had lower rates of IP+ED utilization than those who did not. Pts receiving ICT may also receive closer monitoring, which may help with early identification and intervention to delay or prevent the development of complications and improve outcomes. Closer management of pts with SCD, especially those at risk of becoming high utilizers, is critical to lowering IP+ED utilization and reducing the overall costs of care. Disclosures: Jordan: Novartis Pharmaceuticals Corporation: Consultancy. Adams-Graves:Analysis Group, Inc.: Research Funding. Kanter-Washko:Analysis Group, Inc.: Research Funding. Oneal:Novartis Pharmaceuticals Corporation: Honoraria; Analysis Group, Inc.: Research Funding. Sasane:Novartis Pharmaceuticals: Employment. Vekeman:Novartis Pharmaceuticals: Research Funding. Bieri:Novartis Pharmaceuticals Corporation: Research Funding. Marcellari:Novartis Pharmaceuticals Corporation: Employment. Magestro:Novartis Pharmaceuticals: Employment. Adams:Novartis Pharmaceuticals Corporation: Research Funding. Duh:Novartis Pharmaceuticals: Research Funding.

A Multicentre Study of Environmental Factors on the Severity of Sickle Cell Disease

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 4841-4841
Author(s):  
Sanjay Tewari ◽  
Fred Piel ◽  
Valentine Brousse ◽  
Baba PD Inusa ◽  
Paul Telfer ◽  
...  
Keyword(s):  
Sickle Cell Disease ◽  
Environmental Factors ◽  
Sickle Cell ◽  
Hospital Admissions ◽  
Conflicts Of Interest ◽  
Acute Chest Syndrome ◽  
Electronic Patient Records ◽  
Cell Disease ◽  
Hospital Data ◽  
Significant Difference

Abstract Background: Sickle cell disease (SCD) is a very variable condition, with some patients being asymptomatic and others admitted frequently to hospital. Genetic factors have been extensively investigated but only explain a small amount of the variability to date. Environmental factors are undoubtedly important, but have not been studied in depth, at least in part because of the difficulty of conducting these studies. We have analysed the role of climatic, environmental and temporal factors in determining the frequency of hospital admissions in children with SCD to 4 large sickle cell centres in London and Paris. Participants and Methods: Clinical data were collected from 1st January 2007 to 31st December 2012. Inclusion criteria were children with SCD (HbSS and HbSC) between the ages of 0 and 17 years, admitted to hospital with acute pain, acute chest syndrome or fever. All children lived within 4 miles radius (London) or 10km (Paris) of the hospital. Data were collected using specific electronic patient records of SCD patients. Data were collected on the reason for admission, date and length of admission. Daily air quality records were collected from sites around Paris and London, including details of black smoke, particulate matter, nitric oxide, carbon monoxide, sulphur dioxide and ozone. Daily meteorological records were obtained from weather stations in London and Paris including wind speed, temperature, rainfall and humidity. Statistical analysis including time series studies were conducted using R software version 3.1.1. Results: There were a total of 2717 admissions over the six year study period. Overall for the London hospitals there was a mean of 0.39 admissions/patient/year, with 1406 admissions for pain, 153 for acute chest syndrome and 417 for fever. The rate of admission/patient/year by cause for HbSS and HbSC across the London hospitals is shown in table below: Table 1. Rates of admission/patient/year by cause Sickle genotype/cause of admission All London hospitals Institution A Institution B Institution C HbSS (Pain) 0.31 0.18 0.40 0.43 HbSS (Fever) 0.09 0.03 0.15 0.11 HbSS (acute chest syndrome) 0.04 0.03 0.04 0.04 HbSC (pain) 0.07 0.03 0.08 0.10 HbSC (fever) 0.03 0.01 0.04 0.05 HbSC (acute chest syndrome) 0.004 0.008 0.002 0.002 Overall admission numbers were significantly higher on Mondays and Tuesdays in London but there was no such variation in Paris (Table 2). Table 2. Mean number of admissions on days of week in Paris (1 hospital) and London (3 hospitals). ** denotes significant difference from mean of other days (P<0.001). London Paris Weekday Monday 0.75** 0.35 Tuesday 0.77** 0.36 Wednesday 0.66 0.36 Thursday 0.64 0.32 Friday 0.60 0.32 Saturday 0.51 0.20 Sunday 0.57 0.27 There was no seasonal variation in admission numbers in London, but significantly higher numbers of patients admitted in Paris during autumn and winter. Table 3. Mean number of seasonal admissions in Paris (1 hospital) and London (3 hospitals). ** denotes significant difference from mean of other days (P<0.001). London Paris Season Autumn 0.70 0.35** Spring 0.60 0.31 Summer 0.64 0.25 Winter 0.62 0.34** Conclusion In London, there is a 2-3 fold variation in admission rates for the same complications between different hospitals. Similarly there is a significant difference on the effects of season and weekday between Paris and London. These results are statistically stronger than many effects which are identified in genetic and therapeutic studies, and show the importance of environmental and cultural factors, which are potentially modifiable. The effect of weather and pollution on hospital admissions is currently being analysed. Disclosures No relevant conflicts of interest to declare.

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

Blood ◽  
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.

Characteristics of Sickle Cell Patients with Frequent ED Visits and Hospitalizations: Demographic, Clinical, Laboratory and Psycho-Social Aspects

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 2501-2501 ◽  
Author(s):  
Kyle Michael Kidwell ◽  
Camila Albo ◽  
Michael Pope ◽  
Latanya Bowman ◽  
Hongyan Xu ◽  
...  
Keyword(s):  
Health Care ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Clinical Laboratory ◽  
Anxiety And Depression ◽  
Cell Disease ◽  
High Utilizers ◽  
The Us ◽  
Ed Visits ◽  
High Utilizer

Abstract Vaso-occlusive episodes (VOE), are considered a hallmark of sickle cell disease (SCD), and account for >90% of health care encounters for this patient population. Although an orphan disease (total number of patients in the US ~110,000), SCD has a huge medical-economic impact, with annual hospitalization costs of nearly $ 0.5 billion by 2004 figures, mostly for VOEs. The Cooperative Study of Sickle Cell Disease (CSSCD) was a large natural history study, carried in 23 Centers in the US, enrolling >3000 patients between 1977-93. An analysis of the frequency of VOEs in CSSCD showed that the majority of patients (80%) experienced 0-3 major pain crises/year; this was similar across all genotypes of the disease (SS, SC, Sβ0 thalassemia, Sβ+ thalassemia). Only a small minority (~5%) experienced ≥6 VOEs/year. Similar findings have been reported in subsequent, smaller studies, with 5-10% of SCD patients with frequent ED visits and hospitalizations. Hydroxyurea (HU), the only disease modifying agent approved for adults with SCD, results in a ~50% reduction in the frequency of VOEs and hospitalizations. Despite this, HU is underutilized in SCD. Recent NIH evidence based guidelines includes strong recommendations for HU therapy in the majority of SCD patients. Although 230 of the 650 adult SCD patients at our Center are prescribed HU, in a recent study we found that ~40% of these patients were non-adherent, based upon their own admission, and/or the lack of anticipated change in several laboratory parameters (Hb F, MCV, Hb, WBC, reticulocyte and platelet count). A minority of SCD patients followed at our Center have frequent ED visits and hospitalizations. We conducted a study analyzing demographic, clinical, laboratory and psycho-social characteristics of 25 patients with ≥6 ED visits and hospitalizations per year (high utilizers), and compared these with 9 patients (controls) who experienced ≤2 ED visits/hospitalizations (low utilizers). Data on gender, age, genotype, number of ED visits and hospitalizations, CBC, chemistry panel, Hb F, HU usage, opioid use (morphine equivalents), education level, employment, annual income and marital status were collected. All subjects were also administered a depression, anxiety and Health Locus of Control Questionnaire, and underwent quantitative sensory testing (QST) with three different modalities: pressure pain sensitivity with a hand held, computerized algometer (AlgoMed, Medoc, Israel), heat and cold sensitivity (Q-Sense, Medoc, Israel) and Von Frey monofilament testing for neuropathic pain. Of the 25 patients (13M, 12F), 19 were SS, 4 SC, 1 SD-Los Angeles and 1 Sdβ-thalassemia. The median age was 28 (range 21-49). In the low utilizer group (6M, 3F) all were SS with a median age of 39 (range 23-46). The average number of hospitalizations in the high utilizer group was 15.6/year (range 6-33), while in the low utilizer group it was 0.44/year. Annual opioid usage as mg morphine equivalents was significantly higher in the high utilizers (12125.7 mg vs 2423.1 mg, p=0.0048). 19/25 (76%) of high utilizers, and 7/9 (78%) of low utilizers were on HU. Laboratory data on both groups are shown in Table 1. High utilizers had significantly higher WBC, ANC, total bilirubin and lower MCV. Hb F was also lower in the high utilizers (11.8% vs 17.5%) although this did not reach significance. QST results showed significantly lower pressure pain threshold at ulna (224.4 KPa vs 338.9 KPa, p=0.04), and higher baseline sensitivity with von Frey monofilament (0.92 vs 0.33, p=0.056) in the high utilizer group. High utilizers also had a higher anxiety score (9.0 vs 4.6, p=0.039) and depression score (10.0 vs 6.0, p=0.051). While the low utilizers had higher education levels with more associate and bachelor degrees (p=0.009), there was no difference in household income. These data show that multiple factors contribute to high health care utilization in SCD; these include biologic (younger age, disease severity as indicated by higher WBC and ANC, bilirubin, opioid induced hyperalgesia, and poor adherence to HU) as well as psycho-social factors (higher anxiety and depression scores, lower educational status). A multi-disciplinary and multi-faceted approach, including a sound patient education and transition program, a concerted effort to increase adherence to HU therapy, and psycho-social as well as pharmacologic approaches to anxiety and depression will be required to address this complex problem. Disclosures Kutlar: Novartis Pharmaceuticals: Research Funding.

Using the Risk Assessment Index (RAI) to predict 90-day mortality and hospital utilization in cancer patients at UPMC Hillman Cancer Center.

2018 ◽  
Vol 36 (30_suppl) ◽  
pp. 243-243
Author(s):  
Christine Ann Garcia ◽  
Jeffrey Borrebach ◽  
Stefanie C Altieri Dunn ◽  
Johanna E Bellon ◽  
Ellen Ormond ◽  
...  
Keyword(s):  
Risk Assessment ◽  
Cancer Patients ◽  
Hospital Admissions ◽  
Hospital Utilization ◽  
Cancer Center ◽  
Mortality Data ◽  
Cancer Type ◽  
Assessment Index ◽  
Significant Difference ◽  
Ed Visits

243 Background: Patients with cancer vary considerably in health status and functional reserve. Identifying the most frail patients whom are at risk of treatment toxicity or death can be difficult. The Risk Assessment Index (RAI) is a validated tool used to assess frailty in patients prior to surgery. Thus, we aimed to investigate frailty assessment utilizing the RAI in cancer patients and its ability to predict hospital utilization and 90-day mortality. Methods: From 9/15/2017 to 1/31/2018, new patients with solid tumor malignancies at the UPMC Hillman Cancer Center completed the RAI. Age, cancer type and stage, and treatments were abstracted. ED visits, hospitalizations and mortality data were provided by the Wolff Center at UPMC. Mann-Whitney U and likelihood-ratio tests were performed comparing RAI, ED usage/hospitalizations, and mortality. Elective hospital admissions were excluded. Results: 273 patients completed the RAI. 58.6% of pts were male and average age was 62.7 (21-88), and the average RAI score was 39.9 (IQR 35-44). The most common cancer types were melanoma (22.7%), prostate (14.3%), and lung (11.4%). 43.6% of patients had stage IV cancer. Within 90 days after RAI, 51 patients (18.7%) experienced at least one unplanned ED visit or hospitalization, and 10 patients (3.7%) were deceased. Patients with an ED visit/hospitalization had an average RAI of 42 (IQR 37-46) compared to 39.4 (IQR 35-43) for patients without one: a 2.6-point difference (p = 0.008). 90-day mortalities had an average RAI score of 47.5 (IQR 42-53) compared to 39.6 (IQR 35-44) for non-mortalities: a 7.9-point difference (p = 0.003). Six of 242 (2.5%) patients without a hospitalization experienced mortality whereas 4 of 31 (12.9%) patients with a hospitalization experienced mortality (p = 0.017). Conclusions: This study shows that the RAI may be utilized to predict 90-day mortality in cancer patients. Patients at greatest risk of 90-day mortality were more likely to have unplanned hospitalizations. While there was a statistically significant difference in RAI scores between patients with and without unplanned ED visits/hospitalizations, this difference was too small to be clinically meaningful.

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