scholarly journals Emergency Department Quality of Care for Sickle Cell Disease in Ontario, Canada: A Population-Based Matched Cohort Study

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 38-39
Author(s):  
Derek Chan ◽  
Fiona Kouyoumdjian ◽  
Uma Athale ◽  
Jacob Pendergrast ◽  
Madeleine Verhovsek
Keyword(s):  
Emergency Department ◽  
Quality Of Care ◽  
Sickle Cell Disease ◽  
Hospital Admission ◽  
Sickle Cell ◽  
Cell Disease ◽  
Matched Group ◽  
High Acuity ◽  
Ed Visits

Background: Acute vaso-occlusive crisis (VOC) in sickle cell disease (SCD) frequently leads patients to seek emergency department (ED) care. Whether or not health inequities exist, and their exact nature, is poorly understood in ED visits for SCD VOC within a universal publicly funded healthcare system. In this study, we aimed to address this knowledge gap by characterizing the landscape of ED care burden and quality indicators for SCD VOC management in the province of Ontario, Canada. Methods: We used population-level health administrative data to identify patients with SCD in Ontario who presented to the ED with SCD VOC (ICD-10-CA code D57.0) from 2006 to 2018. We evaluated quality of care indicators in the ED for this population and compared these with a general population group matched by age, sex, neighbourhood income quintile, geography (forward sortation area) and date of ED visit (-15 to +15 days per visit) (35,370 ED visits; 27,195 patients). Results: We identified 1,811 patients who presented to the ED with SCD VOC for a total of 13,123 ED visits over the study period. Of ED presentations, 40% were pediatric (< 18 years), 47% were male and 99% lived in urban settings. Compared to ED visits for the matched group, ED visits for SCD VOC had a significantly higher proportion of high acuity triage scores (CTAS 1 or 2) (74% vs 18%; p < 0.001), shorter time to initial physician assessment (76 ± 82 vs 90 ± 86 minutes; mean ± SD, p < 0.001), longer period of ED assessment and observation (432 ± 261 vs 212 ± 179 minutes; p < 0.001), increased likelihood of hospital admission (62% vs 5%; p < 0.001), longer duration of inpatient stay (5.2 ± 6.7 vs 4.0 ± 8.1 days; p < 0.001), and higher rates of repeat ED visits within 30 days of ED discharge (0.57 ± 1.44 vs 0.26 ± 0.79 visits; p < 0.001). We found specific socio-demographic variables associated with a poorer quality of care in ED visits for SCD VOC, including patients who were adults, male, from a low-income neighbourhood, having a greater number of dependents, a higher neighbourhood level of material deprivation, from an ethnically-concentrated neighbourhood, and those who lived in a residentially unstable region. Bivariate analyses for clinically meaningful outcomes (defined as ED disposition, repeat ED visit within 30 days, length of hospital admission stay, and being among the highest user bracket of ED care) further revealed significant socio-demographic associations that validated the clinical relevance of these determinants underlying ED metric disparities found within the SCD cohort (Table 1). In subgroup comparisons, we observed a significant difference in triage acuity scoring for adults compared with children with SCD VOC, with a 25% lower rate of high acuity triage score (CTAS 1 or 2) (66% vs 86%). We also found that despite a majority of adults with SCD VOC receiving these scores compared to those in the matched group (66% vs 18%), their mean times to initial physician assessment were not significantly different (90 ± 94 vs 91 ± 89 minutes), reflecting an average SCD VOC wait time longer than the clinical practice guideline recommendation of first dose analgesic within the first 60 minutes of ED arrival. Furthermore, we identified a negative correlation between poor ED metrics and patients with SCD who were highly dependent on ED care (defined as 4-9 or ≥ 10 ED visits for SCD VOC per year) at levels significantly above the matched comparative baseline. Conclusions: Indicators of ED care for SCD largely reflect the clinical acuity and severity of VOC presentations in Ontario, Canada. However, significant disparities in the quality of care received and in clinical outcomes for specific subgroups of patients with SCD, including those most vulnerable within this patient population, raises concern from a health equity perspective.By leveraging this landscape of SCD ED care, future policy, clinical and research efforts must work to understand, address and close these gaps in order to achieve best and equitable care for all. Disclosures No relevant conflicts of interest to declare.

Emergency Department Management of Children with Sickle Cell Disease.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 1660-1660
Author(s):  
Melissa J. Frei-Jones ◽  
Amy L. Baxter ◽  
Charles T. Quinn ◽  
George R. Buchanan
Keyword(s):  
Emergency Department ◽  
Steady State ◽  
Sickle Cell Disease ◽  
Hospital Admission ◽  
Sickle Cell ◽  
Admission Rate ◽  
Categorical Variables ◽  
Continuous Variables ◽  
Cell Disease ◽  
Ed Visits

Abstract Vaso-occlusive crises (VOC) are a common cause of emergency department (ED) visits for children with sickle cell disease (SCD). To better understand our patient population and compare with reports from other centers, we sought to describe the presentation, management, and disposition of children with VOC at our center’s ED. We also aimed to identify predictors of hospital admission. We retrospectively reviewed hospital records of all patients with SCD, age 8–19 years, who presented to our urban pediatric ED in 2003 with a chief complaint of pain. We identified all subjects diagnosed with VOC and not another cause of pain. We obtained the following data for each: SCD genotype; duration of VOC and treatment prior to ED presentation; the nature of analgesia and use of intravenous fluids (IVF) in the ED; hemoglobin (Hgb) concentration; and disposition (admitted, discharged, discharged with subsequent ED visit for same crisis). Categorical variables were evaluated by the χ2 and Fisher exact tests and continuous variables by the t-test. Odds ratios (OR) and 95% confidence intervals (CI) were calculated where appropriate. In 2003, there were 320 ED visits for patients with SCD and pain. Among these, there were 279 diagnoses of VOC in 105 individual patients: 45 had one visit, 25 two visits, and 16 ≥5 visits. Mean number of visits per patient was 2.7; 23 (22%) patients accounted for 145 (55%) visits. Homozygous sickle cell anemia (Hgb SS) was present in 73/105 patients, accounting for 222 (79%) ED visits. Overall admission rate was 179/279 (64%), with 167/179 admitted on their first visit and 12 on their return visit. Subjects with Hgb SS accounted for 147/179 (82%) admissions. Among those discharged who later returned to the ED during the same VOC, the admission rate was 86% (5 returned in 24 hours, 5 in 48 hours, 3 in 72 hours, and one 4 days later). Pre-ED home opioid use was reported in 75% of visits and was associated with increased likelihood of discharge (OR 1.63, CI 0.94–2.84, p=0.082). Duration of VOC before presentation did not significantly affect admission rate and averaged 53.2 hours for admitted patients and 49.7 hours for those discharged (p=0.689). Patients who received IVF in the ED (219/279; 79%) were less likely to be admitted (31% vs 56%, p<0.001). Hgb concentration was increased in 61%, decreased in 36% and unchanged in 3% of patients from steady-state values and was not associated with admission. After receiving 2 doses of morphine, 31 patients were discharged from the ED, while only 5 patients were discharged after receiving 3 or 4 doses of morphine. A departmental VOC protocol was followed for 25.4% of patients, with no impact on admission rate (p=0.290). In this retrospective analysis of a large series of pediatric sickle cell ED visits, patients presented later in their VOC, and admission rate was higher than previously reported. A small proportion of older patients with SCD accounted for most ED visits and hospitalizations. Hgb variation from steady-state was neither clinically significant nor predictive of admission or discharge. In contrast to previous studies, receiving IVF in the ED was associated with a greater likelihood of discharge. Home opioids prior to ED presentation seemed to decrease hospital admission. Adherence to our center’s VOC protocol did not appear to influence disposition from the ED.

Continuity of Care for Acute Visits In Sickle Cell Disease: Do Patients Go to More Than One Site?

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 735-735
Author(s):  
Julie A. Panepinto ◽  
Pamela L Owens ◽  
Andrew Mosso ◽  
Claudia A Steiner ◽  
David C Brousseau
Keyword(s):  
Emergency Department ◽  
Quality Of Care ◽  
Sickle Cell Disease ◽  
Acute Care ◽  
Sickle Cell ◽  
Private Insurance ◽  
Cell Disease ◽  
Public Insurance ◽  
Number Of Visits

Abstract Abstract 735 Sickle cell disease is characterized by frequent and recurrent vaso-occlusive events that often require multiple acute care visits to the emergency department (ED) or hospital. Multiple visits for sickle cell disease are more common among younger adults and those with public insurance than children and older adults and those with private insurance or who are uninsured.1 It is not known, however, whether these multiple visits are made to more than one site of care which could potentially reduce the patient's quality of care. The objective of this study was to examine the continuity of acute care visits for patients with sickle cell disease, as defined by having one site of care (versus multiple sites of care). We hypothesized that children with sickle cell disease and those sickle cell disease patients with private insurance would be more likely to use one ED or hospital for their acute care, while adults with sickle cell disease and those sickle cell disease patients with public insurance would be more likely to use multiple sites of care. We conducted a retrospective cohort study using 2005 and 2006 data from the Healthcare and Cost Utilization Project State Inpatient Databases and State Emergency Department Databases. Data from eight states (AZ, CA, FL, MA, MO, NY, SC, and TN) with an encrypted patient identifier were used to examine all acute care visits for sickle cell-related diagnoses in children and adults with sickle cell disease. Our primary outcome was the proportion of patients with all acute care visits to one site. We derived a logistic regression model to examine the association between age and primary expected payer and likelihood of having a single site of care, adjusting for rurality of the patient's residence, gender, number of visits and state of residence. A total of 21,118 patients with sickle cell disease had one or more sickle cell disease -related acute care visits to the ED or hospital. There were 13,533 patients who made two or more visits. Approximately 66% of these patients (n=8,895) had public insurance as the primary expected payer. Of the 5,030 children (ages 1–17 years) with multiple visits, 77.3% went to the same site for their acute care over the two year time period. This is in contrast to the adults (n=8,503) for whom only 51.3% received all acute care at the same site. The proportion of patients who went to one site of care decreased as the number of visits made increased for both children and adults. In multivariable analyses, adolescents (10- 17 years olds) were more likely than young adults (18-30 years old) to go to one site for all acute care (adjusted odds ratio (AOR) 3.78, 95% confidence interval (CI) 3.23–4.43). Analyzing the likelihood of going to one site for all acute care by primary expected payer, uninsured patients were less likely to have one site of care compared to patients with private insurance as the expected payer, even after controlling for the number of visits. This association was especially pronounced among patients with an increased number of visits during the two year study period. When examining adults who made four acute care visits, 41.2% of those without insurance went to one site for care compared to 56.4% with private insurance and 56.5% with public insurance. In children with 4 acute care visits, 54.5% of those without insurance went to one site compared to 78.7% with private insurance and 75.2% of those with public insurance. In multivariable analysis, having public insurance and being uninsured were associated with decreased likelihoods of going to one site for all acute care (AOR 0.85, 95% CI 0.77–0.93 and AOR 0.64, 95% CI 0.55–0.74 respectively) compared to having private insurance. Young adults and patients who are uninsured or who have public insurance are more likely to go to multiple sites for their acute care compared with children and those with private insurance. Although the long-term effects of having multiple sites of acute care are unknown, it may indicate a lack of a medical home and may contribute to lower quality of care. 1. Brousseau DC, Owens PL, Mosso AL, Panepinto JA, Steiner CA. Acute Care Utilization and Rehospitalizations for Sickle Cell Disease. JAMA 2010;303(13):1288-1294. Disclosures: No relevant conflicts of interest to declare.

scholarly journals Biopsychosocial Predictors of Quality of Life in Paediatric Patients With Sickle Cell Disease

2021 ◽  
Vol 12 ◽  
Author(s):  
Anna M. Hood ◽  
Melanie Kölbel ◽  
Hanne Stotesbury ◽  
Jamie Kawadler ◽  
April Slee ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Emergency Department ◽  
Executive Function ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Pain Coping ◽  
Cell Disease ◽  
Paediatric Patients ◽  
Ed Visits

Sickle cell disease (SCD) refers to a group of inherited blood disorders with considerable morbidity that causes severe pain, reduces life expectancy, and requires significant self-management. Acute painful episodes are the hallmark of SCD, but persistent daily pain is also highly prevalent in this population. Characterising the impact and experience of SCD-related morbidity (i.e., sleep disruption, frequent emergency department visits, cognitive dysfunction) on health-related quality of life (HRQOL) requires multiple assessment methods to best capture the underlying mechanisms. To gain a greater understanding of the effect of common symptom categories on HRQOL and to determine potential pain coping targets, the present study investigated whether demographic, socioeconomic, sleepiness, pain burden, frequency of emergency department (ED) visits, and cognition predicted HRQOL in a paediatric sample of patients with SCD. Our study was a secondary analysis of baseline assessment data of children with SCD aged 8–15 years (n = 30) in the Prevention of Morbidity in Sickle Cell Anaemia Phase 2b (POMSb2) randomised controlled clinical trial of auto-adjusting continuous positive airways pressure. Patients completed cognitive testing (IQ, Processing Speed Index, Delis-Kaplan Executive Function Scale (DKEFS) Tower, Conner's Continuous Performance Test), sleepiness (Epworth Sleepiness Scale), and HRQOL (PedsQL Sickle Cell Module) at baseline. Patients reported pain burden (Sickle Cell Pain Burden Inventory-Youth) each month over 8 visits. Caregivers provided demographic information and reported their child's executive function (Behavioural Rating Inventory of Executive Function) at baseline. Data from our analysis demonstrated that demographic factors (i.e., age, gender, level of neighbourhood deprivation) and treatment variables (i.e., hydroxyurea use) did not independently predict HRQOL, and laboratory values (i.e., haemoglobin, haematocrit, mean oxygen saturation) were not significantly correlated with HRQOL (ps &gt; 0.05). However, sleepiness, pain burden, ED visits, and executive dysfunction independently predicted HRQOL (R2 = 0.66) with large effects (η2 = 0.16 to 0.32). These findings identify specific, measurable symptom categories that may serve as targets to improve HRQOL that are responsive to change. This knowledge will be useful for multimodal interventions for paediatric patients with SCD that include sleep management, pain coping strategies, and executive function training.

scholarly journals Patient Controlled Analgesia for Adults with Sickle Cell Disease Awaiting Admission from the Emergency Department

2016 ◽  
Vol 2016 ◽  
pp. 1-5 ◽  
Author(s):  
Josue Santos ◽  
Sasia Jones ◽  
Daniel Wakefield ◽  
James Grady ◽  
Biree Andemariam
Keyword(s):  
Emergency Department ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Treatment Algorithm ◽  
Retrospective Chart Review ◽  
Cell Disease ◽  
Patient Controlled Analgesia ◽  
Analgesic Treatment ◽  
Pain Scores ◽  
Ed Visits

Background.A treatment algorithm for sickle cell disease (SCD) pain in adults presenting to a single emergency department (ED) was developed prioritizing initiation of patient controlled analgesia (PCA) for patients awaiting hospitalization.Objectives.Evaluate the proportion of ED visits in which PCA was started in the ED.Methods.A two-year retrospective chart review of consecutive SCD pain ED visits was undertaken. Data abstracted included PCA initiation, low versus high utilizer status, pain scores, bolus opioid number, treatment times, and length of hospitalization.Results.258 visits resulted in hospitalization. PCA was initiated in 230 (89%) visits of which 157 (68%) were initiated in the ED. Time to PCA initiation was longer when PCA was begun after hospitalization versus in the ED (8.6 versus 4.5 hours,p<0.001). ED PCA initiation was associated with fewer opioid boluses following decision to admit and less time without analgesic treatment (allp<0.05). Mean pain intensity (MPI) reduction did not differ between groups. Among visits where PCA was begun in the ED, low utilizers demonstrated greater MPI reduction than high utilizers (2.8 versus 2.0,p=0.04).Conclusions.ED PCA initiation for SCD-related pain is possible and associated with more timely analgesic delivery.

scholarly journals Views and Experiences of Parents and Physicians on the Care Provided to Children with Sickle Cell Disease in Cameroon

2020 ◽  
Author(s):  
Ettamba Agborndip ◽  
Benjamin Momo Kadia ◽  
Domin Sone Majunda Ekaney ◽  
Lawrence Tanyi Mbuagbaw ◽  
David C Rees ◽  
...  
Keyword(s):  
Quality Of Care ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Good Knowledge ◽  
Cell Disease ◽  
National Guidelines ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
North West

AbstractBackgroundSickle Cell Disease (SCD) affects two in 100 Cameroonian new-borns, with 50-90% of affected children dying before their fifth birthday. Despite this burden, there is no national SCD programme in Cameroon. This study aimed to assess parents’ and physicians’ knowledge of SCD, their satisfaction with the quality of care and their recommendations to improve the treatment of SCD in Cameroon.MethodsA multi-centre cross-sectional survey was conducted in English and French, using structured questionnaires distributed in electronic format to physicians throughout Cameroon. Paper-based questionnaires were also administered to parents in the West and North West regions of Cameroon. Data were entered into Microsoft Excel and analysed using the SPSS statistical software.ResultsFifty-four parents and 205 physicians were recruited. We found that 72.2% of parents had good knowledge of SCD, 72.2% of parents were satisfied with the quality of care. Attending a sickle cell clinic (AOR 22, 95% CI 17.70-250) was significantly associated with having good knowledge. Just 14.2% of physicians had good knowledge and 23.3% of physicians were satisfied with the available management standards of SCD. Seeing more than five patients per month (AOR 3.17, 95% CI 1.23-8.20) was significantly associated with having good knowledge. Sickle cell clinics, national guidelines and subsidised treatment were the top three measures proposed by physicians and parents to improve the management of SCD.ConclusionKnowledge of SCD and satisfaction with care were poor among Cameroonian physicians. There is a need for a national programme and a comprehensive system of care for SCD in Cameroon.

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 Improving Completion Rates of Transcranial Doppler Ultrasounds in Children with Sickle Cell Disease Using Quality Improvement Efforts: In-Clinic Vs. Population-Based Assessments

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 1886-1886
Author(s):  
Madhav Vissa ◽  
Marsha Treadwell ◽  
Naomi Bardach
Keyword(s):  
Quality Improvement ◽  
Quality Of Care ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Chart Review ◽  
Claims Data ◽  
Administrative Claims ◽  
Completion Rates ◽  
Cell Disease

Abstract Introduction: People living with sickle cell disease (SCD) are at risk for stroke due to progressive cerebral vasculopathy. The Stroke Prevention Trial in Sickle Cell Anemia (STOP) study showed that transfusion therapy in patients with abnormal cerebral blood flow velocities measured by transcranial doppler (TCD) ultrasound significantly reduced the risk for stroke. Based on the STOP and STOP II studies, the National Heart, Lung and Blood Institute (NHLBI) and American Society of Hematology (ASH) recommend annual TCD screenings for children with HbSS and HbSb0 genotypes from age 2-16. Despite this recommendation, studies show that fewer than half of eligible children with SCD complete annual TCD screening. Recently, Cabana and Treadwell et al. (2020) found high TCD referral and completion rates in a multi-site quality improvement (QI) initiative (85% baseline) using chart review. Another feasible approach to tracking guideline adherence uses administrative claims data which are derived from diagnostic and billing codes from statewide claims. Claims data can be used to assess population estimates for a clinic or a state, for all eligible patients, including those who may not routinely access care. In this study, we use administrative claims to assess TCD completion rates in the same clinics participating in the aforementioned QI initiative. We hypothesized that, population level rates would be lower than those assessed via chart review and that QI strategies may not lead to sustained TCD completion rates. Methods: Between August 2017 to August 2018, a QI initiative within the Pacific Sickle Cell Regional Collaborative (PSCRC) was conducted to improve referral and completion rates of TCD screenings. Site leads participated in a monthly QI learning collaborative, implementing and reporting on Plan-Do-Study-Act (PDSA) cycles, with bimonthly chart review data collection. Medicaid administrative claims from the four states with participating clinics, from 2017, 2018 (to assess baseline and post-QI initiative performance) and 2019 (to assess sustainability), were used to assess rates of TCD completion in the eligible pediatric population, using the specifications of a previously validated quality measure by Reeves et al (2019). Annual TCD completion rates and changes in completion rates over time were assessed for each site and state. Results: Five sites from four states in the PSCRC were included in the analysis. There was large variability in the number of eligible patients in each clinic (13-75) and state (23-588). Based on administrative claims, TCD clinic-level completion rates at baseline ranged from 41.7% to 69.2% at individual clinics. After 12 months of QI participation, TCD completion rates improved at all sites (range 4.6% to 29.2%). The site with the largest change improved TCD completion rate from 41.7% to 70.8% (n=24). All but one site had a decrease in TCD completion rate after completing the QI initiative and in 2019, TCD completion rates were within 10% of baseline completion rates at all sites (range -8.2% to 8.3%). At the statewide level, one state had a sustained improvement in TCD completion (improvement from baseline: 8.8%). In three of the four states providing data, TCD completion rates decreased from baseline (range -0.7% to -12.6%). Discussion: In a regional collaborative, we found improvements in TCD completion in the setting of a QI initiative focused on TCD, which were not sustained in the year after. This suggests the need for a systems-level approach to improvement, leading to feasible sustainability when no longer the focus of a collaborative. In addition, our data show that, when using administrative claims, rates of TCD completion are lower than rates when using chart review data (41.7% to 69.2% vs. 85% by chart review noted in prior publication). Thus, while site-specific medical record review provides insight into the quality of care for patients seen in the clinic, administrative claims data allow for a global understanding of the quality of care for the clinic population at risk, including those who do not attend clinic regularly. This suggests additional potential focus for quality improvement initiatives, such as systems to optimize outreach to patients who may not routinely access care. This type of outreach may best be done by health plans, potentially in partnership with sickle cell specialists, and would be an important tool for improving health for children with SCD. Disclosures Vissa: Global Blood Therapeutics Inc: Research Funding. Treadwell: National Alliance of Sickle Cell Centers: Other: Early Evaluation of the Use of Crizanlizumab in Sickle Cell Disease.

Health Care Utilization Patterns and Emergency Department Reliance During Transition of Care From Pediatric to Adult Providers In Sickle Cell Disease

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 83-83 ◽  
Author(s):  
Bradd G. Hemker ◽  
David C Brousseau ◽  
Ke Yan ◽  
Raymond G Hoffmann ◽  
Julie A. Panepinto
Keyword(s):  
Emergency Department ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Medical Home ◽  
Transition Period ◽  
Age Groups ◽  
Cell Disease ◽  
Outpatient Visits ◽  
Transition Group ◽  
Ed Visits

Abstract Abstract 83 Background: Improved survival of patients with sickle cell disease has led to increased attention on the transition of care from pediatric to adult providers. Recent studies have shown increased emergency department (ED) utilization as well as an increased risk of mortality during this transition period for patients with sickle cell disease. Suggested reasons for such changes include loss of a medical home, loss of insurance, and loss of access to outpatient clinics as pediatric sickle cell patients transition to adult services. Emergency Department Reliance (EDR), defined as the number of ED visits divided by the number of ED and outpatient visits, views ED visits in relation to all ambulatory visits. Those with more severe disease, who utilize the ED more, should also have more outpatient visits, while those without adequate outpatient clinic access simply use the ED more without a rise in outpatient clinic visits, thus increasing EDR. EDR, therefore, is used to differentiate increased ED use due to need for care from increased ED use as an access issue. We hypothesized that as patients transition from pediatric to adult centered care, loss of a primary medical home would lead to an increase in the EDR. Methods: We conducted a retrospective cohort study using the Wisconsin State Medicaid database from 2003–2007. This database includes 757 patients of any age with sickle cell disease who are part of the Wisconsin Medicaid system. Consistent with previous literature, having sickle cell disease was defined by having at least one inpatient hospitalization, or two outpatient visits at least one month apart, with a diagnosis of sickle cell disease. All encounters during the study period were extracted from the database and linked by unique anonymous identifiers. Information extracted included age, all diagnosis codes, and classification as ED visit, outpatient visit, or inpatient hospitalization. The study population was divided into three mutually exclusive age groups: 1) children: ≤ 18 years old for the entire study period, 2) the transition group who turned 19 years old during the study period; and 3) Young adults age ≥ 19–45 years at first encounter. Adults age 3 46 at first encounter were eliminated from the analysis as the goal was to compare the transition group to the age groups immediately above and below. The median Emergency Department Reliance (ED visits/[ED + outpatient visits]) was compared for each age group for sickle cell related diagnoses, all diagnoses, and sickle cell crisis diagnoses using non-parametric, multiple-comparisons adjusted tests. Results: The 687 remaining patients had a total of 32,258 ambulatory visits over the five year study period, including 20,418 outpatient visits and 11,840 emergency department visits. There were 345 children, 65 patients in the transition group, and 277 young adults. For sickle cell diagnoses, the transition group had a significantly higher EDR than children (0.50 vs. 0.39, p=0.031) and a higher EDR than young adults, though this increase failed to achieve statistical significance (0.50 vs. 0.41, p=0.360). The difference in EDR between the children and adults for sickle cell diagnoses was not significant. A similar pattern emerged when computing EDR based on all diagnoses, with the EDR for the transition group being significantly higher than for children (0.35 vs. 0.28, p<0.001) as well as increased compared to adults, although this did not reach statistical significance (0.35 vs. 0.31, p=0.073). Lastly, the EDR was highest in all age groups for sickle cell crisis diagnoses (EDR ≥ 0.68 in all three groups). Conclusions: Patients with sickle cell disease who are transitioning from pediatric to adult centered care have an increased reliance on the emergency department as a location of care for sickle cell diagnoses. As adults, emergency department reliance returns to similar levels as childhood, suggesting a stabilization of a medical home following the transition period. The EDR is highest for all groups at times of acute pain crisis related to sickle cell disease, consistent with the need for emergent care in those situations. These findings support the hypothesis that increased ED utilization during the transition period from pediatric to adult providers is potentially due to limitations in access to care. Disclosures: No relevant conflicts of interest to declare.

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