Emergency Department Treat-and-Release Visits for Sickle Cell Disease: A sIgn of acute events to come

Abstract Abstract 169 Background: Patients with sickle cell disease have very high rates of rehospitalization, with rates as high as 40% for young adults. Many institutions have invested significant resources to utilize an inpatient hospitalization as a trigger to alter care and prevent further hospital utilization. While this focus on hospitalizations is important, there has been little attention given to return visits following treat-and-release emergency department (ED) visits. It has been shown that patients with sickle cell disease have high use of acute care resources, including the ED. Given that only half of ED visits by patients with sickle cell disease result in an inpatient stay, it may be possible to use an ED visit as a trigger for improved care rather than waiting for an inpatient hospitalization. We hypothesized that patients with sickle cell disease who were treated and released from the ED would have high rates of return for acute care utilization, both to the ED and the inpatient unit, within 14 days. We further hypothesized that young adults and those with public insurance would have the highest return for acute care utilization rates. Methods: We conducted a retrospective cohort study using 2005 and 2006 State Emergency Department Databases and State Inpatient Databases. The data are from the Healthcare Cost and Utilization Project (HCUP), a Federal-State-Industry partnership sponsored by the Agency for Healthcare Research and Quality. Data for all sickle cell-related ED visits and hospitalizations within the following eight states (AZ, CA, FL, MA, MO, SC, TN, and NY) were extracted for each patient. One-third of patients with sickle cell disease in the United States live within these states. All sickle cell related visits were linked via encrypted person-level identifiers to allow linkage of record level information, thus clustering visits by patient. Each treat-and-release ED visit served as an index visit; all subsequent ED treat-and-release visits and inpatient hospitalizations (whether through the ED or not) were tracked for periods of 7 and 14 days. ED treat-and-release visits within the seven days following a hospital discharge were excluded from being index visits. Results: A total of 12,109 patients with sickle cell disease made 39,775 ED treat-and-release visits during the two-year study period. Of the index ED treat-and-release visits, 4,162 (34.4%) children (ages 1–17 yrs) made 8,636 (21.7%) visits compared to 4,166 (34.4%) 18–30 year olds who made 17,070 (42.8%) ED treat-and-release visits. Overall, 16,731 (42.1%) of the ED treat-and-release visits had either an inpatient hospitalization or another ED treat-and-release visit within 14 days of the index ED visit; 39.7% of those return visits were inpatient hospitalizations meaning that 16.7% of ED treat-and-release visits are followed by an inpatient hospitalization within 14 days. Analyzing the 42.1% return visit rate by age and payer revealed that 49.0% of ED treat-and-release visits by 18 – 30 year old patients resulted in return visits compared to 24.7% of children and 38.6% of 46–64 year olds. 46.5% of ED treat-and-release visits by those with public insurance resulted in a return visit compared to 32.2% of visits by those with private insurance and 35.0% of those who were uninsured. As the timing of return visits might direct the intervention, we also evaluated 7 day return visits. Of the 16,731 return visits within 14 days, 12,561 (75.1%) occurred in the first 7 days; 41.1% of the 7 day return visits were inpatient hospitalizations meaning that 13% of ED treat-and-release visits were followed by an inpatient hospitalization within 7 days. Conclusions: A significant proportion of patients with sickle cell disease return for acute care following an ED treat-and-release visit, with young adults and those with public insurance having the highest rates of return visits. A high percentage of those return visits are hospitalizations. Given these findings, ED treat-and-release visits should serve as a trigger to focus enhanced outpatient comprehensive care on these patients in order to prevent a subsequent inpatient hospitalization and to ultimately improve care for patients with sickle cell disease. Disclosures: No relevant conflicts of interest to declare.

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

Blood ◽

10.1182/blood.v116.21.735.735 ◽

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.

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Acute Care Visits in Sickle Cell Disease: a Population-Based Multi- State Study

Blood ◽

10.1182/blood.v112.11.165.165 ◽

2008 ◽

Vol 112 (11) ◽

pp. 165-165 ◽

Cited By ~ 1

Author(s):

David Brousseau ◽

Julie A. Panepinto ◽

Pamela Owens ◽

Claudia Steiner

Keyword(s):

Emergency Department ◽

Sickle Cell Disease ◽

Acute Care ◽

Sickle Cell ◽

Population Based ◽

Emergency Department Visits ◽

Cell Disease ◽

Principal Diagnosis ◽

Inpatient Hospitalization ◽

Entire Cohort

Abstract Background: The number of times a patient will seek acute care in the emergency department or require hospitalization for sickle cell related illness has not been described in a population-based manner. Twenty years ago, rates of acute care visits for 3,578 patients who were part of the Cooperative Study of Sickle Cell Disease were reported, eloquently describing patterns of acute care utilization for people followed at select centers. In that study, only 1% of patients had more than six visits per year and 5% of the population (who made three to 10 visits per year) accounted for almost one-third of all visits. The objective of this study is to describe the emergency department and hospital utilization for patients with sickle cell related conditions over a two- year period. This study will be the first to provide a complete assessment of the utilization patterns of patients with sickle cell disease, one that is multi-state, inclusive of all ages, all insurance types, and includes patients that are followed at community, academic and tertiary care centers. Methods: We conducted a retrospective cohort study using 2005 and 2006 State Emergency Department and State Inpatient Databases that include encrypted personlevel identifiers to allow linkage of record level information. The data are from the Healthcare Cost and Utilization Project (HCUP), a Federal-State-Industry partnership sponsored by the Agency for Healthcare Research and Quality. Data for all sickle cell related emergency department visits and hospitalizations within the following seven states (Arizona, California, Florida, Missouri, South Carolina, Tennessee, and New York) were extracted for each patient. To be eligible, a patient had at least one sickle cell specific visit, defined as a visit with a principal diagnosis of sickle cell crisis or a secondary diagnosis of sickle cell disease with a principal diagnosis that was sickle cell related (e.g. pneumonia, stroke, fever). All sickle cell related visits were linked by unique personal identifiers, thus clustering visits by patient and allowing population-based statewide assessments of utilization. An emergency department visit on the same day as an inpatient hospitalization was counted only as an inpatient hospitalization to avoid over counting care-seeking visits. The distribution of acute care visits for each patient (presented as numbers of emergency department visits and hospitalizations over the two-year period) was determined for the entire cohort, then stratified as child versus adult. Results: A total of 24,668 patients with sickle cell disease made 86,535 acute care visits during the two-year study period, 33,520 (38.7%) were emergency department visits and 53,015 (61.3%) were inpatient visits. Of the 24,668 patients, 8,895 (36.1%) were less than 18 years of age; 15,773 were adults. 52.8% of the entire cohort made one visit in the two year period. 1,320 (5.4%) patients had more than 12 visits over the two-year time period; 3,210 (13.0%) made 6–20 visits over two years, and accounted for 31,752 (36.7%) acute care visits. An additional 579 (2.4%) patients had more than 20 visits over two years, accumulating 18,701 (21.6%) acute care visits. Children were less likely to have more than 12 visits over the two years (1.9%) compared to adults aged 18–45 (8.1%) and were also less likely to be in the high utilization group of 6–20 visits over two years (9.9% of children compared to 15.8% of those 18–45 years old). Conclusions: A significant proportion of patients with sickle cell disease seek acute care multiple times in an emergency department setting or through hospitalization. Our population-based study demonstrates an increased proportion of high utilizers compared to previous work, especially among adult patients. Our findings likely reflect the difference in healthcare utilization in the broader community as compared to that within a cooperative study in academic settings. It suggests that some patients, adults in particular, may have limited access to urgent care in a primary care setting and would benefit from better access and more aggressive preventive care. Further work on patterns of and reasons for utilization, especially emergency department care, in this high-utilizer group, would be helpful in targeting and improving overall care for these patients.

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Emergency Department Management of Children with Sickle Cell Disease.

Blood ◽

10.1182/blood.v104.11.1660.1660 ◽

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.

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

Pain Research and Management ◽

10.1155/2016/3218186 ◽

2016 ◽

Vol 2016 ◽

pp. 1-5 ◽

Cited By ~ 3

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.

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

Blood ◽

10.1182/blood-2020-142803 ◽

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.

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

Blood ◽

10.1182/blood.v116.21.83.83 ◽

2010 ◽

Vol 116 (21) ◽

pp. 83-83 ◽

Cited By ~ 1

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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Acute Care in the Emergency Department Differs before and after Transition for Adolescents and Young Adults with Sickle Cell Disease

Blood ◽

10.1182/blood.v126.23.3267.3267 ◽

2015 ◽

Vol 126 (23) ◽

pp. 3267-3267

Author(s):

Nathan R. Stehouwer ◽

Bohyung Park ◽

Preston Edge ◽

Hong Li ◽

Connie M. Piccone ◽

...

Keyword(s):

Emergency Department ◽

Young Adults ◽

Sickle Cell Disease ◽

Acute Care ◽

Sickle Cell ◽

Acute Pain ◽

Medication Administration ◽

Wait Times ◽

Cell Disease ◽

Transition Age

Abstract Background Painful vaso-occlusive crises (VOC) are the most common cause of emergency department (ED) visits in patients with sickle cell disease (SCD) and are a major point of contact between patients and the health care system. Transition from pediatric to adult care has not been studied in the acute care setting. We examined whether management of VOC in adolescents and young adults differed between the pediatric and the adult ED. Methods A retrospective chart review was performed for all ED encounters in our hospital system for acute pain in patients with SCD, ages 13-23 years, between 2011-2013. Comprehensive medication administration data was collected for the ED visit as well as for the ensuing hospitalization, when applicable. Demographics and baseline medical data were collected. The equianalgesic dose, expressed as mg of intravenous (IV) morphine, and time to first analgesic administration were calculated. Equianalgesic dose and time to first analgesic were compared between the pediatric and adult ED using analysis of variance. In patients who were hospitalized, the total opioid dose received in the first 24 hours and the mean daily total opioid dosage during hospitalization were compared. Results were adjusted for correlation within multiple visits by individual patients, baseline hemoglobin, and presenting pain scores. Results: 193 visits by 45 subjects, half of whom were male (44% M pediatric, 56% M adults), and most of whom had either HbSS or HbSβ0 (59% pediatric, 83% adults), were examined. Time to medication administration in the pediatric ED was 72 minutes vs 131 minutes in the adult ED (p<0.05, Figure 1A). Opioid medications were administered in 96% of all visits. The adjusted equianalgesic dose of the first opioid medication was 5.4 mg and 10.6 mg in the pediatric and the adult ED, respectively (p<0.0001, Figure 1B). The first opioid administered was parenteral hydromorphone in 4% of pediatric visits and 72% of adult visits. Preliminary analysis suggests that transition-age patients also received higher medication dosages during ensuing admissions to the adult hospital when compared with the pediatric hospital. In a secondary analysis of 5 patients seen in both the pediatric and adult EDs during the study period, wait times were 56 and 158 minutes (p<0.05), and the equianalgesic doses of the first opioid administered were 4.7 mg and 7 mg, respectively (p<0.05). Conclusions These data suggest significant differences in acute pain management between pediatric and adult hospitals for transition-age patients with SCD. Possible reasons for observed differences include a larger patient volume in the adult ED, increasing disease severity with age, and the preference for use of higher potency hydromorphone among adult providers. Our data suggest that optimal transition management for adolescents with SCD must include strategies for transition in acute care management, focusing on limiting wait times and consistent dosing and titration of pain medications. Disclosures No relevant conflicts of interest to declare.

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Age-Related Emergency Department Reliance and Healthcare Resource Utilization in Patients with Sickle Cell Disease

Blood ◽

10.1182/blood.v120.21.475.475 ◽

2012 ◽

Vol 120 (21) ◽

pp. 475-475

Author(s):

Morey A. Blinder ◽

Francis Vekeman ◽

Medha Sasane ◽

Alex Trahey ◽

Carole Paley ◽

...

Keyword(s):

Emergency Department ◽

Sickle Cell Disease ◽

Sickle Cell ◽

Healthcare Costs ◽

Research Funding ◽

Transition Period ◽

Cell Disease ◽

Adult Care ◽

Age Related ◽

Ed Visits

Abstract Abstract 475 Introduction: For sickle cell disease (SCD) patients (pts), inadequate care during pediatric to adult transition may result in increased emergency department (ED) utilization. Emergency department reliance (EDR: total ED visits/total ambulatory [outpatient + ED] visits) identifies the proportion of ED visits in relation to all ambulatory visits and differentiates between acute episodic ED users from those who may not have adequate access to outpatient care. The aim of this study is to investigate age-related patterns of EDR and associated healthcare costs in pediatric SCD pts and those transitioning from pediatric to adult care. Methods: State Medicaid data from FL (1998–2009), NJ (1996–2009), MO (1997–2010), IA (1998–2010), and KS (2001–2009) were used for this study. Pts with ≥2 SCD diagnoses (ICD-9 282.6x) and ≥1 blood transfusion were included in the analysis. Pts were followed for as long as they were enrolled in Medicaid. Quarterly rates of outpatient visits, ED visits, EDR, SCD complications associated with ED visits, and ED visits resulting in hospitalization were evaluated. Total healthcare costs were calculated and stratified by outpatient (OP), inpatient (IP), ED, and prescription drug (Rx). SCD complications included pain, stroke, leg ulcers, avascular necrosis, infections, as well as pulmonary, renal, and cardiovascular events. Based on published thresholds, high EDR was defined as >0.33. A logistic regression model was used to assess associations between high EDR and transition age (<18 vs. ≥18 years [yrs]), transfusions, hydroxyurea use, and SCD complications. Other covariates included transfusions during the previous quarter, other relevant medications (e.g.: pain medication, diuretics, anticoagulants), comorbidities (e.g.: hypertension, myocardial infarction, liver disease), and, serving as proxies for overall health status, the frequency of OP, IP, and ED visits during the previous quarter. Regressions analyses were also used to calculate adjusted costs differences between pts with high vs. low EDR. Findings: A total of 3,208 pts were included (FL: 1,550, NJ: 992, MO: 489, KS: 121, IA: 56) in the study. Each pt was observed for an average (SD) of 6.0 (3.1) yrs. Average ED visits/quarter increased from 0.76 to 2.29 between age 15 and 24, reaching a peak of 2.9 at age 36 (Figure 1). Regardless of age, the most common SCD complications associated with ED visits were pain, infection, and pneumonia. Beginning at age 15, EDR rose from 0.17 to reach 0.29 at age 22, and remained high throughout adulthood. The quarterly rate of ED visits resulting in hospitalizations followed a similar pattern. Regression analysis indicated that pts were more likely to have high EDR during the post-transition period (≥18 yrs old, odds ratio [OR]: 2.38, p<0.001) and when experiencing an SCD complication (OR: 4.18, p<0.001). Pts with high EDR incurred statistically significantly higher inpatient and ED costs, resulting in significantly higher total costs (high vs. low EDR, unadjusted costs difference, OP: -$441, p<.001; IP: $7,427, p<.001; ED: $442, p<.001; Rx: -$447, p=0.182; total: $7,376, p<.001 [Table 1]; adjusted costs difference, OP: -$285; IP: $3,485; ED: $120; Rx: -$91; total: $3,086, p<.001 for all). Conclusion: Compared to children, pts transitioning to adulthood relied more on ED for their care. Moreover, pts with high EDR incurred more frequent hospitalizations and significantly higher healthcare costs, highlighting the need to improve transition related support including better access to primary care and increased engagement with SCD patients. Disclosures: Blinder: Novartis Pharmaceuticals: Consultancy, Research Funding. Vekeman:Novartis Pharmaceuticals: Research Funding. Sasane:Novartis Pharmaceuticals: Employment. Trahey:Novartis Pharmaceuticals: Research Funding. Paley:Novartis Pharmaceuticals: Employment. Magestro:Novartis Pharmaceuticals: Employment. Duh:Novartis Pharmaceuticals: Research Funding.

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Episodic Patterns of High Emergency Department Utilization Among Sickle Cell Disease Patients

Blood ◽

10.1182/blood.v128.22.316.316 ◽

2016 ◽

Vol 128 (22) ◽

pp. 316-316

Author(s):

Susan Paulukonis ◽

Lisa Feuchtbaum ◽

Elliott Vichinsky ◽

Mary Hulihan

Keyword(s):

Emergency Department ◽

Sickle Cell Disease ◽

Sickle Cell ◽

Surveillance System ◽

Research Funding ◽

Cell Disease ◽

Ed Visits ◽

High Utilization ◽

The Mean ◽

Over Time

Abstract Background: High utilization of emergency department (ED) services among those with sickle cell disease (SCD) compared to the general population and compared to those with other chronic diseases is well documented in the literature. Some reports note that high utilization is episodic. Most analyses address the problem as a consistent one within patients, rather than consistent over time across the patient population but sporadic for patients. Reducing the high rate of ED utilization among patients with SCD requires an understanding of temporal patterns of ED utilization, the consistency of ED utilization over time by patients and the proportion of the population affected at any given time. Methods: CDC has developed the Sickle Cell Data Collection program (SCDC) to conduct state level surveillance in this disease, and to continue and improve upon work begun through the Registry and Surveillance System in Hemoglobinopathies (RuSH). Through SCDC, California has collected ED and hospitalization data for years 2005-2014 on 4,325 people with SCD. A period of high ED utilization among this cohort was defined as three or more ED encounters (either treat and release or admission to the hospital from the ED) for any diagnosis (not only SCD diagnoses) each fewer than 30 days from the prior visit. The start of an episode of high utilization is the date of the first ED encounter; the end is the date of the last eligible ED encounter. All cohort members were divided into categories of utilization using the proportion of time spent in periods of high utilization divided by the total time in cohort. Total time is cohort is defined as the length of time from the earliest appearance in the ED or hospital data 2005-2014 to the latest appearance. The five categories were defined as no episodes of high ED utilization, and approximate quartile groups for those with high ED utilization: 1.1 to 3.0%, 3.1-10.0%, 10.1% or greater. Age categories (pediatric is < 21 years, and adult is 21 years or older) are defined as patient age at close of study (end of 2014) or at death if prior. Patient ID beginning with P is a pediatric, A is adult in the figures. Results: There were 4,325 individuals with 27,694 person years in the cohort (mean 6.4 person years, median 7.6 person years). Sixty-three percent (n=2,715) of the cohort were aged 21 years and older. Forty-five percent, (n=1,955, 513 pediatric and 1,442 adults) had at least one episode of high utilization during the 10 year study for a total of 7,866 episodes of high utilization. Forty-three percent of patients with one or more high utilization episodes were male, and 63% were between the ages of 20 and 50. Nine percent of these high utilizing patients' total time in the cohort was made up of episodes of high utilization. The mean time span from start of episodes of high utilization to end of the episodes was 63.3 days, median 35 days; mean number of ED visits per episode was 9.0, median 4.0. Most episodes of high utilization were brief: 42.2% included just three visits, and 70.7% included five or fewer ED visits. Among these individuals with episodes of high utilization, the mean number of such episodes was 4.0 over the 10 years study period, and the median was 2.0. Most (76.4%) had five or fewer high utilization episodes, and 35.5% had just one (n = 693). Sample utilization patterns, including hospital admissions, are shown in Figure 1. Conclusions: We demonstrate that among individuals with SCD seen in a population-based, statewide surveillance system, periods of high ED utilization are common, but most SCD patients have only a limited number of short episodes of such utilization. We found that high ED utilization is episodic rather than consistent within individuals, and that while the range of time spent in episodes of high utilization varies, few patients are high utilizers of ED services over a long period of time. Statewide surveillance that follows individual patients over time and in different hospital settings and includes ED utilization (including visits not coded as being related to SCD), provides high quality public health information to inform clinicians and healthcare systems in their development of efforts to reduce ED utilization among those living with SCD. Figure 1 Figure 1. Disclosures Paulukonis: Pfizer: Research Funding; Biogen: Research Funding.

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Characteristics and Trends of Sickle Cell Disease Patients Once Presented to the Emergency Department, Reflecting on a Possible Burden: United States (2010-2015)

Blood ◽

10.1182/blood-2019-126871 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 4845-4845

Author(s):

Tarek Haykal ◽

Ragheed Al-Dulaimi ◽

Josiane Kerbage ◽

Varun Samji ◽

Sowmya Goranta ◽

...

Keyword(s):

United States ◽

Emergency Department ◽

Sickle Cell Disease ◽

Life Expectancy ◽

Medical Care ◽

Sickle Cell ◽

National Database ◽

Cell Disease ◽

The Us ◽

Ed Visits

Background: Sickle cell disease (SCD) is an autosomal recessive, multisystem disorder, characterized by chronic hemolytic anemia, painful episodes of vaso-occlusion, progressive organ failure and a reduced life expectancy. SCD is the most common monogenetic disease, with millions affected worldwide. It is estimated that there are 100,000 people living with SCD in the United States (US). Patients with SCD often use emergency department (ED) services to obtain medical care. Limited nationwide information in the recent years is available about ED use among patients with SCD. Methods: Data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for the years 2010-2015 were analyzed, to examine the prevalence and care of SCD patients in the EDs across the US. The NHAMCS is a survey of hospital ED and outpatient visits. Cases were identified using ICD 9 codes and all analyses accounted for complex survey structure of the data. Results: On average, approximately 1.4 million ED visits were estimated to have occurred between the years 2010 and 2015 with SCD as one of the diagnoses listed, where 860,000 were attributed to sickle cell crises. 37.29% were of female sex while 62.71% were males. 11.62% were under 15 years of age, 28.22% were between 15 and 24 years of age, 51.15% were between the ages of 25 and 44 years and 9.02% were older than 45 years. The chief complaint for the majority of cases was pain. The expected source of payment were Medicare and Medicaid at 30.45% and 41.98% respectively, while private insurance coverage and self-pay were only at 11.71% and 5.81% respectively. Of all SCD ED visits, 68.5% were considered as initial presentations and up to 23.37% were considered as follow-up. 33.31% of the visits ended up needing a hospital admission while 66.69% got discharged from the ED.In 43.39% of the visits, a form of imaging was ordered, compared to 56.61% where it was not. Upon getting triaged in the ED, 67.62% of all SCD visits needed either emergent or urgent medical attention, while the rest were either none-urgent, or a regular check-up. Conclusion: In well-resourced countries, like the US, comprehensive care programs have increased life expectancy of sickle cell disease patients, with almost all infants surviving into adulthood. However unfortunately with poor control of the disease due to limited therapeutic options and with growing morbidity for the aging SCD patients, the burden on the medical system becomes extremely high. Our study highlights the significant burden SCD creates in the EDs across the US based on data collected from a national database. Disclosures No relevant conflicts of interest to declare.

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