Health status and healthcare use in a national sample of children with sickle cell disease

Association of care in a medical home and health care utilization among children with sickle cell disease

OBJECTIVE

Sickle cell disease (SCD) is marked by high utilization of medical services. The aim of this study was to determine whether having a patient-centered medical home (PCMH) is associated with a reduction in emergency care (ED) utilization or hospitalizations among children with SCD.

METHODS

We collected and analyzed data from parents of 150 children, ages 1 to 17 years, who received care within a large children's hospital. The primary dependent variables were rates of parent-reported ED visits and hospitalizations. The principal independent variable was parent-reported experience with an overall PCMH or its four individual components (regular provider, comprehensive care, family-centered care, and coordinated care). Multivariate negative binomial regression, yielding incident rate ratios (IRR), was used for analysis.

RESULTS

Children who received comprehensive care had half the rate of ED visits (IRR 0.51, 95% confidence interval, 0.33-0.78) and nearly half the rate of hospitalizations (IRR 0.56, 95% confidence interval, 0.33-0.93) compared to children without comprehensive care. No other component of the PCMH was significantly associated with ED visits or hospitalizations. Children reported to have excellent/very good/good health status had lower odds of ED visits and hospitalizations compared to those reported to be in fair/poor condition.

CONCLUSIONS

Children with SCD reported to experience comprehensive care had lower rates of ED encounters and hospitalizations after controlling for demographics and health status. The overall findings highlight that the provision of comprehensive care--having a usual source of care and no problems with referrals--may provide a strategy for improving pediatric SCD care.

Long-term persistency and costs associated with the use of iron chelation therapies in the treatment of Sickle cell disease within Medicaid programs

OBJECTIVE

This retrospective study evaluated iron chelating therapy (ICT) discontinuation and costs in Sickle cell disease (SCD) Medicaid recipients using healthcare claims from 2006-2010.

METHODS

Patients with ≥1 SCD diagnosis claim, ≥2 claims for deferoxamine (DFO) or deferosirox (DFX), and continuous enrollment ≥6 months prior to and 18 months following ICT initiation were included. Outcomes included treatment discontinuation, persistence (i.e., refill gaps ≥6 weeks), and total healthcare costs.

RESULTS

The average age among 404 SCD patients meeting study inclusion criteria was 18.7 (±11.0) years, with 45.8% being males and 66.7% being Blacks. Switches or combinations from DFO at index occurred in 124 (74.7%) patients compared to 10 (4.2%) with DFX at index. The Cox regression model that assessed long-term medication persistence indicated a 1.30-times higher likelihood of treatment discontinuation with DFO compared to DFX (95% CI: 1.06-1.61). Some 19.7% of patient remained on DFX relative to 4.8% on DFO. Both inpatient and total costs were similar in DFX and DFO treatment groups. Following 1 year of treatment, 37.4% remained on DFX compared to 15.7% on DFO. Meaningful differences in treatment discontinuation between the two treatment groups did not occur until 220+ days during the study period. At 18-months, treatment discontinuation rates were high in both groups; 95% for DFO and 80% for DFX.

CONCLUSION

This study of SCD Medicaid patients found more therapeutic switches from DFO to DFX and a higher medication persistency rate with DFX than DFO. The conclusions are limited by the study's retrospective nature, which depends on multivariate statistics to account for patient heterogeneity and risk factors.

Adverse neurological outcomes in Nigerian children with sickle cell disease

Sickle cell disease (SCD) is reported to be the most common genetic disorder affecting Nigerians. Children with SCD are at a high risk of neurological morbidity. The main objective of this study was to determine the pattern of adverse neurological outcomes among a cohort of Nigerian children with SCD. All children with SCD seen in the Department of Paediatrics, University College Hospital, Ibadan, Nigeria, over a period of 2 years were carefully evaluated for symptoms and signs of neurological complications, defined as clinical outcomes referable to the central nervous system. Of the 214 children evaluated, 187 were diagnosed with Hb SS disease and 27 with Hb SC disease. Neurological complications were identified in 78 (36.4 %) of the cases. The most common complications were headache (17.8 %), seizure (9.3 %) and stroke (8.4 %). Other less frequent complications included bacterial meningitis (2.8 %), spontaneous visual loss (1.4 %), paraplegia (0.9 %) and transient ischaemic attacks (0.9 %). Neurological complications occurred more frequently in children with sickle cell anaemia than in those with Hb SC disease (P = 0.002, 95 % CI 1.450-82.870). Adverse neurological events are common in Nigerian children with SCD, with a significantly higher risk in Hb SS than Hb SC disease. Stroke represents a major underlying cause of symptomatic epilepsy in SCD. Institution of primary preventive measures for stroke in SCD will significantly reduce the burden of stroke and epilepsy associated with SCD in Nigeria.

Ambulatory care connections of Medicaid-insured children with sickle cell disease

BACKGROUND

Sickle cell disease (SCD) requires coordinated ambulatory care from generalists and hematologists. We examined when children with SCD establish ambulatory care connections, whether these connections are maintained, and how these connections are used before and after hospitalizations.

PROCEDURE

We conducted a retrospective cohort study of Medicaid-insured Maryland children with SCD from 2002 to 2008. For children enrolled from birth, time to first, second, and third generalist and first hematologist visits was plotted. For all children, we analyzed ambulatory visits by age group, by emergency department (ED) and hospital use, and before and after hospitalizations.

RESULTS

The overall study cohort comprised 851 children; 178 provided data from birth. Ambulatory care connections to generalists were made rapidly; connections to hematologists occurred more slowly, if at all (38% of children had not seen a hematologist by age 2 years). Visits with generalists decreased as patients aged, as did visits with hematologists (54% of children in the 12-17 year age group had no hematology visits in 2 years). Children with higher numbers of ED visits or hospitalizations also had higher numbers of ambulatory visits (generalist and hematologist). Most children had visits with neither generalists nor hematologists in the 30 days before and after hospitalizations.

CONCLUSIONS

Medicaid-insured children with SCD rapidly connect with generalists after birth; connections to hematologists occur more slowly. The observation that connections to generalists and hematologists diminish with time and are infrequently used around hospitalizations suggests that the ambulatory care of many Medicaid-insured children with SCD may be inadequate.

A transition pilot program for adolescents with sickle cell disease

INTRODUCTION

Transition from pediatric to adult care is challenging for adolescents with chronic illnesses, including those with sickle cell disease (SCD). We describe a pilot program created to facilitate transition from pediatric to adult care by helping adolescents with SCD identify an adult medical home.

METHODS

We investigated the feasibility of this program by evaluation of overall participation, satisfaction, and acceptance. A secondary objective was to compare the proportion of adolescents who fulfilled a first appointment with an adult hematologist among participants and nonparticipants.

RESULTS

During the first 18 months of the program, 83 adolescents were invited and 34 (41%) agreed to participate; 25 (74%) completed their first visit within 3 months after leaving the pediatric program, compared with 16 of 49 (33%) of nonparticipants (p = .0002). Overall, 41 of 83 adolescents (49%) completed an appointment with an adult SCD program, regardless of program participation, in contrast with 11 of 75 adolescents (15%) who did so during the 18 months before the program was created (p < .0001).

DISCUSSION

This transition pilot program was feasible, and most adolescent participants with SCD established an adult medical home.

Examination of risk and resiliency in a pediatric sickle cell disease population using the psychosocial assessment tool 2.0

OBJECTIVE

To evaluate the Psychosocial Assessment Tool 2.0 (PAT) as an appropriate screening measure of risk for patient and family psychological distress in pediatric sickle cell disease (SCD).

METHODS

219 caregivers completed the PAT during regular hematology clinic visits. Confirmatory factor analysis and tests of reliability were conducted. Multilevel modeling examined change and predictors of risk scores across four assessments.

RESULTS

Confirmatory factor analysis factor loadings ranged from .03 to .81, and reliability coefficients ranged from .43 to .83. Risk for patient and sibling emotional problems, family problems, and parent stress reaction decreased over time. Increased patient age, chronic blood transfusion, lower caregiver education, caregivers being divorced, fewer adults and more children in the home, and greater financial difficulties were independent predictors of psychosocial risk.

CONCLUSIONS

Results suggest that the PAT has utility in a pediatric sickle cell disease sample. Most caregivers reported low distress and high resiliency factors in this population.

Birth prevalence of disorders detectable through newborn screening by race/ethnicity

PURPOSE

The purpose of this study was to describe the birth prevalence of genetic disorders among different racial/ethnic groups through population-based newborn screening data.

METHODS

Between 7 July 2005 and 6 July 2010 newborns in California were screened for selected metabolic, endocrine, hemoglobin, and cystic fibrosis disorders using a blood sample collected via heel stick. The race and ethnicity of each newborn was self-reported by the mother at the time of specimen collection.

RESULTS

Of 2,282,138 newborns screened, the overall disorder detection rate was 1 in 500 births. The disorder with the highest prevalence among all groups was primary congenital hypothyroidism (1 in 1,706 births). Birth prevalence for specific disorders varied widely among different racial/ethnic groups.

CONCLUSION

The California newborn screening data offer a unique opportunity to explore the birth prevalence of many genetic disorders across a wide spectrum of racial/ethnicity classifications. The data demonstrate that racial/ethnic subgroups of the California newborn population have very different patterns of heritable disease expression. Determining the birth prevalence of these disorders in California is a first step to understanding the short- and long-term medical and treatment needs faced by affected communities, especially those groups that are impacted by more severe disorders.

Medical-legal partnership: impact on patients with sickle cell disease

OBJECTIVE

To determine the types of legal problems addressed by the Health Law Partnership (HeLP) and the impact of the legal interventions in pediatric patients with sickle cell disease (SCD) or its variants. We hypothesized that an interdisciplinary team that includes lawyers would positively affect the social determinants of health that affect patients with SCD.

METHODS

The HeLP database was retrospectively queried for all patients with the diagnosis of SCD or 1 of its variants who had been seen by the lawyers of HeLP between April 2004 and September 2010. Data collected in this cohort of patients included income level of the patient/client, the initial presenting problems, any patient/parent/guardian problems identified during the legal checkup, and the type of legal assistance provided. Estimated annualized financial outcomes were calculated.

RESULTS

From April 2004 through September 2010, 71 parents/guardians with 76 children with SCD were referred to the HeLP for legal intervention. Of the 71 parents/guardians, 33 were at <100% of the federal poverty level. There were 106 initial case problems identified in the 71 parents/guardians; 51 of 106 problems were directly related to the child. An additional 93 issues were identified during the legal checkup. Of 106 cases, 99 were closed with 21 resulting in a measurable gain of benefits.

CONCLUSIONS

In a cohort of families of children with SCD, incorporating access to legal services as part of the care plan resulted in a positive impact on these patients/parents/guardians. The impact was directly attributable to the intervention of the HeLP.

Disability among individuals with sickle cell disease: literature review from a public health perspective

CONTEXT

Young people with blood disorders face challenges in maintaining their physical health as they age. Sickle cell disease has well-documented complications in various organ systems. Increasingly, professionals, consumers, and advocates involved in blood disorders are concerned about the cumulative and ongoing effect of organ-specific complications on function and participation.

EVIDENCE ACQUISITION

Publications were identified that looked at the relationship between sickle cell disease and associated impairments and restrictions in participation as defined by the International Classification of Function, Disability, and Health (ICF).

EVIDENCE SYNTHESIS

This article organizes a literature review in PubMed using ICF terms that define functional limitations and participation restrictions in sickle cell disease.

CONCLUSIONS

Individuals with sickle cell disease experience complications in multiple organ systems that affect related functions and, consequently, participation in community living. The effects begin early in childhood and accumulate across the life course into adulthood. Intervention research is needed to understand how contextual factors can promote optimal function and participation in the face of mounting impairments.

Unmet health care needs in children with cerebral palsy: a cross-sectional study

Children with potentially severe health conditions such as cerebral palsy (CP) are at risk for unmet health care needs. We sought to determine whether children with CP had significantly greater unmet health care needs than children with other special health care needs (SHCN), and whether conditions associated with CP increased the odds of unmet health care needs. We analyzed data from the National Survey of Children with Special Health Care Needs, 2005-2006, using multivariate logistic regression to calculate the adjusted odds of children with CP having one or more unmet health care needs compared to children with other SHCN. We also determined the association of CP-related conditions with unmet health care needs in children with CP. After weighting to national averages, our sample represented 178,536 children with CP (1.9%), and 9,236,794 with children with other SHCN (98.1%). Although having CP increased the odds that children had unmet health care needs (OR = 1.46, 95% CI [1.07-1.99]), the presence of a "severe" health condition weakened the association. Gastrointestinal problems and emotional problems increased the odds that children with CP would have unmet health care needs above that of children without the associated conditions (p ≤ .01). Children with CP are similar to children with other SHCN and may benefit from collaborative programs targeting severe chronic conditions. However, children with CP and associated conditions have increased odds of unmet health care needs in comparison to children without those problems.

Urgency of emergency department visits by children with sickle cell disease: a comparison of 3 chronic conditions

OBJECTIVE

Children with sickle cell disease (SCD) often receive care in the emergency department (ED), but the urgency of these frequent visits is not well understood. This study examined ED use by children with SCD by comparing the urgency of ED visits among children with SCD, asthma, and diabetes mellitus.

METHODS

We conducted a retrospective cohort study of Maryland ED visits for SCD, diabetes, or asthma from 2000 to 2004. ED visits resulting in hospital admission were deemed urgent. The urgency of ED visits not resulting in admission was determined using 2 methodologies: evaluation and management (E/M) coding and resource utilization. Multivariable logistic regression models were used to compare the likelihood of admission or urgent, treat-and-release ED visits across the 3 chronic conditions.

RESULTS

Nearly half (45%) of ED visits with a primary diagnosis of SCD resulted in admission, which was substantially higher than the 12% seen for asthma (adjusted odds ratio [AOR] 6.9, 95% confidence interval [CI], 6.4-7.4) and comparable to that seen for diabetes (41%). ED visits associated with primary diagnoses of SCD (AOR 5.9, 95% CI, 5.3-6.5) and diabetes (AOR 6.6, 95% CI, 6.0-7.3) were more likely than those associated with asthma to result in either admission or a discharge of higher urgency, as measured by E/M coding. These relationships persisted among repeat ED visitors, for visits with any diagnosis (ie, primary or nonprimary) of SCD, diabetes, and asthma, and when evaluated using the resource utilization method.

CONCLUSIONS

Similar to visits by children with diabetes, ED visits by children with SCD are substantially more likely than those by children with asthma to be of high urgency.

Evaluation and Treatment of Sickle Cell Pain in the Emergency Department: Paths to a Better Future

Pain is the hallmark of sickle cell disease in children and adolescents. Many children seek relief from their pain in the emergency department. These visits have historically been characterized by undertreatment, bias and distrust. Through compassionate care, aggressive pain management, and the development of clinical pathways or care guidelines, better analgesia and a better experience can be assured for the child with sickle cell disease in need of emergency care.

Administrative data sets and health services research on hemoglobinopathies: a review of the literature

CONTEXT

Large administrative healthcare data sets are an important source of data for health services research on sickle cell disease (SCD) and thalassemia. This paper identifies and describes major U.S. healthcare administrative databases and their use in published health services research on hemoglobinopathies.

EVIDENCE ACQUISITION

Publications that used U.S. administrative healthcare data sets to assess healthcare use or expenditures were identified through PubMed searches using key words for SCD and either costs, expenditures, or hospital discharges; no additional articles were identified by using thalassemia as a key word. Additional articles were identified through manual searches of related articles or reference lists.

EVIDENCE SYNTHESIS

A total of 26 original health services research articles were identified. The types of administrative data used for health services research on hemoglobinopathies included federal- and state-specific hospital discharge data sets and public and private health insurance claims databases. Gaps in recent health services research on hemoglobin disorders included a paucity of research related to thalassemia, few studies of adults with hemoglobinopathies, and few studies focusing on emergency department or outpatient clinic use.

CONCLUSIONS

Administrative data sets provide a unique means to study healthcare use among people with SCD or thalassemia because of the ability to examine large sample sizes at fairly low cost, resulting in greater generalizability than is the case with clinic-based data. Limitations of administrative data in general include potential misclassification, under-reporting, and lack of sociodemographic information.

Sickle cell disease-related pediatric medical expenditures in the U.S

BACKGROUND

Although it is known that people with sickle cell disease (SCD) have relatively high utilization of medical care, most previous estimates of SCD-attributable expenditures have been limited to either inpatient care or single-state data.

PURPOSE

To extend known findings by measuring the attributable or incremental expenditures per child with SCD compared to children without this illness and to thereby estimate SCD-attributable expenditures among children in the U.S.

METHODS

MarketScan Medicaid and Commercial Claims databases for 2005 were used to estimate total medical expenditures of children with and without SCD. Expenditures attributable to SCD were calculated as the difference in age-adjusted mean expenditures during 2005 for children with SCD relative to children without SCD in the two databases.

RESULTS

Children with SCD incurred medical expenditures that were $9369 and $13,469 higher than those of children without SCD enrolled in Medicaid and private insurance, respectively. In other words, expenditures of children with SCD were 6 and 11 times those of children without SCD enrolled in Medicaid and private insurance, respectively.

CONCLUSIONS

Using a large, multistate, multipayer patient sample, SCD-attributable medical expenditures in children were conservatively and approximately estimated at $335 million in 2005.

Sickle-cell pain: advances in epidemiology and etiology

New epidemiological findings recast pain in sickle-cell disease (SCD) as being more often a chronic manifestation than was previously thought, although acute pain is still the hallmark of the disease. SCD pain intensity, the number of painful locations, and the frequency of hospitalizations due to SCD pain may worsen with age. In adults and even in children, the quantity and severity of SCD pain may be vastly underestimated, because most of the "iceberg" of SCD pain is "submerged" at home, and only the tip of the iceberg is seen by health care providers when acute SCD care is rendered in emergency rooms and hospitals. Implications of this "iceberg phenomenon" are significant for clinicians, researchers, employers, policy makers, and the public. Nevertheless, both emergency room and hospital utilization for SCD pain remain prevalent. Often, utilization recurs early, perhaps emblematic of poor acute pain management. New data show the protean impacts of SCD pain on health-related quality of life, sleep, and psychological and social health. The relationship of the severity of SCD pain to the severity of underlying sickle vasculopathy is unclear, but epidemiologic evidence and patient descriptors suggest a temporal evolution of pain mechanisms. At first, increasingly worse nociceptive pain from vaso-occlusion and local lesions may evolve over the first two decades of life. Then, in the third and following decades, central neuropathic pain may also evolve due to past and continuing nociceptive stimuli. New findings confirm environmental contributors to SCD pain, including seasonal (colder) temperatures, barometric pressure, and wind speed.