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Mahesri M, Lee SB, Levin R, Imren S, Zhang L, Beukelman T, Titievsky L, Desai RJ. Infrequent Resolution of Vaso-Occlusive Crises in Routine Clinical Care Among Patients Mimicking the Exa-Cel Trial Population: A Cohort Study of Medicaid Enrollees. Clin Pharmacol Ther 2024. [PMID: 39328080 DOI: 10.1002/cpt.3449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 09/04/2024] [Indexed: 09/28/2024]
Abstract
The CRISPR-based gene editing therapy exagamglogene autotemcel (exa-cel) recently received FDA approval for patients with severe sickle cell disease (SCD). The approval was based on a phase III trial (CLIMB SCD 121), which showed 97% efficacy of this treatment in eliminating vaso occlusive crises (VOCs) for 12 consecutive months. To help contextualize results from this trial, we aimed to investigate the proportion of patients with severe SCD who remain VOC-free for a 1-year period in routine clinical care. Using Medicaid claims data (2000-2018), we identified a cohort of patients, 12-35 years old with severe SCD, defined by ≥ 2 VOCs per year for 2 consecutive years, who met other exa-cel trial inclusion criteria to mimic a trial-like population. A VOC was identified using ICD diagnosis codes during hospitalization and ER visits. The primary outcome was the proportion of patients with no VOCs during a 1-year follow-up. A total of 7,425 patients with severe SCD [mean (SD) age: 20.5 (6.0) years, 54.6% females, 84% African Americans], had a mean of 5.2 VOCs, 5.1 ER visits and 3.5 hospitalizations per year during the baseline period. The proportion of patients with no VOCs during the 1-year follow-up was 7.7% (95% confidence interval: 7.1%-8.3%). In conclusion, less than one in 12 patients with severe SCD achieved VOC-free status within 1 year in routine clinical care. These findings suggest that the high efficacy observed for exa-cel in the trial, if replicated in routine clinical care, could translate into a significant public health impact.
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Affiliation(s)
- Mufaddal Mahesri
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital & Harvard Medical School, Boston, Massachusetts, USA
| | - Su Been Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital & Harvard Medical School, Boston, Massachusetts, USA
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital & Harvard Medical School, Boston, Massachusetts, USA
| | - Suzan Imren
- Vertex Pharmaceuticals Inc., Boston, Massachusetts, USA
| | - Lanju Zhang
- Vertex Pharmaceuticals Inc., Boston, Massachusetts, USA
| | - Timothy Beukelman
- Vertex Pharmaceuticals Inc., Boston, Massachusetts, USA
- Epi Excellence LLC, Garnet Valley, Pennsylvania, USA
| | | | - Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital & Harvard Medical School, Boston, Massachusetts, USA
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Wachnik AA, Welch-Coltrane JL, Adams MCB, Blumstein HA, Pariyadath M, Robinson SG, Saha A, Summers EC, Hurley RW. A Standardized Emergency Department Order Set Decreases Admission Rates and In-Patient Length of Stay for Adults Patients with Sickle Cell Disease. PAIN MEDICINE 2022; 23:2050-2060. [PMID: 35708651 PMCID: PMC9714532 DOI: 10.1093/pm/pnac096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/20/2022] [Accepted: 06/10/2022] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Pain associated with sickle cell disease (SCD) causes severe complications and frequent presentation to the emergency department (ED). Patients with SCD frequently report inadequate pain treatment in the ED, resulting in hospital admission. A retrospective analysis was conducted to assess a quality improvement project to standardize ED care for patients presenting with pain associated with SCD. METHODS A 3-year prospective quality improvement initiative was performed. Our multidisciplinary team of providers implemented an ED order set in 2019 to improve care and provide adequate analgesia management. Our primary outcome was the overall hospital admission rate for patients after the intervention. Secondary outcome measures included ED disposition, rate of return to the ED within 72 hours, ED pain scores at admission and discharge, ED treatment time, in-patient length of stay, non-opioid medication use, and opioid medication use. RESULTS There was an overall 67% reduction in the hospital admission rate after implementation of the order set (P = 0.005) and a significant decrease in the percentage admission rate month over month (P = 0.047). Time to the first non-opioid analgesic decreased by 71 minutes (P > 0.001), and there was no change in time to the first opioid medication. The rate of return to the ED within 72 hours remained unchanged (7.0% vs 7.1%) (P = 0.93), and the ED elopement rate remained unchanged (1.3% vs 1.85%) (P = 0.93). After the implementation, there were significant increases in the prescribing of orally administered acetaminophen (7%), celecoxib (1.2%), and tizanidine (12.5%) and intravenous ketamine (30.5%) and ketorolac (27%). ED pain scores at discharge were unchanged for both hospital-admitted (7.12 vs 7.08) (P = 0.93) and non-admitted (5.51 vs 6.11) (P = 0.27) patients. The resulting potential cost reduction was determined to be $193,440 during the 12-month observation period, with the mean cost per visit decreasing by $792. CONCLUSIONS Use of a standardized and multimodal ED order set reduced hospital admission rates and the timeliness of analgesia without negatively impacting patients' pain.
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Affiliation(s)
| | | | | | | | | | | | - Amit Saha
- Department of Anesthesiology and Pain Service Line
| | - Erik C Summers
- Department of Internal Medicine Section of Hospital Medicine
| | - Robert W Hurley
- Correspondence to: Robert W. Hurley, MD, PhD, FASA, Department of Anesthesiology, Neurobiology and Anatomy, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27051, USA. Tel: 336-716-2266; Fax: 336-716-8773; E-mail:
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Time to First Completed Visit and Health Care Utilization Among Young Adults Transferring From Pediatric to Adult Rheumatologic Care in a Safety‐Net Hospital. Arthritis Care Res (Hoboken) 2021; 73:1730-1738. [DOI: 10.1002/acr.24409] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 08/04/2020] [Indexed: 12/13/2022]
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Cooper SH, Phipps EJ, Lawson D, Meier ER. How we coordinate care for uninsured children with nonmalignant hematologic disorders. Pediatr Blood Cancer 2021; 68:e29103. [PMID: 34125474 DOI: 10.1002/pbc.29103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 04/21/2021] [Accepted: 04/26/2021] [Indexed: 11/12/2022]
Abstract
Providing medical care for uninsured children with nonmalignant hematologic diagnoses presents unique challenges to medical providers and multidisciplinary staff. Financial and psychosocial stressors can hinder optimal care of the uninsured child. Maximizing coverage of medical costs through patient enrollment in state and charity care programs and capitalizing upon community partnerships can help providers achieve comprehensive care for these children. Collaboration between primary care providers, subspecialists, and multidisciplinary teams can be optimized to facilitate provision of hematology care for uninsured children. We detail our experience in establishing these collaborations to improve access to subspecialty care for children with nonmalignant hematologic disorders.
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Affiliation(s)
- Sarah Hall Cooper
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana, USA
| | - Erin Jane Phipps
- Eskenazi Health/Indiana University Health, Indianapolis, Indiana, USA
| | - DeAuntae Lawson
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana, USA
| | - Emily Riehm Meier
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana, USA
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Abdallah K, Buscetta A, Cooper K, Byeon J, Crouch A, Pink S, Minniti C, Bonham VL. Emergency Department Utilization for Patients Living With Sickle Cell Disease: Psychosocial Predictors of Health Care Behaviors. Ann Emerg Med 2020; 76:S56-S63. [PMID: 32928463 PMCID: PMC7486179 DOI: 10.1016/j.annemergmed.2020.08.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Study objective Individuals living with sickle cell disease (SCD) often require urgent care; however, some patients hesitate to present to the emergency department (ED), which may increase the risk of serious clinical complications. Our study aims to examine psychosocial, clinical, and demographic factors associated with delaying ED care. Methods This was a cross-sectional study of 267 adults with SCD from the national INSIGHTS Study. The binary outcome variable asked whether, in the past 12 months, participants had delayed going to an ED when they thought they needed care. Logistic regression was performed with clinical, demographic, and psychosocial measures. Results Approximately 67% of the participants reported delaying ED care. Individuals who delayed care were more likely to have reported higher stigma experiences (odds ratio [OR]=1.09; 95% confidence interval [CI] 1.03 to 1.16), more frequent pain episodes (OR=1.15; 95% CI 1.01 to 1.32), lower health care satisfaction (OR= 0.74; 95% CI 0.59 to 0.94), and more frequent ED visits (OR=6.07; 95% CI 1.18 to 31.19). Disease severity and demographics, including sex, age, and health insurance status, were not significantly associated with delay in care. Conclusion Psychosocial factors, including disease stigma and previous negative health care experiences, are associated with delay of ED care in this SCD cohort. There is a need to further investigate the influence of psychosocial factors on the health care–seeking behaviors of SCD patients, as well as the downstream consequences of these behaviors on morbidity and mortality. The resulting knowledge can contribute to efforts to improve health care experiences and patient-provider relationships in the SCD community.
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Affiliation(s)
- Khadijah Abdallah
- Social and Behavioral Branch, National Human Genome Research Institute, National Institute of Health, Bethesda, MD.
| | - Ashley Buscetta
- Social and Behavioral Branch, National Human Genome Research Institute, National Institute of Health, Bethesda, MD
| | - Kayla Cooper
- Social and Behavioral Branch, National Human Genome Research Institute, National Institute of Health, Bethesda, MD
| | - Julia Byeon
- Social and Behavioral Branch, National Human Genome Research Institute, National Institute of Health, Bethesda, MD
| | - Andrew Crouch
- Division of Hematology/Sickle Cell Center, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Sabrina Pink
- Division of Hematology/Sickle Cell Center, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Caterina Minniti
- Division of Hematology/Sickle Cell Center, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Vence L Bonham
- Social and Behavioral Branch, National Human Genome Research Institute, National Institute of Health, Bethesda, MD
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Desai RJ, Mahesri M, Globe D, Mutebi A, Bohn R, Achebe M, Levin R, Schneeweiss S. Clinical outcomes and healthcare utilization in patients with sickle cell disease: a nationwide cohort study of Medicaid beneficiaries. Ann Hematol 2020; 99:2497-2505. [DOI: 10.1007/s00277-020-04233-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 08/24/2020] [Indexed: 02/07/2023]
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Social Determinants of Health and Emergency Department Use Among Children With Sickle Cell Disease. J Pediatr Hematol Oncol 2020; 42:e42-e45. [PMID: 31743315 DOI: 10.1097/mph.0000000000001669] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Sickle cell disease (SCD) is associated with disproportionate emergency department (ED) use. This study described the social determinants of health associated with ED visits and hospital admission from the ED among children with SCD using a nationally representative dataset. We analyzed data from 126 children 0 to 17 years of age with SCD included in the 2011 to 2017 rounds of the National Health Interview Survey (mean age, 8 y; 50% female individuals; 74% African American). Study variables were summarized using weighted means and proportions and compared according to ED use and admission by Wald tests. Fifty-two identified children had visited the ED within the last 12 months and 21 were admitted to the hospital after their most recent ED visit. Children living in a single-mother household were more likely to visit the ED (P=0.040), as were younger children (mean age, 6 vs. 9 y; P=0.034), with no evaluated social determinants of health significantly impacting hospital admission from the ED. The lack of association between ED use and either poverty or insurance type may be related to the overall high level of social disadvantage among children with SCD. Our findings demonstrate the need to better characterize specific social factors impacting acute care use among children with SCD.
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Lubeck D, Agodoa I, Bhakta N, Danese M, Pappu K, Howard R, Gleeson M, Halperin M, Lanzkron S. Estimated Life Expectancy and Income of Patients With Sickle Cell Disease Compared With Those Without Sickle Cell Disease. JAMA Netw Open 2019; 2:e1915374. [PMID: 31730182 PMCID: PMC6902797 DOI: 10.1001/jamanetworkopen.2019.15374] [Citation(s) in RCA: 163] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE Individuals with sickle cell disease (SCD) have reduced life expectancy; however, there are limited data available on lifetime income in patients with SCD. OBJECTIVE To estimate life expectancy, quality-adjusted life expectancy, and income differences between a US cohort of patients with SCD and an age-, sex-, and race/ethnicity-matched cohort without SCD. DESIGN, SETTING, AND PARTICIPANTS Cohort simulation modeling was used to (1) build a prevalent SCD cohort and a matched non-SCD cohort, (2) identify utility weights for quality-adjusted life expectancy, (3) calculate average expected annual personal income, and (4) model life expectancy, quality-adjusted life expectancy, and lifetime incomes for SCD and matched non-SCD cohorts. Data sources included the Centers for Disease Control and Prevention, National Newborn Screening Information System, and published literature. The target population was individuals with SCD, the time horizon was lifetime, and the perspective was societal. Model data were collected from November 29, 2017, to March 21, 2018, and the analysis was performed from April 28 to December 3, 2018. MAIN OUTCOMES AND MEASURES Life expectancy, quality-adjusted life expectancy, and projected lifetime income. RESULTS The estimated prevalent population for the SCD cohort was 87 328 (95% uncertainty interval, 79 344-101 398); 998 were male and 952 were female. Projected life expectancy for the SCD cohort was 54 years vs 76 years for the matched non-SCD cohort; quality-adjusted life expectancy was 33 years vs 67 years, respectively. Projected lifetime income was $1 227 000 for an individual with SCD and $1 922 000 for a matched individual without SCD, reflecting a lost income of $695 000 owing to the 22-year difference in life expectancy. One study limitation is that the higher estimates of life expectancy yielded conservative estimates of lost life-years and income. The analysis only considered the value of lost personal income owing to premature mortality and did not consider direct medical costs or other societal costs associated with excess morbidity (eg, lost workdays for disability, time spent in the hospital). The model was most sensitive to changes in income levels and mortality rates. CONCLUSIONS AND RELEVANCE In this simulated cohort modeling study, SCD had societal consequences beyond medical costs in terms of reduced life expectancy, quality-adjusted life expectancy, and lifetime earnings. These results underscore the need for disease-modifying therapies to improve the underlying morbidity and mortality associated with SCD.
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Affiliation(s)
| | - Irene Agodoa
- Global Blood Therapeutics Inc, South San Francisco, California
| | - Nickhill Bhakta
- Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Mark Danese
- Outcomes Insights Inc, Westlake Village, California
| | - Kartik Pappu
- Global Blood Therapeutics Inc, South San Francisco, California
| | - Robin Howard
- Global Blood Therapeutics Inc, South San Francisco, California
| | | | | | - Sophie Lanzkron
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
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9
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Lee L, Smith-Whitley K, Banks S, Puckrein G. Reducing Health Care Disparities in Sickle Cell Disease: A Review. Public Health Rep 2019; 134:599-607. [PMID: 31600481 DOI: 10.1177/0033354919881438] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Sickle cell disease (SCD) is an inherited blood disorder most common among African American and Hispanic American persons. The disease can cause substantial, long-term, and costly health problems, including infections, stroke, and kidney failure, many of which can reduce life expectancy. Disparities in receiving health care among African Americans and other racial/ethnic minority groups in the United States are well known and directly related to poor outcomes associated with SCD. As an orphan disease-one that affects <200 000 persons nationwide-SCD does not receive the research funding and pharmaceutical investment directed to other orphan diseases. For example, cystic fibrosis affects fewer than half the number of persons but receives 3.5 times the funding from the National Institutes of Health and 440 times the funding from national foundations. In this review, we discuss the health inequities affecting persons with SCD, describe programs intended to improve their care, and identify actions that could be taken to further reduce these inequities, improve care, control treatment costs, and ease the burden of disease.
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Affiliation(s)
- LaTasha Lee
- Department of Clinical Research & Leadership, School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
| | - Kim Smith-Whitley
- Comprehensive Sickle Cell Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Perlman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sonja Banks
- Sickle Cell Disease Association of America, Baltimore, MD, USA
| | - Gary Puckrein
- National Minority Quality Forum, Washington, DC, USA
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Jae G. The Anticipatory Politics of Improving Childhood Survival for Sickle Cell Disease. SCIENCE, TECHNOLOGY & HUMAN VALUES 2018; 43:1122-1141. [PMID: 31406391 PMCID: PMC6690626 DOI: 10.1177/0162243918778342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Crediting scientific discovery for prolonging life is pervasive in biomedical histories of the genetic blood disorder, sickle cell disease. This includes the preventive strategies, such as newborn screening, that have underwritten the success of its life-extending interventions. Newborn screening is a technology that relies not only upon intact health infrastructures but also expertise and enhanced vigilance on the part of caregivers to anticipate complications while they are still open to circumvention. This paper posits that even after overcoming institutional barriers to make newborn screening equitably available, care and vigilance are resources that are themselves subject to what i term anticipatory politics, where structural conditions also stratify expectations for the future, including the affective appeal of medical innovations. This paper elaborates the paradigm of anticipatory politics through an ethnographic examination of newborn screening to connect the comprehensive care practices that have improved survival for sickle cell disease, and as the burden of mortality shifts to young adulthood, to expose how those who are resourced to care for these futures preferentially stand to benefit from preventive interventions.
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Affiliation(s)
- Gina Jae
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
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11
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Benenson I, Jadotte YT, Holly C. The need for care integration across hospital services for adults with sickle cell disease. JOURNAL OF INTEGRATED CARE 2018. [DOI: 10.1108/jica-03-2018-0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The purpose of this paper is to examine the risk factors and characteristics that influence the integration of quality care across hospital services by adult Sickle cell disease (SCD) patients.
Design/methodology/approach
This paper is a systematic review.
Findings
Painful vaso-occlusive crisis was the major cause of hospital and emergency department admissions in patients with SCD, although high utilizing patients had more diagnoses of acute chest syndrome and sepsis. High utilizers also had more SCD complications (aseptic necrosis) and infections. Patients who were publically insured accounted for 76.5 percent (95% CI: 0.632–0.861) of all patients. Patients aged 18–30 years had the highest rate of utilization, which declined in those over 50. Women were more likely than men to seek hospital services.
Research limitations/implications
There is a need for prospective studies with a prolonged follow-up, reasonable sample size, objective methods of data collection and similar outcome measures that address characteristics of utilization and integration across different clinical settings for this population.
Practical implications
There is a small subset of patients with SCD who consume a large percentage of resources. This may lend itself well to targeted collaborative and integrated care management services for these high consumers of healthcare resources.
Social implications
SCD patients who used hospital services for care, regardless of the frequency of their encounters, were more likely young women who relied heavily on public insurance to seek relief from the pain of vaso-occlusive crises. The majority were from African–American and Hispanic communities.
Originality/value
This study examines the consumption of resources by a high utilizing group as a necessary step in the development of an integrated care management pathway.
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Bou-Maroun LM, Meta F, Hanba CJ, Campbell AD, Yanik GA. An analysis of inpatient pediatric sickle cell disease: Incidence, costs, and outcomes. Pediatr Blood Cancer 2018; 65. [PMID: 28801954 DOI: 10.1002/pbc.26758] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 07/11/2017] [Accepted: 07/13/2017] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To identify characteristics of pediatric sickle cell disease (SCD) hospitalizations and to examine admission demographics and medical expenditures. METHODS Admissions with SCD were identified from the 2009 and 2012 releases of the Healthcare and Cost Utilization Project's Kids Inpatient Database. Disease-specific secondary diagnoses including acute chest syndrome (ACS), vaso-occlusive pain crisis (VOC), splenic sequestration, and stroke/transient ischemic attack were analyzed for patient and hospital demographics. Analytical endpoints included total healthcare expenditures and mortality. RESULTS We reviewed 75,234 inpatient hospitalizations with a diagnosis of SCD. Over $900,000,000 was spent annually in associated healthcare expenditure. The median length of hospitalization stay (LOS) for all admissions was 3 days (interquartile range [IQR] 2-5 days). VOC was the most frequent secondary diagnosis, recording 48,698 total hospitalizations and a median LOS of 3 days (IQR 2-6 days). Of the 8,490 hospitalizations with ACS, the infant population had a significantly higher mortality rate compared to other age groups (2% vs. 0.3%, P < 0.001). Cerebral vascular accidents incurred the second highest median hospitalization cost ($18,956), behind ACS ($22,631). A high proportion of Caucasian patients died during hospitalization for VOC (0.4% vs. 0.1%, P = 0.014) and ACS (4% vs. 0.2%, P < 0.001) when compared to non-Caucasians. CONCLUSION Inpatient hospitalizations for secondary manifestations of pediatric SCD were associated with significant healthcare expenditures. Patients with an increased statistical risk for death during hospitalization included Caucasians with SCD complications of ACS and VOC, and patients <1-year-old with ACS. Further research is needed to substantiate the associated clinical significance of these findings.
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Affiliation(s)
- Laura M Bou-Maroun
- Central Michigan University, College of Medicine, Mt. Pleasant, Michigan
| | - Fabien Meta
- Department of Hematology, Wayne State University School of Medicine, Detroit, Michigan
| | - Curtis J Hanba
- Department of Hematology, Wayne State University School of Medicine, Detroit, Michigan
| | - Andrew D Campbell
- Comprehensive Sickle Cell Program, University of Michigan Medical Center, Ann Arbor, Michigan
- Division of Pediatric Hematology Oncology, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Gregory A Yanik
- Division of Pediatric Hematology Oncology, University of Michigan Medical Center, Ann Arbor, Michigan
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Identifying Social-Behavioral Health Needs of Adults with Sickle Cell Disease in the Emergency Department. J Emerg Nurs 2017; 43:444-450. [DOI: 10.1016/j.jen.2017.04.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 03/29/2017] [Accepted: 04/08/2017] [Indexed: 11/17/2022]
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Osteonecrosis of the femoral head in sickle cell disease: prevalence, comorbidities, and surgical outcomes in California. Blood Adv 2017; 1:1287-1295. [PMID: 29296770 DOI: 10.1182/bloodadvances.2017005256] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 06/07/2017] [Indexed: 01/03/2023] Open
Abstract
Osteonecrosis of the femoral head (ONFH) is a prevalent complication of sickle cell disease (SCD) that has not been well described in population-based cohort studies. Using California's Office of Statewide Planning and Development discharge databases (1991-2013), we estimated the cumulative incidence of ONFH after accounting for the competing risk of death and used a multivariable Cox proportional hazards regression to identify factors associated with ONFH diagnosis. We also calculated rates of readmissions to the hospital or emergency department within 30 to 90 days of hip replacement surgery. Of the 6237 patients in our SCD cohort, 22% (n = 1356) developed ONFH at a median age of 27 years, and 23% (n = 308) of the patients with ONFH underwent hip replacement surgery at a median age of 36 years. The cumulative incidence of ONFH to age 30 years was higher among SCD patients with more severe disease (24%; vs 8% in less severe) and those with antecedent acute chest syndrome (ACS) (18%; vs 8% without prior history of ACS). From 2003 to 2013, SCD patients with more severe disease (hazard ratio [HR], 2.77; 95% confidence interval [CI], 2.38-3.23) or with antecedent ACS (HR, 1.61; CI, 1.35-1.91) were more likely to develop ONFH. Twenty-seven percent of post-hip surgery patients were readmitted within 30 days, mostly for painful vaso-occlusive crises. ONFH is a common SCD complication that increases with age; ongoing studies into prevention and effective nonsurgical interventions for SCD-induced osteonecrosis must remain a high research priority.
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Paulukonis ST, Feuchtbaum LB, Coates TD, Neumayr LD, Treadwell MJ, Vichinsky EP, Hulihan MM. Emergency department utilization by Californians with sickle cell disease, 2005-2014. Pediatr Blood Cancer 2017; 64:10.1002/pbc.26390. [PMID: 28000344 PMCID: PMC5403550 DOI: 10.1002/pbc.26390] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/14/2016] [Accepted: 10/31/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND Clinical care for children and adults living with sickle cell disease (SCD) is often provided in the emergency department (ED). Population-based surveillance data can be used to describe the ED utilization patterns of this patient population. PROCEDURE A cohort of pediatric and adult California patients with SCD was identified from multiple data sources, and 10 years (2005-2014) of their treat-and-release ED utilization data were analyzed. RESULTS Among a cohort of 4,636 patients with SCD, 4,100 (88%) had one or more treat-and-release ED visits. There were 2.1 mean annual visits per person for the cohort (median 0.7; range 0-185). In a single year (2005), 53% had 0 treat-and-release ED visits, 35% had 1-3 visits, 9% had 4-10 visits, and 3% had 11 or more visits; this highest utilization group accounted for 45% of all patients' ED visits. ED utilization in this cohort was highest among young adults and also higher among older adults than pediatric patients. CONCLUSION The majority of identified patients in each of the 10 years did not go to the ED, but nearly all had one or more such visits over the full span of time. This study highlights the power and utility of a multisource longitudinal data collection effort for SCD. Further study of the segment of the population with highest ED utilization may highlight areas where changes in healthcare and health policy could improve and extend the lives of patients with SCD.
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Affiliation(s)
- Susan T. Paulukonis
- California Rare Disease Surveillance Program, Public Health Institute, Richmond, California
| | - Lisa B. Feuchtbaum
- Genetic Disease Screening Program, California Department of Public Health, Richmond, California
| | - Thomas D. Coates
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital of Los Angeles, Los Angeles, California
| | - Lynne D. Neumayr
- Division of Hematology/Oncology, University of California San Francisco Benioff Children’s Hospital Oakland, Oakland, California
| | - Marsha J. Treadwell
- Division of Hematology/Oncology, University of California San Francisco Benioff Children’s Hospital Oakland, Oakland, California
| | - Elliott P. Vichinsky
- Division of Hematology/Oncology, University of California San Francisco Benioff Children’s Hospital Oakland, Oakland, California
| | - Mary M. Hulihan
- Division of Blood Disorders, Centers for Disease Control and Prevention, Atlanta, Georgia
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Benenson I, Jadotte Y, Echevarria M. Factors influencing utilization of hospital services by adult sickle cell disease patients: a systematic review. JBI DATABASE OF SYSTEMATIC REVIEWS AND IMPLEMENTATION REPORTS 2017; 15:765-808. [PMID: 28267033 DOI: 10.11124/jbisrir-2016-002983] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Painful vaso-occlusive crisis is a hallmark of sickle cell disease (SCD) that commonly results in utilization of hospital services. Recurrent use of hospital services by SCD patients is associated with high healthcare costs and adverse clinical outcomes. Understanding the factors influencing the pattern of utilization is a first step in improving medical care of this patient population while reducing healthcare expenditures. OBJECTIVES The primary objective of this systematic review was to determine what modifiable and non-modifiable factors influence utilization of hospital services by adult SCD patients. INCLUSION CRITERIA TYPES OF PARTICIPANTS Adult SCD patients of both sexes who utilized hospital services for acute or emergency care. TYPES OF FACTORS/EXPOSURE Non-modifiable and modifiable factors influencing utilization of hospital services. TYPES OF STUDIES Prospective and retrospective cohort studies, case-control and analytical cross-sectional studies. OUTCOMES The primary outcome of interest was high utilization of hospital services by adult SCD patients based on non-modifiable and modifiable factors measured as an odds ratio (analytical outcome). The secondary outcome was the prevalence of non-modifiable and modifiable factors among SCD patients who utilized hospital services measured as an event rate (descriptive outcome). SEARCH STRATEGY A comprehensive multi-step search was undertaken to find both published and unpublished studies. Only studies published in the English language were included. The search was not limited by year of publication. METHODOLOGICAL QUALITY Retrieved papers were assessed for methodological quality using standardized critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument. DATA EXTRACTION Data were extracted using a researcher-developed tool. DATA SYNTHESIS Included studies were combined in a statistical meta-analysis. The meta-analysis was based on a random effect model. For studies that did not allow statistical pooling, the findings have been presented in a narrative form. RESULTS Fourteen studies were included in this review. The analysis demonstrated that male patients accounted for 40.8% (95% confidence interval [CI] 0.370-0.447) of all utilizing patients. Sickle cell disease patients who were publically insured accounted for 76.5% (95% CI 0.632-0.861) of all patients who had hospital encounters. Patients aged 25-35 years had the highest rate of utilization, and the rate of utilization declined in patients older than 50 years. High utilizing patients had more diagnoses of acute chest syndrome and sepsis than patients who were moderate or low utilizers. CONCLUSION The majority of SCD patients who utilized hospital services were women, young people and publically insured individuals. Patients with particularly high level of utilization had more frequent diagnoses of acute chest syndrome and sepsis.
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Affiliation(s)
- Irina Benenson
- 1School of Nursing, Rutgers University, Newark, USA 2The Northeast Institute for Evidence Synthesis and Translation (NEST): a Joanna Briggs Institute Center of Excellence 3Division of Nursing Science, School of Nursing, Rutgers University, Newark, USA 4Department of Quantitative Methods, Epidemiology and Biostatistics, School of Public Health, Rutgers University, Newark, USA 5Division of Advanced Nursing Practice, School of Nursing, Rutgers University, Newark, USA
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Ahmed AE, Alaskar AS, McClish DK, Ali YZ, Aldughither MH, Al-Suliman AM, Malhan HM. Saudi SCD patients' symptoms and quality of life relative to the number of ED visits. BMC Emerg Med 2016; 16:30. [PMID: 27543088 PMCID: PMC4992320 DOI: 10.1186/s12873-016-0096-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 08/12/2016] [Indexed: 11/12/2022] Open
Abstract
Background Individuals living with sickle cell disease (SCD) have significantly increased emergency department (ED) use compared to the general population. In Saudi Arabia, health care is free for all individuals and therefore has no bearing on increased ED visits. However, little is known about the relationship between quality of life (QoL) and frequency of acute care utilization in this patient population. Methods A cross-sectional study was conducted on 366 patients with SCD who attended the outpatient department at King Fahad Hospital, Hofuf, Saudi Arabia. Data were collected through self-administered surveys, which included: demographics, SCD-related ED visits, clinical issues, and QoL levels. We assessed the ED use by asking for the number of SCD-related ED visits within a 6-month period. Results The self-report survey of ED visits was completed by 308 SCD patients. The median number of SCD-related ED visits within a 6-month time period (IQR) was four (2-7 visits). According to the unadjusted negative binomial model, the rate of SCD-related ED visits increased by (46, 39.3, 40, and 53.5 %) for patients with fever, skin redness with itching, swelling, and blood transfusion, respectively. Poor QoL tends to increase the rate of SCD-related ED visits. Well education and poor general health positively influenced the rate of SCD-related ED visits. Well education tends to increase the rate of SCD-related ED visits by 50.2 %. The rate of SCD-related ED visits decreased by 1.4 % for every point increase in general health. Conclusion Saudi patients with sickle cell disease reported a wide range of SCD-related ED visits. It was estimated that six of 10 SCD patients had at least three ED visits within a 6-month period. Well education and poor general health resulted in an increase in the rate of SCD-related ED visits.
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Affiliation(s)
- Anwar E Ahmed
- King Saud bin Abdulaziz University for Health Sciences, College of Public Health and Health Informatics, MC 2350, P.O.Box 22490, Riyadh, 11426, KSA, Saudi Arabia. .,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
| | - Ahmed S Alaskar
- King Saud bin Abdulaziz University for Health Sciences, College of Public Health and Health Informatics, MC 2350, P.O.Box 22490, Riyadh, 11426, KSA, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Donna K McClish
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Yosra Z Ali
- King Abdulaziz Medical City, Riyadh, Saudi Arabia
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Dupervil B, Grosse S, Burnett A, Parker C. Emergency Department Visits and Inpatient Admissions Associated with Priapism among Males with Sickle Cell Disease in the United States, 2006-2010. PLoS One 2016; 11:e0153257. [PMID: 27078839 PMCID: PMC4831774 DOI: 10.1371/journal.pone.0153257] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 03/26/2016] [Indexed: 12/01/2022] Open
Abstract
People with sickle cell disease (SCD) suffer from numerous acute complications that can result in multiple hospitalizations and emergency department (ED) and outpatient care visits. Priapism, a prolonged unwanted erection of the penis not due to sexual stimulation, is a serious complication among males with SCD. Variations in estimates of prevalence make it difficult to accurately assess the burden of this complication of SCD. We analyzed data from the Nationwide Emergency Department Sample (NEDS), a product of the Healthcare Cost and Utilization Project, for the years 2006 through 2010 to measure the numbers of ED visits and to examine patterns of subsequent hospitalizations associated with priapism among male patients with SCD. We find that among ED visits associated with males with SCD, those prompted by priapism are more likely to result in hospitalization than are those associated with pain.
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Affiliation(s)
- Brandi Dupervil
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
- * E-mail:
| | - Scott Grosse
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Arthur Burnett
- The James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, United States of America
| | - Christopher Parker
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
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Jonassaint CR, Beach MC, Haythornthwaite JA, Bediako SM, Diener-West M, Strouse JJ, Lanzkron S, Onojobi G, Carroll CP, Haywood C. The Association between Educational Attainment and Patterns of Emergency Department Utilization among Adults with Sickle Cell Disease. Int J Behav Med 2016; 23:300-309. [DOI: 10.1007/s12529-016-9538-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Diaz R, Behr J, Kumar S, Britton B. MODELING CHRONIC DISEASE PATIENT FLOWS DIVERTED FROM EMERGENCY DEPARTMENTS TO PATIENT-CENTERED MEDICAL HOMES. IIE TRANSACTIONS ON HEALTHCARE SYSTEMS ENGINEERING 2016; 5:268-285. [PMID: 26770663 PMCID: PMC4709841 DOI: 10.1080/19488300.2015.1095824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Chronic Disease is defined as a long lasting health condition, which can develop and/or worsen over an extended time, but which can also be controlled. The monetary and budgetary toll due to its persistent nature has become unsustainable and requires pressing actions to limit their incidence and burden. This paper demonstrates the utility of the System Dynamics approach to simulate the behavior of key factors involved in the implementation of chronic disease management. We model the patient flow diversion from emergency departments (ED) to patient-centered medical homes (PCMH), with emphasis on the visit rates, as well as the effect of insurance coverage, in an effort to assure continuity of quality care for Asthma patients at lower costs. The model is used as an evaluative method to identify conditions of a maintained health status through adequate policy planning, in terms of resources and capacity. This approach gives decision makers the ability to track the level of implementation of the intervention and generate knowledge about dynamics between population demands and the intervention effectiveness. The functionality of the model is demonstrated through the consideration of hypothetical scenarios executed using sensitivity analysis.
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Affiliation(s)
- Rafael Diaz
- Old Dominion University, Virginia Modeling, Analysis, and Simulation Center, Norfolk, United States
| | - Joshua Behr
- Old Dominion University, Virginia Modeling, Analysis, and Simulation Center, Suffolk, 23435 United States
| | - Sameer Kumar
- University of St. Thomas, Minneapolis, United States
| | - Bruce Britton
- Eastern Virginia Medical School, Norfolk, United States
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Blinder MA, Duh MS, Sasane M, Trahey A, Paley C, Vekeman F. Age-Related Emergency Department Reliance in Patients with Sickle Cell Disease. J Emerg Med 2015; 49:513-522.e1. [DOI: 10.1016/j.jemermed.2014.12.080] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 10/17/2014] [Accepted: 12/21/2014] [Indexed: 11/30/2022]
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Raphael JL, Rattler TL, Kowalkowski MA, Brousseau DC, Mueller BU, Giordano TP. Association of Care in a Medical Home and Health Care Utilization Among Children with Sickle Cell Disease. J Natl Med Assoc 2015. [DOI: 10.1016/s0027-9684(15)30008-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
INTRODUCTION It is vital to engage patients with sickle cell disease (SCD) in the transition process from pediatric to adult care. To better understand the patient perspective during the time of transition, we conducted this research with the goal of incorporating patient comprehension and desires for transition education. MATERIALS AND METHODS We surveyed 37 adolescent patients with SCD about their understanding of SCD and transition education preferences. In addition, patient responses were analyzed to understand differences among urban and rural patients. RESULTS The mean age of surveyed participants was 14.9 years (SD=2.1). Forty-three percent of participants responded that the topic of transition had been introduced to them, and only 21% responded that they received education about transition. Despite the poor awareness about transition, almost all participants were interested in learning more about the transition process through a technology-based transition education platform where individual health topics could be explored. DISCUSSION Despite a didactic teaching approach to transition education, we identified that sickle cell participants had poor recognition of receiving transition education and poor understanding of their basic medical history. However, patients can identify specific health topics that should be addressed during an individualized transition education program.
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Paulukonis ST, Harris WT, Coates TD, Neumayr L, Treadwell M, Vichinsky E, Feuchtbaum LB. Population based surveillance in sickle cell disease: methods, findings and implications from the California registry and surveillance system in hemoglobinopathies project (RuSH). Pediatr Blood Cancer 2014; 61:2271-6. [PMID: 25176145 DOI: 10.1002/pbc.25208] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 07/10/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND There are no population-based surveillance systems to determine prevalence, impact or outcomes in sickle cell disease (SCD). Estimates of the SCD population in California range broadly from 4,500 to 7,000, and little is known about their health status, health care utilization or health outcomes. A surveillance strategy was implemented using diverse data sources to develop a multi-dimensional, state-based surveillance system for SCD that includes adults and children and describes utilization, treatment and outcomes. PROCEDURE Data from California newborn screening, inpatient and emergency room records, Medi-Cal/Medicaid claims and two SCD special care centers were collected for 2004-2008. A multi-step, iterative linkage process was used to link and de-duplicate these data sources, and case definitions were used to categorize cases. RESULTS After linking and de-duplicating, there were 1,975 confirmed cases of SCD, 3,159 probable cases as well as 8,024 possible cases. Among individual data sources, newborn screening and data from clinics contributed the greatest number of unique cases to the total. Select analyses of utilization and treatments for the population are described. CONCLUSIONS Using linked existing data sources, an estimate of the statewide count of the SCD population is possible. The approach can be used to create an in-depth health status profile of the affected population by aggregating utilization, treatment, and outcomes data including mortality and morbidity information. This effort sets the stage for development of an on-going, state-based surveillance system.
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State-based surveillance for selected hemoglobinopathies. Genet Med 2014; 17:125-30. [PMID: 24991875 DOI: 10.1038/gim.2014.81] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 06/04/2014] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The lack of an ongoing surveillance system for hemoglobinopathies in the United States impedes the ability of public health organizations to identify individuals with these conditions, monitor their health-care utilization and clinical outcomes, and understand the effect these conditions have on the health-care system. This article describes the results of a pilot program that supported the development of the infrastructure and data collection methods for a state-based surveillance system for selected hemoglobinopathies. METHODS The system was designed to identify and gather information on all people living with a hemoglobinopathy diagnosis (sickle cell diseases or thalassemias) in the participating states during 2004-2008. Novel, three-level case definitions were developed, and multiple data sets were used to collect information. RESULTS In total, 31,144 individuals who had a hemoglobinopathy diagnosis during the study period were identified in California; 39,633 in Florida; 20,815 in Georgia; 12,680 in Michigan; 34,853 in New York, and 8,696 in North Carolina. CONCLUSION This approach provides a possible model for the development of state-based hemoglobinopathy surveillance systems.
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Blinder MA, Vekeman F, Sasane M, Trahey A, Paley C, Duh MS. Age-related treatment patterns in sickle cell disease patients and the associated sickle cell complications and healthcare costs. Pediatr Blood Cancer 2013; 60:828-35. [PMID: 23335275 DOI: 10.1002/pbc.24459] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 12/04/2012] [Indexed: 11/11/2022]
Abstract
BACKGROUND This study explored the blood transfusion patterns, SCD complications, utilization of iron chelation therapies (ICT), healthcare resource use, and costs in pediatric, transitioning (18 years old) and adult patients with SCD. PROCEDURE Data from Florida (1998-2009), New Jersey (1996-2009), Missouri (1997-2010), Kansas (2001-2009), and Iowa (1998-2010) state Medicaid were used. Patients with ≥2 SCD diagnoses and ≥1 transfusion event were included. Rates of transfusion events, SCD complications, and proportion of eligible patients receiving ICT were calculated. ICT eligibility was defined as receiving ≥10 transfusions over lifetime. SCD complications included pain, pulmonary event, infection event, renal, cardiovascular, stroke, leg ulcers, and avascular necrosis. Regressions were used to assess risk factors for transfusion and identify the main drivers of costs. RESULTS The sample included 3,208 patients. The transfusion rate increased from 1-year-old to a peak at 16 years old, then dropped until age 26 and remained stable thereafter. In contrast the frequency of diagnoses for SCD complications increased markedly after age 16. Post-transition patients (≥18 years old) were significantly associated with fewer transfusions (odds ratio: 0.80, P = 0.002). Among eligible patients for ICT, there was no statistically significant difference in total cost between the ICT and no ICT groups (adjusted cost difference, $136, P = 0.114). CONCLUSIONS Patients transitioning to adult care received less transfusions and hydroxyurea, less ICT when eligible for chelation therapy, had higher healthcare costs and suffered from more frequent SCD related complications than pediatric patients. These findings highlight the changes in treatment patterns corresponding to transition to adult care.
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Affiliation(s)
- Morey A Blinder
- Department of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA.
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Raphael JL, Rattler TL, Kowalkowski MA, Mueller BU, Giordano TP. The medical home experience among children with sickle cell disease. Pediatr Blood Cancer 2013; 60:275-80. [PMID: 22522496 PMCID: PMC3427710 DOI: 10.1002/pbc.24184] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Accepted: 04/02/2012] [Indexed: 11/06/2022]
Abstract
BACKGROUND While a large body of research documents acute care services for children with sickle cell disease (SCD), little is known about the primary care experiences of this population. The goal of this study was to determine to what extent children with SCD experienced care consistent with a patient-centered medical home (PCMH). PROCEDURE We collected and analyzed data from 150 children, ages 1-17 years, who received care within a large children's hospital. The primary dependent variable was access to a PCMH or its four individual components (regular provider, comprehensive care, family-centered care, and coordinated care) as determined by parental report. Multivariate logistic regression was conducted to investigate associations between socio-demographic variables and having access to a PCMH. RESULTS Only 11% (16/150) of children qualified as having a PCMH, achieving the required thresholds in all four components. Approximately half of children had access to two or fewer components. Over 90% of children were reported to have a personal provider. Two-thirds of children had access to comprehensive care. Almost 60% of children were reported to receive family-centered care. Only 20% of children had access to coordinated care. No consistent associations were found between socio-demographic variables and having access to a PCMH or its individual components. CONCLUSIONS Within our study sample, children with SCD experienced multiple deficiencies in having access to a PCMH, particularly with respect to care coordination. However, further studies with larger samples are needed to determine associations between socio-demographic variables and having a PCMH.
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Affiliation(s)
- Jean L. Raphael
- Department of Pediatrics, Baylor College of Medicine, Hematology/Oncology, Houston, TX
| | - Tiffany L. Rattler
- Department of Pediatrics, Baylor College of Medicine, Hematology/Oncology, Houston, TX
| | | | - Brigitta U. Mueller
- Department of Pediatrics, Baylor College of Medicine, Hematology/Oncology, Houston, TX
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Raphael JL, Rattler TL, Kowalkowski MA, Brousseau DC, Mueller BU, Giordano TP. Association of care in a medical home and health care utilization among children with sickle cell disease. J Natl Med Assoc 2013; 105:157-65. [PMID: 24079216 PMCID: PMC3834259 DOI: 10.1016/s0027-9684(15)30109-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
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.
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Tanabe P, Hafner JW, Martinovich Z, Artz N. Adult emergency department patients with sickle cell pain crisis: results from a quality improvement learning collaborative model to improve analgesic management. Acad Emerg Med 2012; 19:430-8. [PMID: 22506947 PMCID: PMC3691105 DOI: 10.1111/j.1553-2712.2012.01330.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The aims of this study were to 1) estimate differences in pain management process and patient-reported outcomes, pre- and postimplementation of analgesic protocols for adults with sickle cell disease (SCD), and 2) examine the effects of site and visit frequency on changes in pain scores and time to analgesic. METHODS A multicenter, prospective, longitudinal study enrolled patients from three academic medical centers between October 2007 and September 2009. All ED patients 18 years or older with a chief complaint of a sickle cell pain episode were enrolled. Sites formed a SCD quality improvement (QI) team and implemented standard nurse-initiated emergency department (ED) analgesic protocols; outcomes were compared between study periods defined as pre- and postimplementation of protocols. Medical record review was conducted to measure time to administration of initial analgesic, opioids used, route of opioid administration, the change in pain scores from arrival to discharge (negative numbers reflect a decrease in pain scores), and the number of ED visits per individual patient during the study period at each site. On day 7 after the ED visit, a follow-up phone interview was conducted. Patients were queried about their ED pain management using a scale from 1 to 10 (1 = outstanding, 10 = worst). Descriptive statistics are used to report the results. Ordinary least-squares regression models were constructed to measure the effect of time period, site, and number of visits per patient on change in pain score. RESULTS During the study period, 342 unique patients (57% female, mean ± SD age = 32 ± 11 years) were enrolled and had a total of 2,934 visits. There was no difference in time to administration of the initial analgesic between study periods. Overall, there was a significant decrease in pain scores from arrival to discharge between the pre- and postintervention study periods: the average difference in arrival to discharge pain scores (cm) was greater during the postimplementation period than during the preintervention period (-4.1 vs. -3.6, t = 2.6, p < 0.01). Site 1 had significant improvement between study periods (mean difference = -0.87, t = 2.63, p < 0.01; F = 14.3, p < 0.01). Patients with few ED visits (one to six annual visits, mean difference = -1.55, t = 2.1, p = 0.04) and those with frequent ED visits (7 to 19 annual visits, mean difference = -1.65, t = 3.52, p < 0.01) had a significant decrease in pain scores compared to patients with very frequent ED visits (>19 visits). There was an overall decrease in the use of morphine sulfate (MS) and increase in the use of hydromorphone (χ(2) = 105.67, p < 0.001) between study periods and a significant increase in the use of oral (PO) and subcutaneous (SC) routes, with a corresponding decrease in the intravenous (IV) route (χ(2) = 13.67, p < 0.001). There were no statistically significant differences in patient-reported satisfaction with the attempt to manage pain in the ED between study periods (p = 0.54). CONCLUSIONS While the use of a learning collaborative and implementation of nurse-initiated analgesic protocols was not associated with improvement in time to administration of the initial analgesic, improvements in the decrease in the arrival to discharge pain score and increased use of hydromorphone and the SC route were noted in adults with SCD in the ED.
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Affiliation(s)
- Paula Tanabe
- Schools of Nursing and Medicine, Duke University, Durham, NC, USA.
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da Silva GB, Libório AB, Daher EDF. New insights on pathophysiology, clinical manifestations, diagnosis, and treatment of sickle cell nephropathy. Ann Hematol 2011; 90:1371-9. [PMID: 21901339 DOI: 10.1007/s00277-011-1327-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2011] [Accepted: 08/25/2011] [Indexed: 12/22/2022]
Abstract
Sickle cell nephropathy is one of the main chronic complications of sickle cell disease (SCD), the most common of the hematological hereditary disorders. Several studies have been performed since the first description of SCD 100 years ago to investigate the mechanisms of kidney involvement in this disease. It has been demonstrated that both glomerular and tubular compartments can be damaged as a direct consequence of SCD, including renal function loss, concentration and acidification deficits, and glomerulopathies. This article highlights the aspects of sickle cell nephropathy pathophysiology and clinical manifestations and describes the most recent advances in the diagnosis and treatment of this disorder.
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Affiliation(s)
- Geraldo Bezerra da Silva
- Post-Graduation Program in Medical Sciences, Department of Internal Medicine, Federal University of Ceará, Rua Vicente Linhares, 1198, CEP 60135-270, Fortaleza, Ceará, Brazil.
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Bundy DG, Strouse JJ, Casella JF, Miller MR. Urgency of emergency department visits by children with sickle cell disease: a comparison of 3 chronic conditions. Acad Pediatr 2011; 11:333-41. [PMID: 21764017 DOI: 10.1016/j.acap.2011.04.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2010] [Revised: 04/25/2011] [Accepted: 04/28/2011] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
- David G Bundy
- Department of Pediatrics, Division of Quality and Safety, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA.
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