Medical and Non-medical Costs of Sickle Cell Disease and Treatments from a US Perspective: A Systematic Review and Landscape Analysis

Burden of employment loss and absenteeism in adults and caregivers of children with sickle cell disease

ABSTRACT

Sickle cell disease (SCD) is a genetic disorder affecting 100 000 people with an estimated annual medical cost of $3 billion in the United States; however, the economic impact on patients is not well described. We aimed to examine the indirect economic burden and test the hypothesis that socioeconomic status and greater social vulnerability risks are associated with increased absenteeism and employment loss. We surveyed adults and caregivers of children with SCD at 5 US centers from 2014 to 2021. Logistic regression models were used to examine the associations of employment loss and missed days of work with demographics and social determinants. Indirect costs were estimated by multiplying the self-reported missed days of work and job loss by 2022 average wages by the state of the participating institution. Of the 244 participants, 10.3% reported employment loss in the last 5 years, and 17.5% reported missing 10 or more days of work. Adults had 3 times more employment loss compared with caregivers of children with SCD (OR, 3.18; 95% CI, 1.12-9.01) but fewer missed days of work (OR, 0.24; 95% CI, 0.11-0.0.51). Participants who did not live with a partner reported increased employment loss (OR, 4.70; 95% CI, 1.04-21.17) and more missed days of work (OR, 4.58; 95% CI, 1.04-20.15). The estimated annual indirect economic burden was $2 266 873 ($9290 per participant). Adults with SCD and caregivers of children with SCD commonly report employment loss and missed days of work as important risk factors. The high indirect economic burden suggests that future economic evaluations of SCD should include SCD-related indirect economic burden.

Regional anesthesia and sickle cell crisis in pediatric patients: An educational-focused review

INTRODUCTION

Sickle cell disease (SCD) is the most common inherited hemoglobinopathy, affecting approximately 100 000 patients in United States and millions worldwide. Although the mainstay of pain management for VOC remains systemic opioids, given the potential for adverse effects including respiratory depression and hypoxemia, there remains interest in the use of regional anesthetic techniques (neuraxial or peripheral nerve blockade).

METHODS

A systematic search of pubMed, Scopus, and Google Scholar was conducted using the terms sickle cell disease, sickle cell crisis, pain crisis, vaso-occlusive crisis, regional anesthesia, peripheral nerve blockade, and neuraxial anesthesia.

RESULTS

We identified 7 publications, all of which were retrospective case series or single case reports, outlining the use of neuraxial anesthesia in a total of 26 patients with SCD. Additionally, we identified 4 publications, including one retrospective case series and 3 single case reports, entailing the use of peripheral blockade in patients with VOC and SCD.

DISCUSSION

The available literature, albeit all retrospective or anecdotal, suggests the potential utility of regional anesthesia to treat pain in patients with SCD. Additional benefits have included avoidance of the potential deleterious physiologic effects of systemic opioids and in one case series, an improvement in respiratory function as judged by pulse oximetry. The anecdotal and retrospective nature of the available reports with an absence of prospective trials limits the evidence based medicine available from which to develop to guidlines for the optimal local anesthetic agent to use, its concentration, the rate of infusion, and the choice of adjunctive agents.

Comparing super-utilizers and lower-utilizers among commercial- and Medicare-insured adults with sickle cell disease

ABSTRACT

Sickle cell disease (SCD) is a rare but costly condition in the United States. Super-utilizers have been defined as a subset of the population with high health care encounters or expenditures. Although super-utilizers have been described in other disease states, little is known about super-utilizers among adults with SCD. This study aimed to characterize the differences in expenditures, overall health care encounters, and pain episode encounters between super-utilizers (top 10% expenditures) and lower-utilizers with SCD (high, top 10%-24.9%; moderate, 25%-49.9%; and low, bottom 50% expenditures). A retrospective longitudinal cohort of adults with SCD were identified using validated algorithms in MarketScan and Medicare claim databases from 2016 to 2020. Encounters and expenditures were analyzed from inpatient, outpatient, and emergency department settings. Differences in encounters and expenditures between lower-utilizers and super-utilizers were compared using logistic regression. Among super-utilizers, differences in encounters and expenditures were compared according to incidences of pain episode encounters. The study population included 5666 patients with commercial insurance and 8600 with Medicare. Adjusted total annual health care expenditure was 43.46 times higher for super-utilizers than for low-utilizers among commercial-insured and 13.37 times higher in Medicare-insured patients. Among super-utilizers, there were patients with few pain episode encounters who had higher outpatient expenditures than patients with a high number of pain episode encounters. Our findings demonstrate the contribution of expensive outpatient care among SCD super-utilizers, in which analyses of high expenditure have largely focused on short-term care. Future studies are needed to better understand super-utilizers in the SCD population to inform the effective use of preventive interventions and/or curative therapies.

Predictors of hospital readmissions in adult patients with sickle cell disease

BACKGROUND

Sickle cell disease (SCD) is the most common inherited blood disorder, affecting primarily Black and Hispanic individuals. In 2016, 30-day readmissions incurred 95,445 extra days of hospitalization, $152 million in total hospitalization costs, and $609 million in total hospitalization charges.

OBJECTIVES

1) To estimate hospital readmissions within 30 days among patients with SCD in the State of California. 2) Identify the factors associated with readmission within 30 days for SCD patients in California.

METHODS

We conducted a retrospective observational study of adult SCD patients hospitalized in California between 2005 and 2014. Descriptive statistics and logistic regression models were used to examine significant differences in patient characteristics and their association with hospital readmissions.

RESULTS

From 2,728 individual index admissions, 70% presented with single admission, 10% experienced one readmission, and 20% experienced ≥ two readmissions within 30 days. Significant predictors associated with zero vs. one readmission were male gender (OR=1.37, CI: 1.06-1.77), Black ethnicity (OR=3.27, CI: 1.71-6.27) and having Medicare coverage (OR=1.89, CI: 1.30-2.75). Lower likelihood of readmission was found in those with a Charlson Comorbidity index of three or more (OR=0.53, CI: 0.29-0.97). For zero vs. ≥ two readmissions, significant predictors were male gender (OR=1.43, CI: 1.17-1.74), Black ethnicity (OR=6.90, CI: 3.41-13.97), Hispanic ethnicity (OR=2.33, CI: 1.05-5.17), Medicare coverage (OR=3.58, CI: 2.68-4.81) and Medi-Cal coverage (OR=1.70, CI: 1.31-2.20). Lower likelihood for having two or more readmissions were associated with individuals aged 65+ (OR=0.97, CI: 0.96-0.98) and those with self-payment status (OR=0.32, CI: 0.12-0.54).

CONCLUSIONS

In California, male, Black, and Hispanic patients, as well as those covered by Medicare or Medi-Cal, were found to have an increased risk of hospital readmissions. Redirecting outpatient goals to address these patient populations and risk factors is crucial for reducing readmission rates.

An alcohol dehydrogenase 7 gene polymorphism associates with both acute and chronic pain in sickle cell disease

Introduction: As the most distressing complication of sickle cell disease (SCD), pain is marked by considerable heterogenicity. In this study we explored the potential association of alcohol dehydrogenase 7 gene (ADH7) polymorphism rs971074 with sickle cell pain. Methods: We analyzed clinical phenotypes and the rs971074 single-nucleotide polymorphism in ADH7 by MassARRAY-iPlex analysis in a cohort of SCD patients. Results: The synonymous rs971074 was significantly associated with both acute and chronic pain in SCD. Patients with the minor T allele(s) recorded significantly more crisis episodes and severe chronic pain symptoms. Conclusion: Our study has identified the rs971074 minor T allele as a genetic biomarker potentially influencing acute and chronic pain. These findings may ultimately help inform strategies to develop precision pain therapies in SCD.

Peripheral transient receptor potential vanilloid type 4 hypersensitivity contributes to chronic sickle cell disease pain

ABSTRACT

Debilitating pain affects the lives of patients with sickle cell disease (SCD). Current pain treatment for patients with SCD fail to completely resolve acute or chronic SCD pain. Previous research indicates that the cation channel transient receptor potential vanilloid type 4 (TRPV4) mediates peripheral hypersensitivity in various inflammatory and neuropathic pain conditions that may share similar pathophysiology with SCD, but this channel's role in chronic SCD pain remains unknown. Thus, the current experiments examined whether TRPV4 regulates hyperalgesia in transgenic mouse models of SCD. Acute blockade of TRPV4 alleviated evoked behavioral hypersensitivity to punctate, but not dynamic, mechanical stimuli in mice with SCD. TRPV4 blockade also reduced the mechanical sensitivity of small, but not large, dorsal root ganglia neurons from mice with SCD. Furthermore, keratinocytes from mice with SCD showed sensitized TRPV4-dependent calcium responses. These results shed new light on the role of TRPV4 in SCD chronic pain and are the first to suggest a role for epidermal keratinocytes in the heightened sensitivity observed in SCD.

Enhancing Equitable Access to Rare Disease Diagnosis and Treatment around the World: A Review of Evidence, Policies, and Challenges

This document provides a comprehensive summary of evidence on the current situation of rare diseases (RDs) globally and regionally, including conditions, practices, policies, and regulations, as well as the challenges and barriers faced by RD patients, their families, and caregivers. The document builds on a review of academic literature and policies and a process of validation and feedback by a group of seven experts from across the globe. Panelists were selected based on their academic merit, expertise, and knowledge regarding the RD environment. The document is divided into five main sections: (1) methodology and objective; (2) background and context; (3) overview of the current situation and key challenges related to RDs covering six dimensions: burden of disease, patient journey, social impact, disease management, RD-related policies, and research and development; (4) recommendations; and (5) conclusions. The recommendations are derived from the discussion undertaken by the experts on the findings of this review and provide a set of actionable solutions to the challenges and barriers to improving access to RD diagnosis and treatment around the world. The recommendations can support critical decision-making, guiding efforts by a broad range of RDs stakeholders, including governments, international organizations, manufacturers, researchers, and patient advocacy groups.