Patients' views on improving sickle cell disease management in primary care: focus group discussion

The Burden of Sickle Cell Disease in Saudi Arabia: A Single-Institution Large Retrospective Study

Purpose

Sickle cell disease (SCD) is a significant burden for patients and healthcare systems due to multiple factors, including high readmission rates. This study aimed to determine the general characteristics, etiology of admissions, annual admission rate, length of stay, and readmission rate of patients with SCD.

Patients and Methods

This retrospective observational study included all adult patients with SCD admitted to the General Internal Medicine (GIM) unit between 2016 and 2021.

Results

There were 160 patients (mean age, 31.08 ± 9.06 years; 51.25% female) with SCD included in this study. Most originated from southern Saudi Arabia (45.62%). The average annual number of emergency department (ED) visits was 4, and approximately 19% of patients had ≥3 annual admissions. The mean length of stay was 6 days. The readmission rates at 7, 30, 60, and 90 days were 8%, 24.5%, 13.6%, and 10.8%, respectively.

Conclusion

SCD generates a significant economic burden on the Saudi society and the effects on the healthcare system and patients' quality of life are evident in the high ED visits, readmission rates and prolonged hospitalization. Thereupon we advocate the implementation of sickle cell disease-specialized multidisciplinary clinics.

Awareness and Use of the Sickle Cell Disease Toolbox by Primary Care Providers in North Carolina

BACKGROUND

Sickle cell disease (SCD) is a complex chronic blood disorder characterized by severe disease complications ideally managed by both hematologists and primary care providers (PCP's). PCP's report knowledge gaps and discomfort with SCD management. Our team developed and a decision support tool for SCD management (SCD Toolbox) based on the National Heart, Lung, and Blood Institute's SCD guidelines. We surveyed PCPs in North Carolina (NC) prior to formal dissemination to determine current co-management practices, assess toolbox acceptability, use, format preferences, and understand which algorithms would be most helpful.

METHOD

A 23-item baseline needs assessment survey was disseminated to PCPs throughout NC.

RESULTS

A total of 63 medical providers responded to the survey and of these respondents, 64% reported caring for 1 to 10 patients with SCD. Only 39% of PCPs reported regular communication with an SCD specialist. Providers reported the highest level of awareness of the pediatric and adult health maintenance tools (41% and 39% respectively) and highest use of the pediatric (26%) and adult (28%) health maintenance tools. Respondents also expressed a desire to have access to multiple toolbox formats (37%) (website, mobile app and/or paper).

LIMITATIONS

The use of a convenience sample and low survey response are study limitations which hinder generalizability.

CONCLUSIONS

PCPs rarely co-managed with a specialist, had low awareness and use of SCD toolbox, and requested multiple formats for the toolbox.

Instruments to Measure Perceptions in the Emergency Department Provider-Patient with Sickle Cell Disease Interaction: Findings of an Integrative Review from a Ph.D. Project

Background & Purpose:

The purpose of this review is to examine instruments that measure providers' perceptions of adult patients with Sickle Cell Disease (SCD), examine instruments that measure adult patients with SCD perceptions of providers' behaviors, and determine optimal instruments to use in evaluating the perceptions of Emergency Department (ED) providers and adult patients with SCD of one another's behaviors after an interaction in the ED.

Methods:

An integrative review was conducted searching EBSCOhost and PubMed databases using the keywords: measure [OR] measure* [OR] assess* [OR] scale [OR] survey [OR] tool [AND] stigma* [OR] stereotype [OR] prejudice [OR] bias [OR] perception [OR] attitude [OR] discrimination [OR] racism [OR] behavior [AND] interaction [OR] relationship [OR] communication [AND] sickle cell. Initial search located 256 articles, but only 15 articles were included in the final review.

Results:

Fifteen articles reporting six instruments were reviewed. Four instruments evaluated a provider’s perceptions of patients with SCD behaviors, and two instruments evaluated how patients with SCD perceived provider behaviors. The two patient-focused instruments and three provider-focused instruments were found to be adequately reliable and valid according to the Psychometric Grading Framework (PGF).

Conclusions:

The findings suggest that the General Perceptions About Sickle Cell Disease Patients Scale would be an optimal instrument to evaluate ED providers' perceptions of adult patients with SCD behaviors. One patient-focused instrument, The Sickle Cell Health-Related Stigma Scale (SCD-HRSS), reported adequate reliability and validity but was not specific to measuring the patient's perceptions of ED providers' behaviors, nor was it administered in the ED environment. The SCD-HRSS Doctors subscale has potential adaptability for use in measuring patients with SCD perceptions of ED provider behaviors in the ED environment.

Sickle-Cell Disease Co-Management, Health Care Utilization, and Hydroxyurea Use

BACKGROUND

Sickle-cell disease (SCD) causes significant morbidity, premature mortality, and high disease burden, resulting in frequent health care use. Comanagement may improve utilization and patient adherence with treatments such as Hydroxyurea. The purpose of this study was to describe acute-care utilization in Medicaid-enrolled patients with SCD, patient factors associated with comanagement, and adherence to Hydroxyurea.

METHODS

Data from 2790 patients diagnosed with SCD, age 1 to 65+ years, enrolled at least 1 month in North Carolina Medicaid between March 2016 and February 2017, were analyzed. Outpatient visits were categorized as primary care, hematologist, and nonhematologist specialist. Nurse practitioners or physician assistants with unidentified specialty type or family practice were categorized separately. Comanagement was defined as a minimum of 1 primary care and 1 hematologist visit/patient during the study period.

RESULTS

There were notable age-related differences in utilization of health care services. Only 34.82% of the sample was comanaged. Comanagement was higher in the 1-to-9-year-old (44.88%) and 10-to-17-year-old groups (39.22%) versus the 31-to-45-year-old (30.26%) and 65+-year-old (18.75%) age groups. Age had the greatest influence (AUC = 0.599) on whether or not a patient was comanaged. Only a third of the sample (32.24%) had at least 1 Hydroxyurea (HU) prescription. Age was the most predictive factor of good HUadherence (AUC = 0.6503). Prediction by comanagement was minimal with an AUC = 0.5615.

CONCLUSION

Comanagement was a factor in predicting HUadherence, but further studies are needed to identify the frequency and components of comanagement needed to increase adherence and reduce acute care utilization.

Shared Care for Adults with Sickle Cell Disease: An Analysis of Care from Eight Health Systems

Adult sickle cell disease (SCD) patients frequently transition from pediatric hematology to adult primary care. We examined healthcare utilization for adult patients with SCD with shared care between hematologists and primary care providers (PCP). We analyzed the OneFlorida Data Trust, a centralized data repository of electronic medical record (EMR) data from eight different health systems in Florida. The number of included adults with SCD was 1147. We examined frequent hospitalizations and emergency department (ED) visits by whether the patient had shared care or single specialty care alone. Most patients were seen by a PCP only (30.4%), followed by both PCP and hematologist (27.5%), neither PCP nor hematologist (23.3%), and hematologist only (18.7%). For patients with shared care versus single specialist care other than hematologist, the shared care group had a lower likelihood of frequent hospitalizations (OR 0.63; 95% CI 0.43-0.90). Similarly, when compared to care from a hematologist only, the shared care group had a lower likelihood of frequent hospitalizations (OR 0.67; 95% CI 0.47-0.95). There was no significant relationship between shared care and ED use. When patients with SCD have both a PCP and hematologist involved in their care there is a benefit in decreased hospitalizations.

Translating evidence in complex systems: a comparative review of implementation and improvement frameworks

PURPOSE

An increasing number of implementation and improvement frameworks seek to describe and explain how change is made in healthcare. This paper aims to explore how existing frameworks conceptualize the influence of complexity in translating evidence into practice in healthcare.

DATA SOURCES

A database was interrogated using a search strategy to identify publications that present frameworks and models for implementation and improvement.

STUDY SELECTION

Ten popular implementation and improvement frameworks were purposively selected.

DATA EXTRACTION

Comparative analysis was conducted using an analytical framework derived from SHIFT-Evidence, a framework that conceptualizes complexity in implementation and improvement initiatives.

RESULTS

Collectively the frameworks accounted for key concepts of translating evidence in complex systems: understanding the uniqueness of each setting; the interdependency of practices/processes and the need to respond to unpredictable events and emergent learning. The analysis highlighted heterogeneity of the frameworks in their focus on different aspects of complexity. Differences include the extent to which problems and solutions are investigated or assumed; whether endpoints are defined as the uptake of interventions or achievement of goals; and emphasis placed on fixed-term interventions versus continual improvement. None of the individual frameworks reviewed incorporated all the implications of complexity, as described by SHIFT-Evidence.

CONCLUSION

This research identifies the differences in how implementation and improvement frameworks consider complexity, suggesting that SHIFT-Evidence offers a more comprehensive overview compared with the other frameworks. The similarity of concepts across the frameworks suggests growing consensus in the literature, with SHIFT-Evidence providing a conceptual bridge between the implementation and improvement fields.

Patient-reported experience measure in sickle cell disease

OBJECTIVES

To develop patient-reported experience measure surveys for patients with sickle cell disease (SCD) to understand their healthcare and lived experience in the UK and for their use in future to inform healthcare service development.

DESIGN

Picker methodology was used as follows: (1) qualitative scoping by focus group discussions; (2) questionnaire development through stakeholder consultations; (3) construct validation of questionnaires through cognitive testing; and (4) further assessment of construct validity by a nationwide pilot survey.

SETTING

Patients with SCD and their carers were eligible. Focus group discussions took place in non-hospital settings, arranged out of hours. Cognitive testing took place in specialist sickle cell clinics. The pilot survey was available to UK participants only and was administered through web-based questionnaires, face-to face completion and in sickle cell community events.

PARTICIPANTS

Thirty-three patients and carers took part in the focus groups, 21 participants undertook cognitive testing and 722 respondents completed the pilot survey.

RESULTS

Findings highlighted a widespread prevalence of poor knowledge about SCD among healthcare providers and the public. Poorer experience of care was present in the emergency setting compared with planned care, of which lack of timely provision of pain relief was of concern. Adolescents and young people reported significantly poorer experience of care in several domains compared with children or adults.

CONCLUSIONS

The new surveys functioned well, with good evidence of validity, and were accessible to the SCD patient population, supporting their future use in assessing patient experience to inform service delivery and improvements in care quality.

Care Coordination for Children With Sickle Cell Disease: A Longitudinal Study of Parent Perspectives and Acute Care Utilization

INTRODUCTION

Care coordination (CC), a core element of the medical home, has the potential to reduce fragmented care and improve patient experience for children with sickle cell disease (SCD). This study aimed to (1) assess CC for pediatric SCD and (2) determine its association with acute care utilization-emergency department encounters and hospitalizations. It was hypothesized that CC would reduce acute care utilization.

METHODS

A longitudinal study of 101 children with SCD was conducted. Parents completed a survey instrument on enrollment. Utilization chart review was conducted 9 months post survey. Outcome variables were emergency department encounters and hospitalizations. Independent variables were parent-reported CC, satisfaction with communication between healthcare providers, and satisfaction with communication between healthcare providers and non-medical providers (e.g., schools, child care centers). Multivariate negative binomial regression was conducted to assess associations between CC and acute care utilization. Data were collected in 2011-2013 and analyzed in 2015.

RESULTS

One third of children had emergency department encounters and 30% had hospitalizations. At enrollment, 25% of parents reported receiving CC help and 20% reported need for extra CC. Most parents were satisfied with communication between physicians but only two thirds were satisfied with communication between their healthcare providers and non-medical providers. No significant associations were found between CC measures and acute care utilization.

CONCLUSIONS

Although parents report multiple CC deficiencies, no associations were found between CC and acute care utilization. Population-based studies are warranted to more definitively determine the association between CC and acute care utilization for children with SCD.

Attitudes among healthcare providers and patients diagnosed with sickle cell disease

Sickle cell disease (SCD) is a chronic condition that affects thousands of people worldwide. The purpose of this study is to illustrate some of the challenges and perceptions of people diagnosed with SCD. The aims were to describe stressors, problematic symptoms, sources of support, and interactions with healthcare providers. This descriptive study, using mostly open-ended questions and conceptual analysis, included a sample of patients with SCD who were older than 18 years in ambulatory (57%) and inpatient (43%) clinics. Participants completed a 20-minute interview. Pain or SCD crisis were the chief reasons for hospitalization, and a wellness checkup was the chief reason people returned to an ambulatory clinic. Most (74%) were able to perform chores. Family was reported to cause the most stress in the home and also provide the most help. Pain is a pervasive aspect of life, limiting activities of daily living. Negative interactions with healthcare providers are common; therefore, advocacy is necessary for patients with SCD.

A retrospective analysis of the cost of hospitalizations for sickle cell disease with crisis in England, 2010/11

BACKGROUND

Sickle cell disease (SCD) is an inherited blood disorder which may result in a broad range of complications including recurring and severe episodes of pain--sickle 'crises'--which require frequent hospitalizations. We assessed the cost of hospitalizations associated with SCD with crisis in England.

METHODS

Hospital Episodes Statistics data for all hospital episodes in England between 2010 and 2011 recording Sickle Cell Anaemia with Crisis as primary diagnosis were used. The total cost of admissions and exceeded length of stay due to SCD were assessed using Healthcare Resource Groups tariffs. The impact of patients' characteristics on SCD admissions costs and the likelihood of incurring extra bed days were also examined.

RESULTS

In 2010-11, England had 6077 admissions associated with SCD with crisis as primary diagnosis. The total cost for these admissions for commissioners was £18,798 255. The cost of admissions increases with age (children admissions costs 50% less than adults). Patients between 10 and 19 years old are more likely to stay longer in hospital compared with others.

CONCLUSION

SCD represents a significant cost for commissioners and the NHS. Further work is required to assess how best to manage patients in the community, which could potentially lead to a reduction in hospital admissions and length of stay, and their associated costs.

Sickle cell disease pain management and the medical home

Pain is the most common cause for hospitalization and acute morbidity in sickle cell disease (SCD). The consequences of SCD-related pain are substantial, affecting both the individual and the health care system. The emergence of the patient-centered medical home (PCMH) provides new opportunities to align efforts to improve SCD management with innovative and potentially cost-effective models of patient-centered care. The Department of Health and Human Services has designated SCD as a priority area with emphasis on creating PCMHs for affected patients. The question for patients, clinicians, scientists, and policy-makers is how the PCMH can be designed to address pain, the hallmark feature of SCD. This article provides a framework of pain management within the PCMH model. We present an overview of pain and pain management in SCD, gaps in pain management, and current care models used by patients and discuss core PCMH concepts and multidisciplinary team–based PCMH care strategies for SCD pain management.

Sickle cell disease pain management and the medical home

Pain is the most common cause for hospitalization and acute morbidity in sickle cell disease (SCD). The consequences of SCD-related pain are substantial, affecting both the individual and the health care system. The emergence of the patient-centered medical home (PCMH) provides new opportunities to align efforts to improve SCD management with innovative and potentially cost-effective models of patient-centered care. The Department of Health and Human Services has designated SCD as a priority area with emphasis on creating PCMHs for affected patients. The question for patients, clinicians, scientists, and policy-makers is how the PCMH can be designed to address pain, the hallmark feature of SCD. This article provides a framework of pain management within the PCMH model. We present an overview of pain and pain management in SCD, gaps in pain management, and current care models used by patients and discuss core PCMH concepts and multidisciplinary team-based PCMH care strategies for SCD pain management.