Translating sickle cell guidelines into practice for primary care providers with Project ECHO

Health Supervision for Children and Adolescents With Sickle Cell Disease: Clinical Report

Sickle cell disease (SCD) is a group of complex genetic disorders of hemoglobin with multisystem manifestations. The scope of this clinical report is such that in-depth recommendations for management of all complications is not possible. Rather, the authors present an overview focused on the practical management of children and adolescents with SCD and the complications that are of particular relevance to pediatric primary care providers. References with detailed commentary provide further information. Timely and appropriate treatment of acute illness is critical, because life-threatening complications may develop rapidly. Specialized comprehensive medical care decreases morbidity and mortality during childhood. The provision of comprehensive care is a time-intensive endeavor that includes ongoing patient and family education, periodic comprehensive evaluations and other disease-specific health maintenance services, nursing support, psychosocial care, and genetic counseling. Ideally, this care includes comanagement by the pediatrician or other pediatric primary care provider and a team of specialist SCD experts: Hematologist, other pediatric specialists, advanced practice providers, nurse specialists, social workers, patient navigators, and educational liaisons.

Patterns of primary and specialty care among children with sickle cell anemia

BACKGROUND AND OBJECTIVE

National guidelines recommend that children with sickle cell anemia (SCA) be seen regularly by primary care providers (PCPs) as well as hematologists to receive comprehensive, multidisciplinary care. The objective is to characterize the patterns of primary and hematology care for children with SCA in Michigan.

METHODS

Using validated claims definitions, children ages 1-17 years with SCA were identified using Michigan Medicaid administrative claims from 2010 to 2018. We calculated the number of outpatient PCP and hematologist visits per person-year, as well as the proportion of children with at least one visit to a PCP, hematologist, or both a PCP and hematologist annually. Negative binomial regression was used to calculate annual rates of visits for each provider type.

RESULTS

A total of 875 children contributed 2889 person-years. Of the total 22,570 outpatient visits, 52% were with a PCP and 34% with a hematologist. Annually, 87%-93% of children had a visit with a PCP, and 63%-85% had a visit with a hematologist. Approximately 66% of total person-years had both visit types within a year. The annual rate ranged from 2.3 to 2.5 for hematologist visits and from 3.7 to 4.1 for PCP visits.

CONCLUSIONS

Substantial gaps exist in the receipt of annual hematology care. Given that the majority of children with SCA see a PCP annually, strategies to leverage primary care visits experienced by this population may be needed to increase receipt of SCA-specific services.

A Mixed-Methods Evaluation of a Project ECHO Program for the Evidence-Based Management of Sickle Cell Disease

Sickle cell disease (SCD) is a group of chronic, genetic disorders of the red blood cells with significant gaps in access to evidence-based clinical care. Sickle Treatment and Outcomes Research in the Midwest (STORM), a provider network, utilized Project ECHO (Extension for Community Health Outcomes), a telementoring model, to deliver evidence-based education about SCD management. The purpose of this mixed-methods study is to evaluate the utility of Project ECHO as an educational strategy for healthcare providers treating children and adults with SCD. Annual evaluations were administered to STORM TeleECHO participants from 2016 to 2021. Survey data showed a statistically significant change in self-reported provider confidence in the ability to provide care for adult patients with SCD; identify suitable candidates for disease-modifying therapies; and confidence to prescribe disease-modifying therapies. Participants who attended at least 10 sessions were invited to participate in a semi-structured interview. Qualitative data were analyzed using thematic analysis and several themes emerged about the benefits, including (1) increased confidence, (2) integrated best-practice care, (3) connection to provider network and access to experts, (4) high-quality educational presentations and (5) opportunities for collaboration and a sense of community. This suggests that Project ECHO is accessible and leads to increased confidence in providers caring for individuals with SCD. Overall, participant knowledge gains successfully demonstrated the utility of Project ECHO as an educational resource for providers.

The Effectiveness of Common Interventions in the Management of Sickle Cell Disease in Primary Care Settings: A Review

Sickle cell disease (SCD), a chronic condition that affects men and women equally, continues to present a public health burden in the United States due to its associated morbidity and complications. Despite advances in medical knowledge and the design of novel therapies for managing the disease, its burden remains compounded because of increasing rates of immigration arising from global displacements and economic unrest in many countries. We thus conducted a comprehensive literature review of publications from 2000 to 2022 to gather guidelines on managing SCD, with a search through four databases, PubMed, Embase, Google Scholar, and Cochrane; 42 articles met the final inclusion criteria after the full-text article screening process. In the United States healthcare system, primary care physicians (PCPs) are generally providers who cater to the lifelong management of chronic medical conditions, SCD not being an exception. While more SCD patients now present to primary care clinics, many PCPs still lack the confidence and adequate experience necessary to manage the condition effectively. The gap created by the shortage of PCPs extensively equipped to provide comprehensive SCD care leads to poor health outcomes for patients. It is imperative now more than ever to continue to raise awareness about this condition at the provider level, to ensure that patients receive well-rounded care to improve their quality of life and clinical outcomes. Providing up-to-date knowledge about existing and novel therapies and/or modalities of SCD treatment would undoubtedly equip the PCPs with self-assurance to manage the condition adeptly. Thus, we explore various public health interventions such as hydroxyurea therapy, pneumococcal vaccination, penicillin therapy, iron chelation therapy, and clinical decision support tools that have been implemented in primary healthcare settings and shown to be effective in improving SCD care. We also discuss recent advancements that can lead to improved outcomes for SCD patients in the future.

"Into the Lion's Den": COVID-19 Experiences of Black Adults with Sickle Cell Disease

Adults living with sickle cell disease are at risk for experiencing severe illness from coronavirus disease 2019 (COVID-19) due to the complexity of their disease. Additionally, self-management and navigating the healthcare system may be challenging during the COVID-19 pandemic. Therefore, we conducted telephone interviews with 25 participants to explore the experiences of Black adults living with sickle cell disease during the early months of the pandemic in the United States. Three overarching themes characterize their experiences: management of sickle cell disease was further complicated by the pandemic, fear of the virus contributed to physical and social isolation, and employment and financial challenges affected well-being. The pandemic contributed to changes in health care maintenance and had a disproportionate impact on this population. Addressing social and structural determinants of health and disruptions in health care accessibility is critical to advancing health and health care equity for individuals living with sickle cell disease.

Expanding a Regional Sickle Cell Disease Project ECHO® to Rapidly Disseminate COVID-19 Education

PURPOSE

Healthcare providers faced numerous knowledge gaps and challenges with adapting practice behaviors in light of the COVID-19 pandemic. In response, an established virtual sickle cell disease (SCD) telementoring program rapidly expanded from monthly evidence-based didactic sessions focused on medical and psychosocial complications of sickle cell disease, to additional supplemental COVID-19 sessions with emerging pandemic topics and forums for shared experiences to address this timely educational need among multidisciplinary healthcare providers.

METHODS

In March 2020, the COVID-19 and Sickle Cell Disease Project ECHO^® telementoring series was launched with a rapidly evolving curriculum of contemporary topics and case presentations. Topics included COVID-19 specific management for children and adults with sickle cell disease and strategies to adapt care and communication during the pandemic. Participants completed evaluations after each session.

RESULTS

From March 2020 to February 2022, there were 20 COVID-19 and SCD Project ECHO^® sessions held with an average of 43 participants per session, which is over a 170% increase from the average SCD ECHO monthly attendance pre-pandemic. Participants represented 21 states and 3 countries. A majority of participants (91%) self-reported significantly improved knowledge of COVID-19.

CONCLUSION

Project ECHO^® is a successful educational strategy to diffuse knowledge using a virtual platform during a public health emergency, by facilitating shared learning among a community of practice that specializes in the management of sickle cell disease.

A Project ECHO and Community Health Worker Intervention for Patients with Diabetes

BACKGROUND

Both community health workers and the Project ECHO model of specialist telementoring are innovative approaches to support primary care providers in the care of complex patients with diabetes. We studied the effect of an intervention that combined these 2 approaches on glycemic control.

METHODS

Patients with diabetes were recruited from 10 federally qualified health centers in New Mexico. We used electronic health record (EHR) data to compare HbA1c levels prior to intervention enrollment with HbA1c levels after 3 months (early follow-up) and 12 months (late follow-up) following enrollment. We propensity matched intervention patients to comparison patients from other sites within the same electronic health records databases to estimate the average treatment effect.

RESULTS

Among 557 intervention patients with HbA1c data, mean HbA1c decreased from 10.5% to 9.3% in the pre- versus postintervention periods (P < .001). As compared to the comparison group, the intervention was associated with a change in HbA1c of -0.2% (95% confidence interval [CI] -0.4%-0.5%) and -0.3 (95% CI -0.5-0.0) in the early and late follow-up cohorts, respectively. The intervention was associated with a significant increase in percentage of patients with HbA1c <8% in the late follow-up cohort (8.1%, 95% CI 2.2%-13.9%) but not the early follow-up cohort (3.6%, 95% CI -1.5% to 8.7%) DISCUSSION: The intervention was associated with a substantial decrease in HbA1c in intervention patients, although this improvement was not different from matched comparison patients in early follow-up. Although combining community health workers with Project ECHO may hold promise for improving glycemic control, particularly in the longer term, further evaluations are needed.

Telehealth: Opportunities to Improve Access, Quality, and Cost in Pediatric Care

The use of telehealth technology to connect with patients has expanded significantly over the past several years, particularly in response to the global coronavirus disease 2019 pandemic. This technical report describes the present state of telehealth and its current and potential applications. Telehealth has the potential to transform the way care is delivered to pediatric patients, expanding access to pediatric care across geographic distances, leveraging the pediatric workforce for care delivery, and improving disparities in access to care. However, implementation will require significant efforts to address the digital divide to ensure that telehealth does not inadvertently exacerbate inequities in care. The medical home model will continue to evolve to use telehealth to provide high-quality care for children, particularly for children and youth with special health care needs, in accordance with current and evolving quality standards. Research and metric development are critical for the development of evidence-based best practices and policies in these new models of care. Finally, as pediatric care transitions from traditional fee-for-service payment to alternative payment methods, telehealth offers unique opportunities to establish value-based population health models that are financed in a sustainable manner.

Trends in quality of care among children with sickle cell anemia

INTRODUCTION

For decades, it has been recommended that children with sickle cell anemia (SCA) receive antibiotic prophylaxis to prevent serious infections and undergo transcranial Doppler (TCD) screening to identify those at highest risk of overt stroke. We assessed recent temporal trends in antibiotic prophylaxis prescription fills and TCD screening among children with SCA using validated quality measures.

PROCEDURE

Using validated claims-based definitions, we identified children with SCA who were enrolled in Michigan or New York State (NYS) Medicaid programs (2011-2018). Among recommended age groups, two outcomes were assessed yearly: (a) filling of ≥300 days of antibiotics, and (b) receipt of greater than or equal to one TCD. The proportion of children with each outcome was calculated by state. Temporal trends in each preventive service were assessed using generalized linear models.

RESULTS

A total of 1784 children were eligible for antibiotic prophylaxis (Michigan: 384; NYS: 1400), contributing 3322 person-years. Annual rates of filling ≥300 days of antibiotics ranged from 16% to 22% and were similar by state. There was no change in rates of antibiotic filling over time in Michigan (p-value: .10), but there was a decrease in NYS (p-value: .02). A total of 3439 children with SCA were eligible for TCD screening (Michigan: 710; NYS: 2729), contributing 10,012 person-years. Annual rates of TCD screening ranged from 39% to 45%, were similar by state, and did not change over time (p-values >.05).

CONCLUSIONS

Most children with SCA do not receive recommended antibiotic prophylaxis and/or TCD screening. New, sustainable, and coordinated interventions across preventive services are urgently needed.

Educational Needs of School Nurses Regarding the Evidence-Based Management of Sickle Cell Disease

Sickle cell disease (SCD) is a rare blood disorder that can have life-threatening complications. This presents a challenge for school nurses who may have had limited experience managing complications in the school setting. This study assessed the experience, self-reported knowledge, confidence and ability of school nurses in managing SCD in the school-setting and identified continuing educational needs and preferences. This study used a qualitative, descriptive approach. A survey was previously administered to over 400 school nurses who worked in K-12 schools in Ohio. Those participants who reported experience with managing SCD were invited to participate in a focus group or semi-structured interview. Data were interpreted using thematic analysis strategy. Four overarching themes emerged from the data: (1) perceived lack of support and resources, (2) self-reported lack of knowledge about SCD, (3) importance of partnerships with parents, and (4) need for continuing education and networking with other school nurses. Easily accessible, educational interventions, along with peer networking, can be designed to improve school nurse knowledge and confidence levels in managing SCD. These types of on-demand interventions are important as many school nurses reported infrequent exposure to students with SCD.

Telehealth: Improving Access to and Quality of Pediatric Health Care

All children and adolescents deserve access to quality health care regardless of their race/ethnicity, health conditions, financial resources, or geographic location. Despite improvements over the past decades, severe disparities in the availability and access to high-quality health care for children and adolescents continue to exist throughout the United States. Economic and racial factors, geographic maldistribution of primary care pediatricians, and limited availability of pediatric medical subspecialists and pediatric surgical specialists all contribute to inequitable access to pediatric care. Robust, comprehensive telehealth coverage is critical to improving pediatric access and quality of care and services, particularly for under-resourced populations.

A Needs Assessment of Persons With Sickle Cell Disease in a Major Medical Center in North Carolina

BACKGROUND Sickle cell disease (SCD) is a complex disease associated with many complications and a shortened lifespan. In 2016, the National Heart, Lung and Blood Institute funded 8 centers in the United States to form the Sickle Cell Disease Implementation Consortium, with the goal of improving SCD care. The aim of our study was to describe SCD self-efficacy, pain interference, and barriers to care from the perspective of persons with SCD in the North Carolina center.METHODS Persons with SCD, aged 15 and older were recruited from a large SCD center in North Carolina. Surveys, focus groups, and interviews were completed.RESULTS Fifty-one people completed a survey, and 14 people completed an interview or focus group. Barriers identified in the survey included self-care barriers, misconceptions related to hydroxyurea (an oral medication that reduces rates of pain crisis), limited provider knowledge, and stigma. Concerning self-efficacy, participants reported that they were able to manage their pain symptoms most of the time. Pain interfered most with the ability to participate in social and day-to-day activities.Common themes from the focus groups and interviews included misconceptions about hydroxyurea, pain, provider knowledge, stigma, co-management, transportation, and insurance. Recommendations to improve care included the use of case managers, utilization of treatment guidelines, individualized pain protocols, and effective co-management by providers.LIMITATIONS Participants were recruited from 1 SCD center and may not be representative of the entire SCD population in North Carolina.CONCLUSIONS Participants described many perceived barriers to care, and their responses suggest a need for improvements in patient hydroxyurea education, provider knowledge, and care coordination.

Mortality and Hospitalizations among Sickle Cell Disease Patients with End-Stage Kidney Disease Initiating Dialysis

BACKGROUND

Sickle cell disease (SCD) is the most common inherited hematological disorder and a well-described risk factor for end-stage kidney disease (ESKD). Mortality and hospitalizations among patients with SCD who develop ESKD remain understudied. Furthermore, prior studies focused only on SCD patients where ESKD was caused by SCD. We aimed to describe mortality and hospitalization risk in all SCD patients initiating dialysis and explore risk factors for mortality and hospitalization.

METHODS

We performed a national observational cohort study of African American ESKD patients initiating dialysis (2000-2014) in facilities affiliated with a large dialysis provider. SCD was identified by diagnosis codes and matched to a reference population (non-SCD) by age, sex, dialysis initiation year, and geographic region of care. Sensitivity analyses were conducted by restricting to patients where SCD was recorded as the cause of ESKD.

RESULTS

We identified 504 SCD patients (mean age: 47 ± 14 years; 48% females) and 1,425 reference patients (mean age: 46 ± 14 years; 49% females). The median follow-up was 2.4 (IQR 1.0-4.5) years. Compared to the reference, SCD was associated with higher mortality risk (hazard ratio 1.66; 95% confidence interval [CI]: 1.36-2.03) and higher hospitalization rates (incidence rate ratio 2.12; 95% CI: 1.88-2.38) in multivariable analyses. Exploratory multivariable mortality risk models showed the largest mortality risk attenuation with the addition of time-varying hemoglobin and high-dose erythropoietin, but the association of SCD with mortality remained significant. Sensitivity analyses (restricted to ESKD caused by SCD) also showed significant associations between SCD and mortality and hospitalizations, but with larger effect estimates. High-dose erythropoietin was associated with the highest risk for mortality and hospitalization in SCD.

CONCLUSIONS

Among ESKD patients, SCD is associated with a higher risk for mortality and hospitalization, particularly in patients where SCD is identified as the cause of ESKD.

Sickle Cell Disease

Sickle cell disease is an umbrella term for a group of hemoglobinopathies characterized by the presence of 2 β-globin gene mutations or deletions, at least 1 of which is the point mutation that leads to the production of hemoglobin S. Sickle cell disease is associated with hemolytic anemia, significant chronic end-organ damage, and early death. In high-income countries, at least 95% of children with the disease survive into adulthood, resulting in a growing population of affected adults with significant comorbidities, complex medical issues, and not enough specialists to provide care. Hydroxyurea is the primary therapy, and recent advances in understanding disease pathophysiology have led to new therapies; progress in bone marrow transplant and gene editing has resulted in cure in some patients. The purpose of this review is to provide an overview of the diagnosis, common acute and chronic clinical manifestations, and best practices for management of sickle cell disease.

Hydroxyurea Optimization through Precision Study (HOPS): study protocol for a randomized, multicenter trial in children with sickle cell anemia

Background

Sickle cell disease (SCD) is a severe and devastating hematological disorder that affects over 100,000 persons in the USA and millions worldwide. Hydroxyurea is the primary disease-modifying therapy for the SCD, with proven benefits to reduce both short-term and long-term complications. Despite the well-described inter-patient variability in pharmacokinetics (PK), pharmacodynamics, and optimal dose, hydroxyurea is traditionally initiated at a weight-based dose with a subsequent conservative dose escalation strategy to avoid myelosuppression. Because the dose escalation process is time consuming and requires frequent laboratory checks, many providers default to a fixed dose, resulting in inadequate hydroxyurea exposure and suboptimal benefits for many patients. Results from a single-center trial of individualized, PK-guided dosing of hydroxyurea for children with SCD suggest that individualized dosing achieves the optimal dose more rapidly and provides superior clinical and laboratory benefits than traditional dosing strategies. However, it is not clear whether these results were due to individualized dosing, the young age that hydroxyurea treatment was initiated in the study, or both. The Hydroxyurea Optimization through Precision Study (HOPS) aims to validate the feasibility and benefits of this PK-guided dosing approach in a multi-center trial.

Methods

HOPS is a randomized, multicenter trial comparing standard vs. PK-guided dosing for children with SCD as they initiate hydroxyurea therapy. Participants (ages 6 months through 21 years), recruited from 11 pediatric sickle cell centers across the USA, are randomized to receive hydroxyurea either using a starting dose of 20 mg/kg/day (Standard Arm) or a PK-guided dose (Alternative Arm). PK data will be collected using a novel sparse microsampling approach requiring only 10 μL of blood collected at 3 time-points over 3 h. A protocol-guided strategy more aggressive protocols is then used to guide dose escalations and reductions in both arms following initiation of hydroxyurea. The primary endpoint is the mean %HbF after 6 months of hydroxyurea.

Discussion

HOPS will answer important questions about the clinical feasibility, benefits, and safety of PK-guided dosing of hydroxyurea for children with SCD with potential to change the treatment paradigm from a standard weight-based approach to one that safely and effectively optimize the laboratory and clinical response.

Trial registration

ClinicalTrials.gov NCT03789591. Registered on 28 December 2018.

Uptake of online HIV-related continuing medical education training among primary care providers in Southeast United States, 2017-2018

Primary care providers play a vital role for HIV prevention and care in high burden areas of the Southeast United States. Studies reveal that only a third of these providers had previous HIV-related training. We evaluated the effects of targeted online continuing medical education training on HIV-related knowledge, attitudes and practices among providers in the Southeast. During April 2017–February 2018, we administered baseline and six-month follow-up surveys to assess changes attributed to online training among a representative sample of providers from six Southeast locations. Data were analyzed using logistic regression analysis (p < 0.05). Baseline and follow-up surveys were completed by 349 participants (61.2% female, 64.6% white, 69.6% physicians, and 27.5% aged 40 years or less); 18% (n = 63) of whom visited online training websites sent following the baseline survey. Comparing baseline versus follow-up responses, providers who completed online training were half as likely to identify “patients’ age” (30% vs. 15%) and “patients’ race” (3% vs. 1.4%) as barriers to discussing sex with clients; survey responses by participants who declined training remained unchanged. Based on baseline versus follow-up responses, providers who visited online training websites were more likely to become familiar with preexposure prophylaxis (PrEP) (38% vs. 58%); participants who declined training remained unchanged at 45%. No impact on clinical practices such as PrEP prescriptions was identified. Targeted online training can enhance HIV readiness and should be explored for providers in the Southeast, particularly for enhancing PrEP service delivery.

A National Measurement Framework to Assess and Improve Sickle Cell Care in 4 US Regions

OBJECTIVES

Coordinated measurement strategies are needed to inform collaborative approaches to improve access to and quality of care for persons with sickle cell disease (SCD). The objective of our study was to develop a multilevel measurement strategy to assess improvements in access to and quality of care for persons with SCD in 4 US regions.

METHODS

From 2014 through 2017, regional grantees in the Sickle Cell Disease Treatment Demonstration Program collected administrative and patient-level electronic health record (EHR) data to assess quality improvement initiatives. Four grantees-covering 29 US states and territories and an SCD population of 56 720-used a collective impact model to organize their work. The grantees collected administrative data from state Medicaid and Medicaid managed care organizations (MCOs) at multiple points during 2014-2017 to assess improvements at the population level, and local patient-level data were abstracted from site-level EHRs at regular intervals to track improvements over time.

RESULTS

Administrative data were an important source of understanding population-level improvements but were delayed, whereas patient-level data were more sensitive to small-scale quality improvements.

CONCLUSIONS

We established a shared measurement approach in partnership with Medicaid and Medicaid MCO stakeholders that can be leveraged to effectively support quality improvement initiatives for persons with SCD in the United States.

Designing a Multistakeholder Collaboration to Improve Preventive Care for Children With Sickle Cell Anemia

Newly developed measures of health care quality for children with sickle cell anemia (SCA) have revealed significant performance gaps in recommended care. Historically, health systems, Medicaid health plans, and state Medicaid programs have not partnered with patients and families to improve SCA care delivery. We organized 2 novel multistakeholder design meetings to identify potential interventions to deliver high-quality preventive care for children with SCA. Invitees included patients with SCA, families, and representatives from pediatric hematology clinics, Medicaid health plans, community organizations, and a state Medicaid program. Participants identified some barriers to care through presentations and facilitated discussions. Over 35 potential interventions and 6 drivers of high-quality SCA preventive care delivery were organized into a key driver diagram. Many barriers to SCA care delivery could be addressed by Medicaid health plan resources to support members with chronic disease; however, these resources are infrequently used in the pediatric SCA population. Bridging gaps between stakeholder groups identified many potential interventions to improve SCA preventive care delivery at all levels of the health care system. Similar multistakeholder discussions may be useful for other communities interested in improving preventive care for children with SCA or other chronic pediatric diseases.

Knowledge of professional healthcare providers about sickle cell disease: Impact of a distance education course

Objective

To assess the impact of the distance education course “Sickle Cell Disease: Primary Health Care Line” on knowledge acquisition of professional healthcare providers.

Methods

A cross-sectional study was conducted with a quantitative approach at the Educational and Support Center for Hemoglobinopathies (Cehmob-MG), state of Minas Gerais, Brazil, in 2016. One hundred and fifty-three out of 300 professional healthcare providers were invited to participate in the proposed distance course. Of the participating professional healthcare providers, 72 (47%) successfully concluded the course (Group A), whereas 81 (53%) did not complete their course assignments and did not meet the minimum requirements for regular attendance (Group B). Knowledge acquisition was assessed with the Knowledge of Sickle Cell Disease Instrument, DFConhecimento, applied using the web tool eSurv. Univariate analysis by Poisson regression was employed to assess the influence of sociodemographic variables on the DFConhecimento score and to select variables to compose the initial multivariate regression model (p-value < 0.20). The analysis was performed in the statistical programming environment R.

Results

The average score was 9.76 for Group A and 6.54 for Group B. The two groups were considered statistically different (p-value < 0.05) for all items with the proportion of correct items being greater in Group A. Professional healthcare providers who concluded the course had a significantly higher DFConhecimento score (45%) when compared to those who did not successfully conclude the course.

Conclusion

Participation in a distance education course on sickle cell disease had a positive impact on the acquisition of knowledge about the disease by professional healthcare providers.

Technology use and preferences to support clinical practice guideline awareness and adherence in individuals with sickle cell disease

Objective

Sickle cell disease (SCD) is a chronic condition affecting over 100 000 individuals in the United States, predominantly from vulnerable populations. Clinical practice guidelines, written for providers, have low adherence. This study explored knowledge about guidelines; desire for guidelines; and how technology could support guideline awareness and adherence, examining current technology uses, and user preferences to inform design of a patient-centered guidelines application in a chronic disease.

Methods

This cross-sectional mixed-methods study involved semi-structured interviews, surveys, and focus groups of adolescents and adults with SCD. We evaluated interest, preferences, and anticipated benefits or barriers of a patient-centered adaptation of SCD practice guidelines; prospective technology uses for health; and barriers to technology utilization.

Results

Forty-seven individuals completed surveys and interviews, and 39 participated in three separate focus groups. Most participants (91%) were unaware of SCD guidelines, but almost all (96%) expressed interest in a guidelines application, identifying benefits (knowledge, activation, individualization, and rewards), and barriers (poor information, low motivation, and resource limitations). Current technology health uses included information access, care coordination, and reminders about health-related actions. Prospective technology uses included informational messaging and timely alerts. Barriers to technology use included lack of interest, lack of utility, and preference for direct communication.

Conclusions

This study's findings can inform the design of clinical practice guideline applications, suggesting a promising role for technology to engage patients, facilitate care decisions and actions, and improve outcomes.

Targeted Hydroxyurea Education after an Emergency Department Visit Increases Hydroxyurea Use in Children with Sickle Cell Anemia

OBJECTIVE

To evaluate the impact of an initiative to increase hydroxyurea use among children with sickle cell anemia (SCA) who presented to the emergency department (ED).

STUDY DESIGN

This observational cohort study included children with SCA not taking hydroxyurea who presented to the ED with pain or acute chest syndrome and then attended a Quick-Start Hydroxyurea Initiation Project (Q-SHIP) session. A Q-SHIP session includes a hematologist-led discussion on hydroxyurea, a video of patients talking about hydroxyurea, and a direct offer to start hydroxyurea.

RESULTS

Over 64 weeks, 112 eligible patients presented to the ED and 59% (n = 66) participated in a Q-SHIP session a median of 6 days (IQR 2, 20 days) after ED or hospital discharge; 55% of participants (n = 36) started hydroxyurea. After a median follow-up of 49 weeks, 83% (n = 30) of these participants continued hydroxyurea. Laboratory markers of hydroxyurea adherence were significantly increased from baseline: median mean corpuscular volume +8.6 fL (IQR 5.0, 17.7, P < .0001) and median hemoglobin F +5.7% (IQR 2.5, 9.8, P = .0001). Comparing Q-SHIP participants to nonparticipants, 12 weeks after ED visit, participants were more likely to have started hydroxyurea than nonparticipants (53% vs 20%, P = .0004) and to be taking hydroxyurea at last follow-up (50% vs 20%, P = .001). Two years after the implementation of Q-SHIP the overall proportion of eligible patients on hydroxyurea presenting to our ED increased from 56% to 80%, P = .0069.

CONCLUSIONS

Participation in a clinic to specifically address starting hydroxyurea after a SCA complication increases hydroxyurea use.

Adapting medical guidelines to be patient-centered using a patient-driven process for individuals with sickle cell disease and their caregivers

Background

Evidence-based guidelines for sickle cell disease (SCD) health maintenance and management have been developed for primary health care providers, but not for individuals with SCD. To improve the quality of care delivered to individuals with SCD and their caregivers, the main purposes of this study were to: (1) understand the desire for patient-centered guidelines among the SCD community; and (2) adapt guideline material to be patient-centered using community-engagement strategies involving health care providers, community -based organizations, and individuals with the disease.

Methods

From May–December 2016, a volunteer sample of 107 individuals with SCD and their caregivers gave feedback at community forums (n = 64) and community listening sessions (n = 43) about technology use for health information and desire for SCD-related guidelines. A team of community research partners consisting of community stakeholders, individuals living with SCD, and providers and researchers (experts) in SCD at nine institutions adapted guidelines to be patient-centered based on the following criteria: (1) understandable, (2) actionable, and (3) useful.

Results

In community forums (n = 64), almost all participants (91%) wanted direct access to the content of the guidelines. Participants wanted guidelines in more than one format including paper (73%) and mobile devices (79%). Guidelines were adapted to be patient-centered. After multiple iterations of feedback, 100% of participants said the guidelines were understandable, most (88%) said they were actionable, and everyone (100%) would use these adapted guidelines to discuss their medical care with their health care providers.

Conclusions

Individuals with SCD and their caregivers want access to guidelines through multiple channels, including technology. Guidelines written for health care providers can be adapted to be patient-centered using Community-engaged research involving providers and patients. These patient-centered guidelines provide a framework for patients to discuss their medical care with their health care providers.

Electronic supplementary material

The online version of this article (10.1186/s12878-018-0106-3) contains supplementary material, which is available to authorized users.

Specialized Care without the Subspecialist: A Value Opportunity for Secondary Care

An underutilized value strategy that may reduce unnecessary subspecialty involvement in pediatric healthcare targets the high-quality care of children with common chronic conditions such as obesity, asthma, or attention deficit hyperactivity disorder within primary care settings. In this commentary, we propose that "secondary care", defined as specialized visits delivered by primary care providers, a general pediatrician, or other primary care providers, can obtain the knowledge, skill and, over time, the experience to manage one or more of these common chronic conditions by creating clinical time and space to provide condition-focused care. This care model promotes familiarity, comfort, proximity to home, and leverages the provider's expertise and connections with community-based resources. Evidence is provided to prove that, with multi-disciplinary and subspecialist support, this model of care can improve the quality, decrease the costs, and improve the provider's satisfaction with care.

Use of telehealth in the delivery of comprehensive care for patients with haemophilia and other inherited bleeding disorders

Advances in technology such as telemedicine (TM) have made access to cost-effective, quality health care feasible for remote patients. TM is especially well suited for patients with chronic disorders such as haemophilia and related haemostatic disorders that benefit not only from more frequent interaction with care providers at a specialized haemophilia treatment center but also from consultations with other specialists. Telehealth refers to a broader application of TM and includes non-clinical services such as education, provider training, administrative meetings etc. Collaboration with the local primary care provider for management and implementation is key for successful and sustainable TM. This review article provides an overview of types of telemedicine, technical aspects, its benefits and challenges and focuses on the applicability of this technology to persons with bleeding and other blood disorders. Examples of TM strategies, process flow of TM clinic and experiences at the authors haemophilia treatment center (HTC) setting are shared. In addition, mobile health (mHealth) and electronic health (eHealth), both a part of telehealth, and their applications are briefly described. Clearly, widespread adoption of this technology will not only enhance care of patients but will enable more people, especially in underserved areas, to receive specialty care.