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Reliance on emergency care for sickle cell disease pain highest among adolescents
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ATLANTA — Reliance on use of the ED for pain among children with sickle cell disease appeared below the threshold for excessive reliance, according to results of a study conducted in Wisconsin presented at the ASH Annual Meeting and Exposition.
Children also used the ED significantly less frequently than all other age groups. However, reliance on the ED for pain increased among patients transitioning to adult care, or those aged 19 years.
“Emergency department visits are frequent occurrences for patients with sickle cell disease — they, in fact, account for 40% of all acute care emergency department visits. The most common reasons for these visits are painful events,” Amanda M. Brandow, DO, pediatric hematologist/oncologist at Children’s Hospital of Wisconsin, said during a presentation. “Given the nature of the disease, these crises are emergent in nature and need attention. Hence, if we want to look at quality of care, emergency department utilization alone does not give the complete picture. However, emergency department reliance ... can be used.”
ED reliance among patients is an important indicator of quality of care and patient access to outpatient settings.
There have been efforts to improve patient care in Wisconsin, including the establishment of a sickle cell clinic for adults, the creation of an electronic health records-based registry for children, and expansion of hydroxyurea indication to all children aged at least 1 year.
Brandow and colleagues evaluated ED reliance using Wisconsin state Medicaid data from 2011 to 2015 to determine the impact of these efforts and identify areas for improvement. They hypothesized the ED reliance for pain had decreased over time.
The analysis included 609 patients with sickle cell disease enrolled continuously in state Medicaid and who had at least one sickle cell pain-related ED visit.
Researchers divided patients into a group of children (0-18 years; n = 248); a transition group, or those who turned 19 years during the study period (n = 54); a group of young adults (19-30 years; n = 170), and a group of adults (31-45 years; n = 137).
Researchers used analyses of variance to compare ED reliance — determined by number of ED visits for pain divided by the number of ED visits for pain plus outpatient visits — for the four groups. They adjusted a linear mixed model over time for age group, adherence to hydroxyurea — calculated as medication possession ratio for hydroxyurea — and interaction between covariates.
The ED reliance for pain in the overall population was 0.24 (standard error, 0.0082), which appeared lower than the 0.33 threshold previously identified as excessive reliance.
Reliance on ED for pain among patients in the transition group (0.33) and young adults (0.33) appeared higher than in children (0.18; P < .001) and adults (0.23; P < .001 for comparison with adults; P = .00014 for comparison with transition group). ED reliance for children appeared lower than for adults aged 30 years or older (P = .0091).
ED reliance among children remained below the excessive threshold over the study period; however, it increased from 0.17 in 2011 to 0.21 in 2015 (P < .001). Reliance among the transition group increased over time, whereas reliance among young adults decreased since 2011 (P = .0013). Researchers observed no significant differences in ED reliance over time among adults.
Brandow noted a higher medication possession ratio suggested an association between adherence to hydroxyurea and lower reliance on the ED for pain.
“In 2015, every 10% increase in medication possession ratio for hydroxyurea was associated with a 1.5% decrease in ED reliance,” Brandow said.
“For the transition group, ED reliance has been increasing over time, which implies we need to focus on this group to improve care and understand the reasons driving this increase,” she added. – by Melinda Stevens
Reference:
Singh A, et al. Abstract 128. Presented at: ASH Annual Meeting and Exposition; Dec. 9-12, 2017; Atlanta.
Disclosures: Brandow reports no relevant financial disclosures. One author reports research funding from the NIH.