Caring for the Adult With Sickle Cell Disease: Results of a Multidisciplinary Pilot Program

Feasibility and preliminary outcomes of an integrated pediatric sickle cell disease and pulmonary care clinic for children with sickle cell disease

BACKGROUND

In children with sickle cell disease (SCD), comorbid asthma is associated with increased disease severity and morbidity, but it remains underdiagnosed and optimal management paradigms are not well defined. The purpose of this study was to determine the feasibility and preliminary outcomes of an integrated pediatric SCD and pulmonary care clinic in children with SCD.

METHODS

We implemented a pre-post quality improvement (QI) project in our pediatric hematology clinic between 2017 and 2019. Guided by the chronic care model, patients who were ages 2-18 years, diagnosed with SCD and suspected pulmonary comorbidities, received care in an interdisciplinary clinic. We examined feasibility and compared clinical outcomes to 24 months prior (2015-2017) to the implementation of the integrated care model.

RESULTS

Twenty-four patients were included in the QI project: 88% (n = 21) received pulmonary function testing, 92% (n = 22) were diagnosed with asthma, and 33% (n = 8) with obstructive sleep apnea. Adherence to pulmonary appointments was increased by 81% (mean difference [MD] = 1.3, 95% confidence interval [CI] = 0.71-1.92; P < .001). Unplanned acute health care utilization was reduced by 59% (MD = 2.9, 95% CI = 1.14-4.69; P < .01) and packed red blood cell transfusion was reduced by 81% (MD = 1.38, 95% CI = 0.71-2.04; P < .001).

CONCLUSION

Asthma is prevalent in children with SCD, and interdisciplinary clinics can improve access to subspecialty pulmonary care and reduce unplanned acute care. Additional patients and a longer follow-up period are required to determine the true treatment effect.

Outcomes of multidisciplinary team interventions in the management of sickle cell disease patients with opioid use disorders. A retrospective cohort study

Objectives:

To identify the magnitude of opioid use disorder (OUD) among sickle cell disease (SCD) patients; emphasize on multidisciplinary team (MDT) role; estimate cost-effectiveness following the proper use of therapeutic guidelines; and facilitate the reduction of emergency room (ER) visits and the length of stay (LOS).

Methods:

This retrospective cohort study included SCD patients aged 14 years and above, who have OUD. Data was collected between January 2016 and December 2018. Data included ER visits, hospital LOS, opioid consumption, and narcotic prescription tracking. The target group was followed with a set of interventions for pain management and healthcare resource utilization.

Results:

Twenty one SCD patients were identified with OUD. Following the interventions, there was a statistically significant decrease in ER visits of these OUD patients (from 8709 visits in 2016 to only 94 in 2018). Morphine consumption decreased by 82% and meperidine by 60%, over the 3-year period. Moreover, there was a huge reduction in both ER and LOS costs for this cohort of patients.

Conclusion:

Establishing an MDT and a series of interventions for SCD patients with OUD, including educational activities for caregivers and patients; establishing a palliative/pain clinic and a SCD addiction clinic; and implementing an adequate opioid prescription tracking system resulted in a significant reduction in both the cost and number of ER visits and hospital LOS and dramatically decreased opioid consumption.

Utilization, financial outcomes and stakeholder perspectives of a re-organized adult sickle cell program

In 2011 Yale New Haven Hospital, in response to high utilization of acute care services and widespread patient and health care personnel dissatisfaction, set out to improve its care of adults living with sickle cell disease. Re-organization components included recruitment of additional personnel; re-locating inpatients to a single nursing unit; reducing the number of involved providers; personalized care plans for pain management; setting limits upon access to parenteral opioids; and an emphasis upon clinic visits focused upon home management of pain as well as specialty and primary care. Outcomes included dramatic reductions in inpatient days (79%), emergency department visits (63%), and hospitalizations (53%); an increase in outpatient visits (31%); and a decrease in costs (49%). Providers and nurses viewed the re-organization and outcomes positively. Most patients reported improvements in pain control and life style; many patients thought the re-organization process was unfair. Their primary complaint was a lack of shared decision-making. We attribute the contrast in these perspectives to the inherent difficulties of managing recurrent acute and chronic pain with opioids, especially within the context of the imbalance in wellness, power, and privilege between persons living with sickle cell disease, predominantly persons of color and poor socio-economic status, and health care organizations and their personnel.

The past, present and future management of sickle cell retinopathy within an African context

Sickle cell retinopathy is a potentially blinding condition that affects young people in the working age group. This review looks at the past, present and future management of sickle cell retinopathy within an African context. After Sickle cell disease was first reported in 1910, some reports from Africa were pivotal in describing the retinal changes associated with the disease. It soon became obvious that there was a varied clinical picture and clinical course. Several landmark studies were carried out in Jamaica to help elucidate the complexities of the disease and outline appropriate clinical management. In most of the developed world, the clinical management of sickle cell disease has improved with concurrent improvement in outcomes. Currently resource constraints in most Sub-Saharan African countries where there is a high burden of disease means that the management of sickle cell retinopathy is fraught with numerous challenges. Future large scale trials in Africa shall hopefully help to better elucidate the mechanisms behind proliferative sickle retinopathy and help in the development of new and improved therapeutic pathways. The use of technology can help immensely in the screening of patients with sickle cell to detect early proliferative changes and if necessary treat accordingly.

Sickle cell disease: Classification of clinical complications and approaches to preventive and therapeutic management

Sickle cell disease (SCD) is an inherited disorder of hemoglobin structure that has no established cure in adult patients. Cure has been achieved in selected children with sickle cell anemia (SCA) using allogeneic bone marrow transplantation or cord blood transplantation. SCD is essentially a triumvirate of (1) pain syndromes, (2) anemia and its sequelae and (3) organ failure, including infection. Pain, however, is the hallmark of SCD and dominates its clinical picture throughout the life of the patients. The prevalence of these complications varies with age from infancy through adult life. However, pain, infections and anemia requiring blood transfusion occur throughout the life span of affected patients. The overall medical care of patients with SCD in developed countries has improved such that their life expectancy has almost doubled since 1951. Currently, there are at least five major approaches for the general management of SCD and its complications. These include (i) symptomatic management, (ii) supportive management, (iii) preventive management, (iv) abortive management, and (v) curative therapy.

Improved Guideline Adherence With Integrated Sickle Cell Disease and Asthma Care

INTRODUCTION

In children with sickle cell disease (SCD), concomitant asthma is associated with increased morbidity and mortality when compared with children with SCD without asthma. Despite the well-established burden of asthma in children with SCD, no paradigm of care exists for the co-management of these two diseases.

METHODS

To address this gap, an integrated SCD and asthma clinic was created in a community health center that included (1) a dual respiratory therapist/asthma case manager; (2) an SCD nurse practitioner with asthma educator certification; (3) an onsite pulmonary function test laboratory; (4) a pediatric hematologist with expertise in managing SCD and asthma; and (5) application of the National Asthma Education and Prevention Program guidelines. A before (2010-2012) and after (2013-2014) study design was used to assess for improved quality of care with implementation of an integrative care model among 61 children with SCD and asthma followed from 2010 to 2014.

RESULTS

Asthma action plan utilization after initial diagnosis increased with the integrative care model (n=16, 56% before, 100% after, p=0.003), as did the use of spirometry in children aged ≥5 years (n=41, 65% before, 95% after, p<0.001) and correction of lower airway obstruction (n=10, 30% before, 80% after, p=0.03).

CONCLUSIONS

Although the use of an integrative care model for SCD and asthma improved evidence-based asthma care, longer follow-up and evaluation will be needed to determine the impact on SCD-related morbidity.

Development of a New Adult Sickle Cell Disease Center Within an Academic Cancer Center: Impact on Hospital Utilization Patterns and Care Quality

BACKGROUND

A national shortage of specialized centers with expertise in the management of adults with sickle cell disease (SCD) remains a concerning public health disparity. Yet, there is an abundance of cancer centers whose operational infrastructure is not only suited to the treatment of the oncology patient, but also can provide medical and procedural care essential to the management of the patient with SCD. Our adult SCD center was formally embedded within an academic hospital-based cancer center in 2009. An evaluation of the impact of this new center has been performed.

METHODS

A retrospective chart review was conducted of all SCD encounters occurring 5 years pre- and post-SCD center establishment. Demographic, clinical, as well as hospital utilization and care quality data were compared.

RESULTS

The SCD population grew from 22 to 165 patients. Following establishment of the SCD center, patients experienced greater average annual outpatient preventative visits for chronic disease management (1 vs. 4.1) and fewer average hospitalizations yearly (2.4 vs. 1). There was a decrease in hospitalization rates for management of acute pain (50 vs. 23 %), average hospitalization length of stay (12 vs. 6 days), and the proportion of hospital discharges resulting in readmission within 30 days (60 vs. 40 %). Hydroxyurea use among eligible patients increased from 30 to 90 %.

CONCLUSION

Findings suggest that embedding adult SCD centers within existing cancer centers can positively impact patterns of health care utilization and improve the quality of care.

Intensive management of high-utilizing adults with sickle cell disease lowers admissions

A minority of super-utilizing adults with sickle cell disease (SCD) account for a disproportionate number of emergency department (ED) and hospital admissions. We performed a retrospective cohort study comparing the rate of admission before and after the opening of a clinic for adults with SCD. Unique to this clinic was an intensive management strategy, focusing on super-utilizing adults with 12 or more admissions per year. ED/hospital and 30 days re-admission rates were compared, 1 year pre- and post-intervention, for those adults who established in the clinic. Prior to the intervention, 17 super-utilizers, comprising 15% of the pre-intervention cohort (n = 115), accounted for 58% of the total admissions and had an admission rate of 28 per patient-year. When pre- and post-intervention years were compared, rate of ED/hospital admission per patient-year for super-utilizers decreased from 27.9 to 13.5 (P < 0.001), while there was not a significant reduction for the entire cohort (7.1 vs. 6.1, P = 0.84). Similarly, the decrease in rate of 30 day re-admission was larger for the super-utilizers (13.5 per patient-year to 1.8, P < 0.001), than the whole cohort (2.6 per patient-year to 0.7, P = 0.006). Among the super-utilizers, the reduced rate of admission from the pre- to post-clinic intervention year equated to 252 fewer ED/hospital admissions and 227 fewer 30 day re-admissions. This management strategy focusing on super-utilizing adults with SCD lowered admission and 30 day re-admission rate.

Facilitators and barriers of implementing the chronic care model in primary care: a systematic review

BACKGROUND

The Chronic Care Model (CCM) is a framework developed to redesign care delivery for individuals living with chronic diseases in primary care. The CCM and its various components have been widely adopted and evaluated, however, little is known about different primary care experiences with its implementation, and the factors that influence its successful uptake. The purpose of this review is to synthesize findings of studies that implemented the CCM in primary care, in order to identify facilitators and barriers encountered during implementation.

METHODS

This study identified English-language, peer-reviewed research articles, describing the CCM in primary care settings. Searches were performed in three data bases: Web of Knowledge, Pubmed and Scopus. Article abstracts and titles were read based on whether they met the following inclusion criteria: 1) studies published after 2003 that described or evaluated the implementation of the CCM; 2) the care setting was primary care; 3) the target population of the study was adults over the age of 18 with chronic conditions. Studies were categorized by reference, study design and methods, participants and setting, study objective, CCM components used, and description of the intervention. The next stage of data abstraction involved qualitative analysis of cited barriers and facilitators using the Consolidating Framework for Research Implementation.

RESULTS

This review identified barriers and facilitators of implementation across various primary care settings in 22 studies. The major emerging themes were those related to the inner setting of the organization, the process of implementation and characteristics of the individual healthcare providers. These included: organizational culture, its structural characteristics, networks and communication, implementation climate and readiness, presence of supportive leadership, and provider attitudes and beliefs.

CONCLUSIONS

These findings highlight the importance of assessing organizational capacity and needs prior to and during the implementation of the CCM, as well as gaining a better understanding of health care providers' and organizational perspective.

"I'm talking about pain": sickle cell disease patients with extremely high hospital use

BACKGROUND

A small minority of sickle cell disease patients accounts for the majority of inpatient hospital days. Admitted as often as several times a month, over successive years, this cohort of patients has not been studied in depth despite their disproportionate contribution to inpatient hospital costs in sickle cell disease.

OBJECTIVE

To characterize the subjective experience of extremely high hospital use in patients with sickle cell disease, and generate hypotheses about the antecedents and consequences of this phenomenon.

DESIGN

Qualitative study involving in-depth, open-ended interviews using a standardized interview guide.

SETTING

A single urban academic medical center.

PARTICIPANTS

Eight individuals, of varying age and gender, identified as the sickle cell disease patients who are among the highest hospital use patients over a 3-year period.

RESULTS

A common narrative emerged from the interview transcripts. Participants were exposed to the hospital environment and intravenous (IV) opioids at a young age, and this exposure was associated with extremely high hospital use in adulthood, evident in descriptions of multiple dimensions of their lives: pain and opioid medication use, interpersonal relationships, and personal development.

CONCLUSIONS

Our results suggest a systematic, self-reinforcing process of isolation from mainstream society, support structures, and caregivers, based on increasing hospitalization, growing dependency on opioid medications, as well as missed developmental milestones. Further study and interventions should be geared towards breaking this spiraling cycle with long-term strategies in disease management and social integration.