Prediction of Onset and Course of High Hospital Utilization in Sickle Cell Disease

Department of Psychiatry and Behavioral Sciences, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
Journal of Hospital Medicine (Impact Factor: 2.3). 05/2011; 6(5):248-55. DOI: 10.1002/jhm.850
Source: PubMed


Although sickle cell disease (SCD) patients typically manage their pain at home, a small subgroup is frequently hospitalized and accounts for the majority of costs.
1) To identify prospective diagnostic and demographic markers of new periods of high utilization; 2) To identify demographic and diagnostic markers of a persistent rather than moderating course of high utilization; 3) To replicate the finding that high utilization tends to moderate.
The State Inpatient Databases for California, 2004-2007, were used. Patients with new onset periods of high utilization were compared with non-high utilizers, and new high utilizers who moderated were compared with those who had a persistent course.
All hospitals in the state of California.
Patients age 13 years or older in 2004 with a recorded diagnosis of sickle cell disease and at least one hospitalization for crisis during the study period.

Groups from hospitals throughout California were compared on demographics and discharge diagnoses of SCD complications and comorbidities. Patients age 13 years or older in 2004 with a recorded diagnosis of sickle cell disease and at least 1 hospitalization for crisis during the study period were included.
New periods of high utilization were associated with more prior hospitalizations and previous diagnoses of aseptic necrosis and renal disease. High utilization typically moderated. A persistent course was associated with slightly more hospitalizations during the initial year of high utilization, and, subsequently, by more mentions of septicemia and mood disorders.
Overall, high utilization was difficult to predict, as was its course. The diagnoses most associated with high utilization indicated more severe sickle cell disease. Septicemia deserves further investigation as a preventable cause for high utilization, as do mood disorders.

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    • "Clinicians are reluctant to order and administer appropriate high-dose opioids, resulting in delays and sub-therapeutic treatment of VOC episodes.6,31 A further frustration of ED clinicians is the frequent use of the ED by a small fraction of patients with SCD, who may make 100 or more visits over several years.6,32,33 The research team hypothesizes that the population of SCD patients with such intense ED use may well have other significant neurocognitive deficits and unmet psychosocial healthcare needs that lead to such dramatically high ED use. "
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    ABSTRACT: Introduction Patients with sickle cell disease (SCD) often seek care in emergency departments (EDs) for severe pain. However, there is evidence that they experience inaccurate assessment, suboptimal care, and inadequate follow-up referrals. The aim of this project was to 1) explore the feasibility of applying a failure modes, effects and criticality analysis (FMECA) in two EDs examining four processes of care (triage, analgesic management, high risk/high users, and referrals made) for patients with SCD, and 2) report the failures of these care processes in each ED. Methods A FMECA was conducted of ED SCD patient care at two hospitals. A multidisciplinary group examined each step of four processes. Providers identified failures in each step, and then characterized the frequency, impact, and safeguards, resulting in risk categorization. Results Many “high risk” failures existed in both institutions, including a lack of recognition of high-risk or high-user patients and a lack of emphasis on psychosocial referrals. Specific to SCD analgesic management, one setting inconsistently used existing analgesic policies, while the other setting did not have such policies. Conclusion FMECA facilitated the identification of failures of ED SCD care and has guided quality improvement activities. Interventions can focus on improvements in these specific areas targeting improvements in the delivery and organization of ED SCD care. Improvements should correspond with the forthcoming National Heart, Lung and Blood-sponsored guidelines for treatment of patients with sickle cell disease.
    The western journal of emergency medicine 07/2014; 15(4):446-58. DOI:10.5811/westjem.2014.4.20489
  • Journal of Hospital Medicine 05/2011; 6(5):245-7. DOI:10.1002/jhm.935 · 2.30 Impact Factor
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    ABSTRACT: Objectives: To identify demographic, medical, and psychosocial characteristics that distinguished sickle cell disease (SCD) patients who were frequent utilizers of urgent or emergent care resources from low-utilizing patients. Methods: Patients at a large urban comprehensive SCD treatment center were recruited from clinic or during urgent care visits. Participants who were high utilizers, defined as having >4 acute or emergency care visits in the prior 12 months, were compared with patients with more typical utilization patterns on lifetime complications of SCD, family background, psychiatric history, occupational function, coping, depressive symptoms, and personality. Results: High utilizers were nearly a decade younger on average; despite this they had a similar lifetime history of SCD complications. High-utilizing patients' parents seemed to have greater educational achievement overall. High utilizers reported a nearly 3-fold greater prevalence of psychiatric illness in family members than low utilizers. On other measures, including coping strategies, social support, and personality, the 2 groups were comparable. Discussion: The study strengthens emerging evidence that disease severity, familial factors related to greater parental education, and psychiatric illness are important factors in high care utilization in patients with SCD.
    The Clinical journal of pain 12/2012; 29(4). DOI:10.1097/AJP.0b013e3182579b87 · 2.53 Impact Factor
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