An Intensive Model Of Care For Adults With Sickle Cell Disease That Rapidly Reduces Hospital Admissions, Readmissions and Cost
Authors: Koch Kathryn L. , Leonard Cynthia L. , Bagemihl Katherine , Marks David , Abshire Thomas C. , Field Joshua J. 
Published: October 2019

Abstract

Background
Adults with sickle cell disease (SCD) have a high rate of acute care utilization that results in increased health care costs. Chronic pain and end-organ dysfunction are prevalent in adults with SCD contributing to the high rate of utilization. Since many of these chronically ill patients do not have access to specialized care, delivery of care is often relegated to the emergency department (ED) and/or hospital. At Froedtert Hospital/Medical College of Wisconsin (FH/MCW) in Milwaukee, Wisconsin, 285 adults with SCD have received care as inpatients, outpatients or in the ED since 2010. Historically there was no dedicated adult SCD clinic. High rates of acute care utilization among adults with SCD at FH/MCW prompted development of an adult SCD clinic that opened on September 1, 2011. This unique clinic model relies on dedicated SCD providers who intensively manage the patients and coordinate care at all access points to the healthcare system (e.g., ED, surgical and obstetric services). The SCD team provides inpatient and outpatient SCD management, social services and has access to additional specialty care. Predominate in this model is a day hospital open Monday through Friday that provides pain management, fluids and urgent care along with widespread use of hydroxyurea and transfusion regimens. The SCD team focuses particular attention on patients with high rates of acute care utilization and manages this subgroup with frequent provider visits (multiple times per week to monthly) and specialized, multi-disciplinary care plans. In this study, we tested the hypothesis that this intensive model of care for adults with SCD will reduce important metrics of healthcare delivery.

Objective
To compare the rate of hospital admission, readmission and cost avoidance before and after an adult SCD clinic model was implemented at FH/MCW.

Methods
This was a retrospective study of adults with SCD, 18 years and older, who were admitted to FH/MCW in Milwaukee, Wisconsin, during the study comparison periods from 2010-2012. We compared the rate of hospital admission, 30-day readmission and patient costs from January 1, 2010-December 31, 2010 (pre-SCD clinic) to September 1, 2011-August 31, 2012 (first year after SCD clinic opened). Hospital admissions and readmissions during the study window were identified from a systematic search of the electronic medical record. Cost avoidance was determined from diagnosis related group (DRG)-weighed calculations for patients with SCD admitted to FH/MCW and translated into mean cost per patient admission. Total cost was calculated as a product of the total number of hospitalizations and the mean cost per admission for a patient with SCD.

Results
Two hundred eighty-five adult SCD patients received care in the FH/MCW healthcare system between 2010 and 2012. During the pre- and post-clinic study periods, 81 of these adults, median age of 25 years, were admitted to the hospital at FH/MCW. In the year prior to the implementation of the SCD clinic model, the mean number of hospital admissions was 38 per month. Of these admissions, 61% were readmitted within 30 days. Following the opening of the adult SCD clinic, 208 unique adults established care in the first year. Implementation of the intense model resulted in 2,797 outpatient visits, or a mean of 13 visits per patient over the year. There were also 312 infusion visits for intravenous fluids and/or pain management. During the first year of the SCD clinic, the number of hospital admissions decreased from a mean of 38 to 24 per month, equaling a 38% decrease in admissions. Similarly, the 30 day readmission rate fell from 61 to 28%. Cost avoidance from a reduced number of hospital admissions was 789,000 dollars when the pre-clinic and post-clinic years were compared.

Conclusions
This intensive model of care for adults with SCD in the FH/MCW healthcare system rapidly reduced the number of hospital admissions and readmissions in the first year of implementation. The model depends on a team of SCD providers who manage care through frequent outpatient visits, coordination with other services and use of a dedicated day hospital for urgent visits and infusions. Intensive management is the cornerstone of this model, requiring frequent provider/patient contact and flexibility by clinic staff to meet the needs of this chronically ill patient population.

Disclosures:
Field: NKT Therapeutics: Consultancy.