Reducing Health Care Utilization in Sickle Cell Disease Patients By Implementation of an Individualized, Multimodal Care Plan during Hospital Admission and at Inpatient to Outpatient Discharge
Authors: Manwani Deepa , Carullo Veronica , Rinke Michael , Choi Steven , Driscoll Catherine 
Published: October 2019

Abstract

Background:
SickleCell Disease (SCD) is a chronic illness characterized by vaso-occlusive complications leading to unpredictable episodes of pain, cumulative organ damage and high health care utilization rates. National estimates of total hospital costs for sickle cell related hospitalizations are approximately $488 billion (Steiner 2006). 30 day readmission rates are used as a quality metric for a variety of chronic diseases: 33% of patients with SCD are readmitted within 30 days, compared to 3.4% for asthma, 12% for pneumonia, 16% for heart failure and 20% for diabetes (Brousseau 2010, Berry 2011).
Multiple factors contribute to this high utilization rate and not all are modifiable. Increasing age and psychosocial comorbidities are associated with a greater length of stay (LOS). 18-30 year old patients, public insurance and admissions for pain crisis are associated with a higher 30 day readmission rate. Lack of outpatient follow up with a trained hematologist following hospital admission has been demonstrated to increase SCD readmission rates (Leschke 2012). Debaun et al have noted that written discharge management guidelines alone had low utilization rates, however when intensive ongoing patient and provider education by a nurse educator was also included, the 30 day readmission rate decreased from 28 to 11% (Frei-Jones 2009). Hydroxyurea responders have been shown to have a reduced LOS.
Hypothesis:
Implementation of an individualized, multimodal care plan during inpatient stay and at inpatient to outpatient discharge will reduce acute care utilization. It is likely that the implementation of the comprehensive care plan at this key transition point will be more effective due to (1) greater psychological readiness in the patient/ family to accept escalation of care soon after an acute event (2) decreased instances of “missed opportunities” in the event that the patient does not follow up with a provider with sickle cell specific expertise and (3) improvement in communication amongst inpatient providers, outpatient providers with specific hematology expertise and the multi-disciplinary team.
Methods:
A SCD quality improvement effort was initiated at The Children’s Hospital at Montefiore (CHAM) in July 2012 with the specific goals of reducing the 30 day readmission rates and length of stay (LOS). Secondary endpoints included admission rates, ED return rates and cost savings. Our efforts were directed at consistent and comprehensive implementation of best-practice guidelines, improved pain management strategies, a multimodal approach to patient care, andutilization of the hospital admission as an opportunity to design a comprehensive care plan. Representatives from the inpatient team, the primary hematologists, nursing, social work, psychology and pain management met weekly to create the care plan. A pre–post design was utilized, comparing data 3.5 years before to 1 year after the initiation of the transition intervention.
Results:
A significant reduction rate in LOS by 10% and 30 day readmission rate by 37%, with even greater gains in the 18-21 year age group was noted. This was not accompanied by an increase in ED visits (3 and 7 days) and in fact there was a significant reduction in the 3 day ED return rate in older patients. We also saw an overall reduction in the SCD inpatient admission rate by 22% and increase in hydroxyurea use.
Table 1: Outcomes from the ongoing SCD Quality Improvement project Number of admissions 3 Day ED Return (%) 7 Day ED Return (%) 30 Day Readmission Rate % LOS (days) < 18 years National Average 17 4.21 Before 556 3.3 0.95 18.1 4.1 After 140 3.4 1.01 14.7 4.0 p-value 0.9 0.8 0.059 0.6 ≥ 18 years National Average 41.1 6.8 Before 1685 11.5 0.9 41.4 6.6 After 592 5 2.1 18.6 5.4 p-value 0.02 0.2 <0.0001 0.04 All Ages Before 2241 5 0.94 24 4.7 After 732 3 1.23 15 4.2 p-value 0.8 0.52 <0.001 0.018 * “Before” and “After” represent data prior to and after the implementation of the ongoing QI initiatives respectively
Conclusion: We demonstrate the feasibility of reducing acute care utilization in SCD patients, with the implementation of an individualized, multimodal, comprehensive care plan during hospital admission and at discharge.

Disclosures
No relevant conflicts of interest to declare.