The First National Level Estimate of Emergency Department Charges for Sickle Cell Disease.
Authors: Lanzkron Sophie , Haywood Carlton 
Published: October 2019

Abstract
Abstract 553
First National Level Estimate of Emergency Department Charges for Sickle Cell Disease
It is estimated that there are 100,000 people with sickle cell disease (SCD) living in the US. Little data is currently availabel on the number of emergency room visits made per year by this patient population. Given prior data demonstrating the cost savings associated with comprehensive care delivery and specialized day hospital units that have decreased ED visits and hospitalizations, our goal was to estimate the national burden of SCD care in the ED setting. The purpose of this study was to estimate the number of ED visits made by SCD patients in 2006, the total and average charges for those visits and the subsequent hospital admissions, and to identify factors that predicted if patients were admitted to the hospital. In addition, we used the online Healthcare Cost and Utilization Project program (HCUP) to compare the number of SCD visits with the number of ED visits and subsequent admissions for other chronic illnesses.

Methods:
The Nationwide Emergency Department Sample (NEDS) contains information from 950 hospitals and approximates a 20% stratified sample of US hospital based EDs. Data is currently only availabel for 2006. Using this dataset we identified all ED visits with the following SCD ICD9 codes 28260,28261,28262,28263,28264,28268,28269,28241,28242 listed anywhere in the diagnosis list. Bivariate and multivariate analyses were conducted using t-tests, oneway ANOVAs, and multiple linear or logisitic regressions as appropriate. Sampling weights are included in the NEDS to allow for the generation of national estimates. In addition to the full NEDS dataset the Agency for Healthcare Research and Quality makes availabel on-line a query system based on HCUP data free on its website. We used this system to collect data on total ED visits for asthma, HIV and congestive heart failure (CHF) that ended in a hospital admission using the clinical classification software codes 128, 5, and 108 as defined in the HCUP system.

Results:
There were a total of 58993 ED visits for patients with SCD sampled in the NEDS in 2006, representing a national estimate of 232,381 ED visits. Using the weighted data there were an estimated 190,000 adult ED visits and 44,000 pediatric visits. The total charges for all of the ED visits were estimated to be $266 million of which 191 million were for patients not subsequently admitted to the hospital. Being female and adult resulted in significantly higher ED charges. 50% of the visits were covered by Medicaid, 22% by Medicare, 18% were private pay, 7.5% self-pay and the remainder were no charge or other. 60% of the visits occurred in the South, 18% in the Northeast, 15% in the Midwest and 7% in the West. 5% of the visits had a code for pneumonia, 0.25% had a code for stroke and 7.3% had a code for asthma. These ED visits resulted in an estimated 91,000 hospitalizations. Pediatric patients were more likely to be admitted than adult patients (44% v 38% p=0.03). The combined ED and inpatient charges for those admitted were estimated to be $2.7 billion with a mean charge of $23,669 (range $591-871,111). 64 individuals are estimated to have died in the ED and another 522 died during their hospital stay. The average age of those that died in the ED was 33 and in the hospital was 42. In adjusted analyses being female, in the pediatric age group, or having a code for sickle crisis, asthma, stroke or pneumonia all were associated with a significant increase in odds of being admitted to the hospital. Table 1 shows the comparison number of admissions from the ED for SCD, asthma, HIV and CHF.

Conclusions:
Given the size of the US sickle population this data suggests that the ED is a major source of care for this patient population. Given that there are over 2 billion dollars in charges for those admitted from the ED, a focus of improving quality of care and decreasing costs of care should be eliminating ED use by the SCD population by providing alternative venues for treatment of painful crises that is more likely to result in a discharge home.

Disclosures:
No relevant conflicts of interest to declare.