Program expansion of a day hospital dedicated to manage sickle cell pain
Authors: Jin Han, Santosh L. Saraf, Laura Kavoliunaite, Shivi Jain, Johara Hassan, Lewis L. Hsu, Robert E. Molokie, Victor R. Gordeuk, Michel Gowhari
Journal: American Journal of Hematology (2017)

Vaso-occlusive crisis (VOC) is the hallmark complication of sickle cell disease (SCD), and the majority of SCD-related healthcare costs in the United States, estimated at $2.4 billion annually, is attributed to frequent emergency department (ED) visits and hospitalizations due to recurrent VOC.1-3 A day hospital (DH) dedicated to manage uncomplicated VOC has been shown to reduce admission rates, decrease inpatient length of stay (LOS), and save health care costs.4, 5 The majority of DH programs have hours of operation from 9 am to 5 pm, and programs with extended hours beyond this are limited by a lack of sufficient resources. The impact of extended hours of DH programs on patient care is less clear. The Comprehensive Sickle Cell Center at the University of Illinois at Chicago (UIC) instituted a DH program to manage uncomplicated VOC in 2009 that was open from 8 am to 5 pm Monday through Friday, modeled upon previous DH.4 Patients who presented with uncomplicated VOC were assessed, and then treated based on previous pain treatment history and current assessment. After treatment in DH, patients were either discharged home or admitted to the hospital if adequate pain relief was not achieved. To improve patient access and decrease the burden on ED, the hours of operation were expanded to 8 am-11 pm in February, 2014. To evaluate the impact of extended hours on patient care, data on VOC-related patient visits from the two years before the expansion to two years after the expansion (2012–2016) were collected from the electronic medical record and evaluated. Descriptive statistics, the Cochrane trend test, the ANOVA test, and a multivariate linear regression were used for data analysis. The study was approved by the UIC Institutional Review Board prior to the initiation of chart review. The number of DH visits increased from 205 visits in 2012 to 1057 visits in 2016, and the program expansion in 2014 alone increased the number of visits by more than 2-fold (292 visits in 2013 vs 691 visits in 2014). The proportion of the DH visit numbers relative to 2012 showed a trend of significant increase during the five-year period compared to the number of ED visits (516% in DH to 93% in ED, P < .0001; Figure 1A). The number of unique patients served in the DH (81 in 2012 to 177 in 2016) also had a greater increase compared to that in ED (269 in 2012 to 282 in 2016), and the proportion relative to 2012 was significantly higher (219% in DH vs. 105% in ED, P < .0001; Figure 1B). The most substantial increase in unique patients treated in the DH occurred in 2014, the year the program hours were expanded (107 patients in 2013 vs. 174 patients in 2014). With increasing utilization of the DH, the inpatient admission rate from the DH over the 5-year span showed a significant decrease (24% in 2012 to 14% in 2016; P < .0001), especially after program expansion in 2014 (Figure 1C). In contrast, the average admission rate for uncomplicated VOC from the ED was 69% during the same 5-year span. To evaluate the impact of the DH program on ED utilization, a subset of patients who had at least one ED or DH visit in each year of 2013–2015 was selected. The timeframe was chosen in order to ensure full years of data for analysis. In this subgroup of patients, the average number of ED visits did not significantly increase for patients who used the DH in 2013 (n = 75, P = .749), whereas the average number of ED visits significantly increased for the patients who had no DH visits in 2013 (n = 112, P = .014). The trend for difference approached statistical significance (P = .062). When analyzing the inpatients admissions from 2012 to 2016, the LOS from either the ED or DH due to a VOC also significantly decreased after program expansion (P < .0001) (Table 1), and the mean of LOS was reduced by approximately 1.5 days per admission when comparing the time period after program expansion (2015–2016) to that before expanded hours (2012–2013). In a multivariate analysis, the ascending calendar year was significantly associated with reduced LOS after adjusting for age, gender, and SCD genotype (P < .0001), which indicates that the DH program expansion was correlated with decreased LOS. DH and ED utilization and admission rates through DH. A and B. The number of visits and unique patients relative to 2012 in DH were compared to ED during 2012–2016. Both showed significantly increasing trend (P < .0001). C. The admission rates in DH showed a significantly decreasing trend during 2012–2016 (P < .0001). The Cochrane trend test was used Here, we show that expanding the operation hours of a DH program increased its utilization by SCD patients by almost 5-fold based on the number of visits from 2012 to 2016. This was accompanied by a reduced hospital admission rate from the DH, a trend for reduced ED utilization, and a decrease in inpatient LOS. The care in the DH was provided by experienced staff members who were familiar with patients with SCD, and delivered prompt and effective treatment for the VOC. Given the complexity of cases in the ED, VOC treatment for patients with SCD tends to be delayed and prolonged, leading to higher admission rates from the ED compared to the DH program.4 With expanding hours of operation in the DH program, care was more accessible to patients experiencing VOC episodes. This could allow patients to feel more comfortable being discharged home and returning to the DH the following day rather than being admitted to the hospital. Even for patients who are admitted to the hospital for VOC, the clinicians may feel more comfortable to discharge patients home, knowing that the patients have the option to return to the DH to receive adequate treatment if additional care is necessary. These factors contribute to the reduction in hospital admission rates and LOS for inpatient admissions after the DH program expansion. In summary, expanding the hours of operation for the DH increased the utilization of this program, improved access to care for patients with SCD during VOC episodes, and reduced the admission rates and LOS for inpatient admissions. Further expansion of the DH program may offer more benefits to patients with SCD. Full financial analysis is likely to show significant cost savings for the healthcare system due to the reduction of admission rates and LOS in the hospital.