A Patient-Centered Emergency Department Management Strategy for Sickle-Cell Disease Super-Utilizers

Simpson GG, Hahn HR, Powel AA, Leverence RR, Morris LA, Thompson LG, Zumberg MS, Borde DJ, Tyndall JA, Shuster JJ, Yealy DM, Allen BR
Source: West J Emerg Med
Publication Year: 2017
Patient Need Addressed: Long-term services and supports
Population Focus: Complex care
Demographic Group: Adult
Intervention Type: Service redesign, Staff design and care management
Study Design: Pre-post without Comparison Group
Type of Literature: White
link: https://www.ncbi.nlm.nih.gov/pubmed/28435481
Abstract

INTRODUCTION:
A subpopulation of sickle-cell disease patients, termed super-utilizers, presents frequently to emergency departments (EDs) for vaso-occlusive events and may consume disproportionate resources without broader health benefit. To address the healthcare needs of this vulnerable patient population, we piloted a multidisciplinary intervention seeking to create and use individualized patient care plans that alter utilization through coordinated care. Our goals were to assess feasibility primarily, and to assess resource use secondarily.

METHODS:
We evaluated the effects of a single-site interventional study targeted at a population of adult sickle-cell disease super-utilizers using a pre- and post-implementation design. The pre-intervention period was 06/01/13 to 12/31/13 (seven months) and the post-intervention period was 01/01/14 to 02/28/15 (14 months). Our approach included patient-specific best practice advisories (BPA); an ED management protocol; and formation of a “medical home” for these patients.

RESULTS:
For 10 subjects targeted initially we developed and implemented coordinated care plans; after deployment, we observed a tendency toward reduction in ED and inpatient utilization across all measured indices. Between the annualized pre- and post-implementation periods we found the following: ED visits decreased by 16.5 visits/pt-yr (95% confidence interval [CI] [-1.32-34.2]); ED length of state (LOS) decreased by 115.3 hours/pt-yr (95% CI [-82.9-313.5]); in-patient admissions decreased by 4.20 admissions/pt-yr (95% CI [-1.73-10.1]); in-patient LOS decreased by 35.8 hours/pt-yr (95% CI [-74.9-146.7]); and visits where the patient left before treatment were reduced by an annualized total of 13.7 visits. We observed no patient mortality in our 10 subjects, and no patient required admission to the intensive care unit 72 hours following discharge.

CONCLUSION:
This effort suggests that a targeted approach is both feasible and potentially effective, laying a foundation for broader study.

Insights Results

Overview of article

  • Because sickle-cell disease predominantly affects minority populations, the manifestations of the disease exacerbate the challenges faced by communities with high proportions of minority residents. This motivated the development of a care protocol in an effort to improve the medical care provided to the sickle-cell disease population. While research on standard sickle-cell disease patient care exists, little is known about very high care utilizers
  • This trial was primarily a feasibility effort and not designed or powered to detect specific differences; while it saw lower resource use across all who had a plan enacted, the small sample does not allow us to quantify a durable magnitude effect but does offer promise for future work in other settings
  • This study did not measure patient satisfaction, though anecdotally the acceptance and unstructured feedback were high among providers and patients

Methods of article

  • This study evaluated the effects of a single-site interventional study targeted at a population of adult sickle-cell disease super-utilizers using a pre- and post-implementation design. The pre-intervention period was 06/01/13 to 12/31/13 (7 months) and the post-intervention period was 01/01/14 to 02/28/15 (14 months). The study approach included patient-specific best practice advisories (BPA); an emergency department (ED) management protocol; and formation of a “medical home” for these patients
  • The ED protocol for super-utilizers helped guide decision-making, reduced redundant resource utilization, and standardized and expedited care. The multidisciplinary team created standing orders for pain control, imaging, and supportive care, which were implemented during the pre- and post-intervention periods to expedite care
  • Medical Home Study patients were referred to the “Care One Clinic,” a multidisciplinary hospital-based clinic for vulnerable patients with high-frequency ED visits. Upon enrollment, patients were seen by a primary care doctor, social worker and pharmacist, and had access to an embedded addiction and pain specialist and clinical psychologist

Key takeaways/implications

  • An individualized care plan created by a multidisciplinary care team can be created and used in a population of sickle-cell disease super-ED users linked to a tendency to reduce healthcare utilization
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