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

  • Author(s): Simpson, Grant Gerald
  • Hahn, Hallie R.
  • Powell, Alex A.
  • Leverence, Robert R.
  • Morris, Linda A.
  • Thompson, Lara G.
  • Zumberg, Marc S.
  • Borde, Deepa J.
  • Tyndall, Joseph Adrian
  • Shuster, Jonathan J.
  • Yealy, Donald M.
  • Allen, Brandon R.
  • et al.
Abstract

Introduction:A subpopulation of sickle-cell disease patients, termed super-utilizers, present frequently to emergency departments (EDs) for vaso-occlusive events and may consume disproportionate resources without broader health benefit. To address the health care needs of this vulnerable patient population, we piloted a multidisciplinary intervention seeking to create and use individualized patient care plans that to 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 (7 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 (figure 1); 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: ED visits decreased by 16.5 visits/pt-yr (95% CI, -1.32 to 34.2); ED length of state (LOS) decreased by 115.3 hours/pt-yr (95% CI, -82.9 to 313.5); in-patient admissions decreased by 4.20 admissions/pt-yr (95% CI, -1.73 to 10.1); in-patient LOS decreased by 35.8 hours/pt-yr (95% CI, -74.9 to 146.7); and visits where the patient left before treatment was 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 ICU care 72 hours following discharge.

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

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