The authors assessed whether care in an infusion center versus an emergency department leads to improved outcomes in uncomplicated vaso-occlusive crises by following adults with sickle cell disease at 4 U.S. sites and evaluating pain outcomes and whether patients were discharged home or hospitalized.
Abstract
Background:
Patients with sickle cell disease (SCD) have vaso-occlusive crises (VOCs). Infusion centers (ICs) are alternatives to emergency department (ED) care and may improve patient outcomes.
Objective:
To assess whether care in ICs or EDs leads to better outcomes for the treatment of uncomplicated VOCs.
Design:
Prospective cohort. (ClinicalTrials.gov: NCT02411396)
Setting:
4 U.S. sites, with recruitment between April 2015 and December 2016.
Participants:
Adults with SCD living within 60 miles of a study site.
Measurements:
Participants were followed for 18 months after enrollment. Outcomes of interest were time to first dose of parenteral pain medication, whether pain reassessment was completed within 30 minutes after the first dose, and patient disposition on discharge from the acute care visit. Treatment effects for ICs versus EDs were estimated using a time-varying propensity score adjustment.
Results:
Researchers enrolled 483 participants; the 269 who had acute care visits on weekdays are included in this report. With inverse probability of treatment–weighted adjustment, the mean time to first dose was 62 minutes in ICs and 132 minutes in EDs; the difference was 70 minutes (95% CI, 54 to 98 minutes; E-value, 2.8). The probability of pain reassessment within 30 minutes of the first dose of parenteral pain medication was 3.8 times greater (CI, 2.63 to 5.64 times greater; E-value, 4.7) in the IC than the ED. The probability that a participant’s visit would end in admission to the hospital was smaller by a factor of 4 (0.25 [CI, 0.18 to 0.33]) with treatment in an IC versus an ED.
Limitation:
The study was restricted to participants with uncomplicated VOCs.
Conclusion:
In adults with SCD having a VOC, treatment in an IC is associated with substantially better outcomes than treatment in an ED.
Primary Funding Source:
Patient-Centered Outcomes Research Institute.
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Author, Article, and Disclosure Information
Sophie Lanzkron,
Johns Hopkins University School of Medicine, Baltimore, Maryland (S.L., H.W., M.S., R.S., J.B., J.S.)
Case Western Reserve University School of Medicine and University Hospitals, Cleveland, Ohio (J.L., B.G., N.A.)
Blood Center of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin (J.J.F., S.F.)
Our Lady of the Lake Hospital, Baton Rouge, Louisiana (J.R.S., A.P.)
The Johns Hopkins Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland (C.H.J.)
William E. Proudford Foundation, Baltimore, Maryland (M.P.)
Maryland Sickle Cell Disease Association, Columbia, Maryland (D.R.)
Kincaid's Kindred Spirits, Euclid, Ohio (A.K.)
Baton Rouge Sickle Cell Disease Association, Baton Rouge, Louisiana (L.B.)
Community Partner, Milwaukee, Wisconsin (C.G.)
Louisiana Health Care Connection, Baton Rouge, Louisiana (M.W.)
Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (N.A.A.)
University of California, San Francisco, San Francisco, California (C.H.)
Oncology Biostatistics and Bioinformatics, Johns Hopkins University, Baltimore, Maryland (R.V.).
Note: The authors dedicate this work to Ms. Lorri Burgess and the many sickle warriors who advocate for this patient population on a daily basis.
Acknowledgment: The authors thank Drs. Constantine Frangakis, Dan Scharfstein, Elizabeth Stuart, and Tom Louis for statistical advice.
Financial Support: By award IHS-1403-11888 from the Patient-Centered Outcomes Research Institute.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-7171.
Reproducible Research Statement: Study protocol and statistical code: Available from Dr. Lanzkron (e-mail, slanzkr@jhmi.
Corresponding Author: Sophie Lanzkron, MD, 1830 East Monument Street, Suite 7300, Baltimore, MD 21205; e-mail, slanzkr@jhmi.
Correction: This article was corrected on 3 August 2021 to report risk ratios and risk differences for admission to the hospital by treatment site in the abstract, the text, and Table 4.
Current Author Addresses: Dr. Lanzkron: 1830 East Monument Street, Suite 7300, Baltimore, MD 21205.
Dr. Little: 3140 Physician's Office Building, Houpt Building, 170 Manning Drive, or Campus Box 7305, Chapel Hill, NC 27599-7235.
Dr. Wang: 2024 East Monument Street, Suite 2-700, Baltimore, MD 21205.
Dr. Field: 9000 West Wisconsin Avenue, Milwaukee, WI 53226.
Dr. Shows: 4950 Essen Lane, Suite 300, Baton Rouge, LA 70809.
Dr. Haywood: 2024 East Monument Street, Suite 2-600, Baltimore, MD 21205.
Dr. Saheed: 1800 Orleans Street, Zayed G1080, Baltimore, MD 21287.
Mr. Proudford: PO Box 42411, Baltimore, MD 21284-2411.
Mr. Robertson: 8775 Centre Park Drive #701, Columbia, MD 21045.
Ms. Kincaid: 784 East 266th Street, Euclid, OH 44132.
Mr. Green: 11405 West Grange Avenue, Hales Corners, WI 53130.
Ms. Seufert: 15 Lauriann Court, Parkton, MD 21120.
Ms. Brooks: 3218 Ravenwood Avenue, Baltimore, MD 21213.
Ms. Piehet: 4985 Lower Roswell Road, Building 100, Marietta, GA 30068.
Ms. Griffin: 11100 Euclid Avenue, Cleveland, OH 44106.
Ms. Arnold: 1000 Liberty Avenue, Pittsburgh, PA 15222.
Mr. Frymark: 7315 County Road South, Sobieski, WI 54171.
Dr. Wallace: 285 LeCirque, Madisonville, LA 70447.
Dr. Abu Al Hamayel: 624 North Broadway, Room 610, Baltimore, MD 21205.
Dr. Huang: 550 16th Street 2535, San Francisco, CA 94158.
Dr. Segal: 624 North Broadway, Room 644, Baltimore, MD 21287.
Dr. Varadhan: 550 North Broadway, Room 1111, Baltimore, MD 21287.
Author Contributions: Conception and design: S. Lanzkron, H. Wang, J.J. Field, C. Haywood, M. Saheed, L. Burgess, N. Abu Al Hamayel, J. Segal, R. Varadhan.
Analysis and interpretation of the data: S. Lanzkron, J. Little, H. Wang, M. Proudford, D. Robertson, L. Burgess, M. Wallace, N. Abu Al Hamayel, C.Y. Huang, J. Segal, R. Varadhan.
Drafting of the article: S. Lanzkron, J.J. Field, D. Robertson, C.Y. Huang, R. Varadhan.
Critical revision of the article for important intellectual content: S. Lanzkron, J. Little, H. Wang, J.J. Field, D. Robertson, A. Kincaid, M. Wallace, N. Abu Al Hamayel, J. Segal, R. Varadhan.
Final approval of the article: S. Lanzkron, J. Little, H. Wang, J.J. Field, J.R. Shows, C. Haywood, M. Saheed, M. Proudford, D. Robertson, A. Kincaid, L. Burgess, C. Green, R. Seufert, J. Brooks, A. Piehet, B. Griffin, N. Arnold, S. Frymark, M. Wallace, N. Abu Al Hamayel, C.Y. Huang, J. Segal, R. Varadhan.
Provision of study materials or patients: S. Lanzkron, J.R. Shows, M. Saheed.
Statistical expertise: H. Wang, C. Haywood, M. Wallace, C.Y. Huang, J. Segal, R. Varadhan.
Obtaining of funding: S. Lanzkron, J. Segal, R. Varadhan.
Administrative, technical, or logistic support: M. Saheed, C. Green, R. Seufert, A. Piehet.
Collection and assembly of data: S. Lanzkron, J. Little, H. Wang, J.J. Field, R. Seufert, J. Brooks, A. Piehet, B. Griffin, N. Arnold, S. Frymark.
This article was published at Annals.org on 6 July 2021.
† Deceased.
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