SCD: Innovative Models of Care

Sophie Lanzkron, MD, MHSAssociate Professor of Medicine and Oncology

Johns Hopkins School of Medicine

Two major system-level barriers to the provision of high quality for adults with SCD care:◦ Lack of established quality indicators◦ Lack of available experts that can provide care to

the SCD population Can people with SCD receive high quality

care outside of specialty care clinics?

High Quality Care

Emergency Department care for SCD has been estimated at $1.5 million/100 patients

Much of the cost driven by resulting hospitalization from ED visits.

These charges were 5 times greater than those for HIV.

75% of adults with SCD are covered by some form of public health insurance (Medicaid or Medicare)

suggests a significant financial impact of SCD on the health care system.

Need for Innovative Models: Acute Care

The Journal of PainVolume 8, Issue 6, June 2007, Pages 460–466

Observational, multicenter, prospective, cohort study of patients who presented to US and Canadian EDs with a chief complaint of moderate to severe pain and were discharged home

Median time interval from triage to analgesic administration was 90 minutes (0 to 962 minutes).

Only 29% of patients who were given analgesics received them within 1 hour of arrival.

Three quarters of patients were discharged with moderate pain (45%; NRS, 4 to 7) or severe pain (29%; NRS, 8 to 10)

Quality of Usual ED Pain Management: Not SCD

Patients and healthcare providers are dissatisfied with the quality of SCD pain management.

SCD patients report: ◦ Not having enough involvement in decisions about their

own care◦ Providers do not demonstrate respect, trust, and

compassion. Basis for this belief- studies have demonstrated:

◦ Providers hold highly negative attitudes toward SCD patients

◦ Providers are strongly predisposed to suspect addiction in patients presenting for VOC care.

Quality of Usual ED Care: SCD

Benjamin et al. in 2000◦ Bronx Comprehensive Sickle Cell Center. ◦ Used a specific assessment and treatment protocol in

the setting of a day hospital, pain was controlled in 90% of patients, hospital admissions decreased by 40% average length of stay for hospitalized patients decreased by

1.5 days. ◦ Key- patients were assessed and started on treatment

within 15-20 minutes of arrival◦ Patients were assessed at half hour intervals for pain,

psychological distress, pain relief and adverse events.

Is there a better way?

Hospitals concerned about losing volumes◦ Lack of financial support

Lack of adult providers nationally to provide these services and build the units.

Current change in landscape creating an environment more conducive to the Infusion Center/Day Hospital model.◦ Goals to decrease in-hospital care (admissions and

readmissions)

Why Hasn’t DH Model Taken Off?

5 treatment slots for acute care visits Open 7 days a week, 8 hours a day Serves the needs of adult patients only 80-100 visits per month Average LOS in SCIC- 4 hrs 43 min. 85% of patients seen for VOC go home after

treatment ED admission rate has dropped from 50% to 20%

The Johns Hopkins Sickle Cell Infusion Clinic (SCIC)

Am J Hematol. 2015 May;90(5):376-80.

SCIC Impact Felt Throughout the State: Admissions

Am J Hematol. 2015 May;90(5):376-80.

SCIC Impact Felt Throughout the State: Readmissions

81% agreed/strongly agreed with: I feel perfectly satisfied with the way I am treated at the Infusion Clinic.

73% agreed/strongly agreed that their pain was adequately controlled.

74% agreed/strongly agreed that my complaints and concerns are addressed

Patient Satisfaction: Results

Rapid, aggressive treatment of pain ◦ Dosing of opioids hourly ◦ Frequent reassessments of pain (at least every 30

minutes)◦ Use of adjuvant therapies (i.e. nonsteroidals)

Continuity of care- team of caregivers dedicated to providing high quality care to people with SCD

Provides comprehensive sickle care (hydroxyurea, etc.)

Social work services Psychiatric services

Why Does SCIC Work?

Standardize quality indicators ◦ Admission rate◦ Readmission rates◦ Time to first dose of opioid when in VOC◦ Appropriate prescribing of

hydroxyurea/transfusion therapy◦ Quality of life

Defining High Quality Care: Acute Care Setting

Can/should infusion center model be widely disseminated? ◦ What size sickle population makes it cost effective

to have dedicated acute care facility?◦ Can acute management of VOC been done in

oncology clinics/ medicine infusion clinics/FQHC/ED obs units? What metrics should we use to judge success?

◦ Who will run these clinics?

Future of this Model