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

Abstract

IntroductionA 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.MethodsWe 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.ResultsFor 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.ConclusionThis effort suggests that a targeted approach is both feasible and potentially effective, laying a foundation for broader study.

Emergency Department Utilization for Patients Living With Sickle Cell Disease: Psychosocial Predictors of Health Care Behaviors

“…However, most studies on ED use tend to report on overall utilization in the SCD population with a focus on superutilizers and ED visit reduction approaches. 4,5,7,11,19,[28][29][30][31][32][33][34][35] Similar to some of these studies, our study also found that the majority of participants were not high ED utilizers. 11 However, the stigma and pervasive negative ED experiences have been empirically noted across our study and several others.…”

Management of Sickle Cell Disease Super Utilizers

“…al. 5 describes a process that requires a significant investment of clinical resources but also a significant improvement in resource utilization. With larger numbers of participants, it may be possible to achieve cost savings through economies of scale.…”

Interventions to Decrease Use in Prehospital and Emergency Care Settings Among Super-Utilizers in the United States: A Systematic Review

“…Ten studies used a medical care plan intervention, three of which with added social supports (Gray-Eurom et al, 2015), disease management (Simpson et al, 2017), or community health workers (Lin et al, 2017). One of the 10 medical care plan evaluations did not report any tests of statistical significance.…”