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Colorectal polyps often recur after incomplete resection
When gastroenterologists resect polyps during colonoscopy, they may inadvertently leave some neoplastic tissue behind. Biopsies from resection margins sometimes contain polyp remnants, even after a lesion has been visibly removed, research has shown. But the significance of incomplete resection has been unclear.
A new study indicates that incomplete resection, compared with complete resection, substantially increases the likelihood that a polyp will be found during follow-up colonoscopy.
The evidence “strongly supports the hypothesis” that residual polyp tissue likely contributes to neoplastic polyp recurrence and, by extension, interval colorectal cancer, said study author Heiko Pohl, MD, and colleagues. Dr. Pohl is affiliated with the White River Junction Veterans Affairs Medical Center in Vermont and Dartmouth-Hitchcock Medical Center and Dartmouth Geisel School of Medicine in Hanover, N.H.
Among 166 participants in the Complete Adenoma Resection (CARE) study who went on to have a surveillance colonoscopy in the following years, metachronous neoplasia was detected more often in colon segments where polyps had been incompletely resected, compared with colon segments with complete resections (52% vs. 23%), according to a study in Annals of Internal Medicine.
In addition, colon segments that had had incomplete resections in the CARE study were more likely to have polyps that were 10 mm or greater (18% vs. 3%). The 32 participants who had at least one incomplete resection during the original CARE study were three times more likely to have a polyp at follow-up, Dr. Pohl and coauthors found.
There were no instances of cancer or high-grade dysplasia during follow-up, however.
Key questions remain, including “Why do people get cancer after colonoscopy?” said Shai Friedland, MD, MS, who was not involved in the study. “Maybe it is because of these polyps that were not removed completely.”
On the other hand, lesions that are more difficult to see in the first place and more dangerous might be responsible when colorectal cancer does occur after colonoscopy, said Dr. Friedland, professor of gastroenterology and hepatology at Stanford (Calif.) University and a gastroenterologist at Veterans Affairs Palo Alto (Calif.) Health Care System.
Although it is not surprising that polyp remnants may appear as polyps during follow-up examinations, the difference in polyp recurrence between groups “must be quite striking” for it to clearly be seen in this small study, Dr. Friedland said. The results suggest that there is a need to “redouble our efforts to make sure that we remove polyps completely and not just hope that they disappear after an incomplete job,” he added.
In the CARE study, which was conducted between 2009 and 2012 at two academic medical centers, researchers found that about 10% of neoplastic polyps with visibly complete removal may nonetheless be incompletely resected, based on the presence of neoplastic tissue in biopsies taken from resection margins.
The investigators focused on 5- to 20-mm nonpedunculated colorectal polyps that were removed during routine polypectomy using electrocautery snare resection.
Participants with incomplete polyp resections were encouraged to have a surveillance examination within 1 year, and those with complete resections received guideline-based surveillance recommendations. In the follow-up analysis, those with an incomplete resection had a median time to first examination of 17 months, and those with complete resections had a median time to first examination of 45 months.
“These results highlight the importance of achieving complete resection because the risk for subsequent advanced neoplasia detection statistically significantly increases without it,” Dr. Pohl said. “The large polyp size after incomplete resection within a generally short follow-up time may imply fast growth, even if none of the presumed recurrent polyps contained advanced histologic characteristics.”
Between-group differences in the participants and polyps could confound the observations, the authors noted. It is possible that endoscopists who did the follow-up colonoscopies looked harder for polyps in colon segments that had prior incomplete resections, on account of the initial study findings, they said. “It is also plausible that endoscopists with a greater incomplete resection rate would be more likely to miss polyps, which could then be detected at follow-up,” though detection and resection skills do not necessarily correlate, the investigators said.
With resection, the goal is to remove the polyp in one piece with clear margins, and researchers have known that the polyp removal techniques used in the study “are far from perfect,” Dr. Friedland said. One question is whether the field should focus on improving standard techniques, or incorporating newer, more advanced techniques such as endoscopic submucosal dissection, which is effective but may entail significant perforation risk when performed by someone who is not proficient, he said.
“One of the major focuses we had over the years is finding the polyps to prevent future cancer,” Dr. Pohl said in an interview. But the CARE study showed that “we do not do a good job of taking polyps off completely,” he added. The present analysis underscores that clinicians should do their best to remove polyps completely, even if they lack a way to confirm complete resection in routine practice, as is currently the case, Dr. Pohl said. To that end, clinicians should aim to refine their skills and techniques. Video evaluations with guidance from experts may prove helpful, he suggested. “We need to think hard about quality assessment,” Dr. Pohl said.
Dr. Pohl disclosed grants from Boston Scientific, Cosmo Pharmaceuticals, and Steris outside of the study. Dr. Friedland had no disclosures.
When gastroenterologists resect polyps during colonoscopy, they may inadvertently leave some neoplastic tissue behind. Biopsies from resection margins sometimes contain polyp remnants, even after a lesion has been visibly removed, research has shown. But the significance of incomplete resection has been unclear.
A new study indicates that incomplete resection, compared with complete resection, substantially increases the likelihood that a polyp will be found during follow-up colonoscopy.
The evidence “strongly supports the hypothesis” that residual polyp tissue likely contributes to neoplastic polyp recurrence and, by extension, interval colorectal cancer, said study author Heiko Pohl, MD, and colleagues. Dr. Pohl is affiliated with the White River Junction Veterans Affairs Medical Center in Vermont and Dartmouth-Hitchcock Medical Center and Dartmouth Geisel School of Medicine in Hanover, N.H.
Among 166 participants in the Complete Adenoma Resection (CARE) study who went on to have a surveillance colonoscopy in the following years, metachronous neoplasia was detected more often in colon segments where polyps had been incompletely resected, compared with colon segments with complete resections (52% vs. 23%), according to a study in Annals of Internal Medicine.
In addition, colon segments that had had incomplete resections in the CARE study were more likely to have polyps that were 10 mm or greater (18% vs. 3%). The 32 participants who had at least one incomplete resection during the original CARE study were three times more likely to have a polyp at follow-up, Dr. Pohl and coauthors found.
There were no instances of cancer or high-grade dysplasia during follow-up, however.
Key questions remain, including “Why do people get cancer after colonoscopy?” said Shai Friedland, MD, MS, who was not involved in the study. “Maybe it is because of these polyps that were not removed completely.”
On the other hand, lesions that are more difficult to see in the first place and more dangerous might be responsible when colorectal cancer does occur after colonoscopy, said Dr. Friedland, professor of gastroenterology and hepatology at Stanford (Calif.) University and a gastroenterologist at Veterans Affairs Palo Alto (Calif.) Health Care System.
Although it is not surprising that polyp remnants may appear as polyps during follow-up examinations, the difference in polyp recurrence between groups “must be quite striking” for it to clearly be seen in this small study, Dr. Friedland said. The results suggest that there is a need to “redouble our efforts to make sure that we remove polyps completely and not just hope that they disappear after an incomplete job,” he added.
In the CARE study, which was conducted between 2009 and 2012 at two academic medical centers, researchers found that about 10% of neoplastic polyps with visibly complete removal may nonetheless be incompletely resected, based on the presence of neoplastic tissue in biopsies taken from resection margins.
The investigators focused on 5- to 20-mm nonpedunculated colorectal polyps that were removed during routine polypectomy using electrocautery snare resection.
Participants with incomplete polyp resections were encouraged to have a surveillance examination within 1 year, and those with complete resections received guideline-based surveillance recommendations. In the follow-up analysis, those with an incomplete resection had a median time to first examination of 17 months, and those with complete resections had a median time to first examination of 45 months.
“These results highlight the importance of achieving complete resection because the risk for subsequent advanced neoplasia detection statistically significantly increases without it,” Dr. Pohl said. “The large polyp size after incomplete resection within a generally short follow-up time may imply fast growth, even if none of the presumed recurrent polyps contained advanced histologic characteristics.”
Between-group differences in the participants and polyps could confound the observations, the authors noted. It is possible that endoscopists who did the follow-up colonoscopies looked harder for polyps in colon segments that had prior incomplete resections, on account of the initial study findings, they said. “It is also plausible that endoscopists with a greater incomplete resection rate would be more likely to miss polyps, which could then be detected at follow-up,” though detection and resection skills do not necessarily correlate, the investigators said.
With resection, the goal is to remove the polyp in one piece with clear margins, and researchers have known that the polyp removal techniques used in the study “are far from perfect,” Dr. Friedland said. One question is whether the field should focus on improving standard techniques, or incorporating newer, more advanced techniques such as endoscopic submucosal dissection, which is effective but may entail significant perforation risk when performed by someone who is not proficient, he said.
“One of the major focuses we had over the years is finding the polyps to prevent future cancer,” Dr. Pohl said in an interview. But the CARE study showed that “we do not do a good job of taking polyps off completely,” he added. The present analysis underscores that clinicians should do their best to remove polyps completely, even if they lack a way to confirm complete resection in routine practice, as is currently the case, Dr. Pohl said. To that end, clinicians should aim to refine their skills and techniques. Video evaluations with guidance from experts may prove helpful, he suggested. “We need to think hard about quality assessment,” Dr. Pohl said.
Dr. Pohl disclosed grants from Boston Scientific, Cosmo Pharmaceuticals, and Steris outside of the study. Dr. Friedland had no disclosures.
When gastroenterologists resect polyps during colonoscopy, they may inadvertently leave some neoplastic tissue behind. Biopsies from resection margins sometimes contain polyp remnants, even after a lesion has been visibly removed, research has shown. But the significance of incomplete resection has been unclear.
A new study indicates that incomplete resection, compared with complete resection, substantially increases the likelihood that a polyp will be found during follow-up colonoscopy.
The evidence “strongly supports the hypothesis” that residual polyp tissue likely contributes to neoplastic polyp recurrence and, by extension, interval colorectal cancer, said study author Heiko Pohl, MD, and colleagues. Dr. Pohl is affiliated with the White River Junction Veterans Affairs Medical Center in Vermont and Dartmouth-Hitchcock Medical Center and Dartmouth Geisel School of Medicine in Hanover, N.H.
Among 166 participants in the Complete Adenoma Resection (CARE) study who went on to have a surveillance colonoscopy in the following years, metachronous neoplasia was detected more often in colon segments where polyps had been incompletely resected, compared with colon segments with complete resections (52% vs. 23%), according to a study in Annals of Internal Medicine.
In addition, colon segments that had had incomplete resections in the CARE study were more likely to have polyps that were 10 mm or greater (18% vs. 3%). The 32 participants who had at least one incomplete resection during the original CARE study were three times more likely to have a polyp at follow-up, Dr. Pohl and coauthors found.
There were no instances of cancer or high-grade dysplasia during follow-up, however.
Key questions remain, including “Why do people get cancer after colonoscopy?” said Shai Friedland, MD, MS, who was not involved in the study. “Maybe it is because of these polyps that were not removed completely.”
On the other hand, lesions that are more difficult to see in the first place and more dangerous might be responsible when colorectal cancer does occur after colonoscopy, said Dr. Friedland, professor of gastroenterology and hepatology at Stanford (Calif.) University and a gastroenterologist at Veterans Affairs Palo Alto (Calif.) Health Care System.
Although it is not surprising that polyp remnants may appear as polyps during follow-up examinations, the difference in polyp recurrence between groups “must be quite striking” for it to clearly be seen in this small study, Dr. Friedland said. The results suggest that there is a need to “redouble our efforts to make sure that we remove polyps completely and not just hope that they disappear after an incomplete job,” he added.
In the CARE study, which was conducted between 2009 and 2012 at two academic medical centers, researchers found that about 10% of neoplastic polyps with visibly complete removal may nonetheless be incompletely resected, based on the presence of neoplastic tissue in biopsies taken from resection margins.
The investigators focused on 5- to 20-mm nonpedunculated colorectal polyps that were removed during routine polypectomy using electrocautery snare resection.
Participants with incomplete polyp resections were encouraged to have a surveillance examination within 1 year, and those with complete resections received guideline-based surveillance recommendations. In the follow-up analysis, those with an incomplete resection had a median time to first examination of 17 months, and those with complete resections had a median time to first examination of 45 months.
“These results highlight the importance of achieving complete resection because the risk for subsequent advanced neoplasia detection statistically significantly increases without it,” Dr. Pohl said. “The large polyp size after incomplete resection within a generally short follow-up time may imply fast growth, even if none of the presumed recurrent polyps contained advanced histologic characteristics.”
Between-group differences in the participants and polyps could confound the observations, the authors noted. It is possible that endoscopists who did the follow-up colonoscopies looked harder for polyps in colon segments that had prior incomplete resections, on account of the initial study findings, they said. “It is also plausible that endoscopists with a greater incomplete resection rate would be more likely to miss polyps, which could then be detected at follow-up,” though detection and resection skills do not necessarily correlate, the investigators said.
With resection, the goal is to remove the polyp in one piece with clear margins, and researchers have known that the polyp removal techniques used in the study “are far from perfect,” Dr. Friedland said. One question is whether the field should focus on improving standard techniques, or incorporating newer, more advanced techniques such as endoscopic submucosal dissection, which is effective but may entail significant perforation risk when performed by someone who is not proficient, he said.
“One of the major focuses we had over the years is finding the polyps to prevent future cancer,” Dr. Pohl said in an interview. But the CARE study showed that “we do not do a good job of taking polyps off completely,” he added. The present analysis underscores that clinicians should do their best to remove polyps completely, even if they lack a way to confirm complete resection in routine practice, as is currently the case, Dr. Pohl said. To that end, clinicians should aim to refine their skills and techniques. Video evaluations with guidance from experts may prove helpful, he suggested. “We need to think hard about quality assessment,” Dr. Pohl said.
Dr. Pohl disclosed grants from Boston Scientific, Cosmo Pharmaceuticals, and Steris outside of the study. Dr. Friedland had no disclosures.
Infusion centers may best EDs for treating sickle cell crises
At infusion centers, patients received pain medication an average of 70 minutes faster compared with patients treated in EDs (62 vs. 132 minutes), according to a study published online in the Annals of Internal Medicine. In addition, patients at infusion centers were 3.8 times more likely to have their pain reassessed within 30 minutes of the first dose. And they were 4 times more likely to be discharged home, the researchers found.
“It’s not that the emergency room doctors don’t want to do the right thing,” study author Sophie Lanzkron, MD, said in an interview. “They do, but they aren’t experts in sickle cell disease. They work in an emergency room, which is an incredibly busy, stressful place where they see trauma and heart attacks and strokes and all of these things that need emergency care. And so it just is not the right setting to treat people with sickle cell disease.”
To assess whether care at specialty infusion centers or EDs leads to better outcomes for patients with sickle cell disease with uncomplicated vaso-occlusive crises, Dr. Lanzkron, director of the Sickle Cell Center for Adults at the Johns Hopkins Hospital, Baltimore, and colleagues conducted the ESCAPED (Examining Sickle Cell Acute Pain in the Emergency vs. Day Hospital) study.
The trial included 483 adults with sickle cell disease who lived within 60 miles of an infusion center in four U.S. cities: Baltimore, Maryland; Cleveland, Ohio; Milwaukee, Wisconsin; and Baton Rouge, Louisiana. Investigators recruited patients between April 2015 and December 2016 and followed them for 18 months after enrollment.
The present analysis focused on data from 269 participants who had infusion center visits or ED visits that occurred during weekdays when infusion centers were open. Two sites had infusion centers solely for adults with sickle cell disease (Baltimore and Milwaukee), and two infusion centers shared infusion space with other hematology-oncology patients. All four sites were in hospitals that also had EDs.
Although participants may have received comprehensive care at one of the sites with an infusion center, those who lived farther from an infusion center were likely to receive care for acute pain at an ED closer to home, the authors explain in the article.
The investigators used propensity score methodology to balance patient characteristics in the study groups.
Quick, effective pain reduction is beneficial
The results suggest that infusion centers “are more likely to provide guideline-based care than EDs,” and this care “can improve overall outcomes,” the authors write.
Although the specialty infusion centers the researchers studied used various models, similar outcomes were seen at all of them.
The study did not include patients who had complications of sickle cell disease in addition to vaso-occlusive crisis, the researchers note.
“[Because] the magnitude of the treatment effects estimated in our study is large and we have captured most of the important potential confounders, an unmeasured confounder that can nullify the treatment effect is unlikely to exist,” the authors write.
“Sickle cell disease is a complicated condition that affects multiple organs. Patients who present with acute pain will have better outcomes being treated under providers who know and understand the disease,” commented Julie Kanter, MD, director of the adult sickle cell disease program and codirector of the Comprehensive Sickle Cell Center at the University of Alabama at Birmingham. “Specialized infusion centers offer the opportunity to both improve outcomes and decrease the cost of care. Most importantly, it is better for the individual with sickle cell disease,” she said.
Dr. Kanter wrote an accompanying editorial about the ESCAPED findings. The editorialist notes that “opioid medications are the only option to reduce the pain caused by microvascular injury” in patients with sickle cell crisis, although these treatments do not reduce the underlying damage and have substantial side effects and risks. Nevertheless, “quick and effective reduction of pain can allow patients to more easily move, stretch, and breathe ... important to increase oxygenation and restore blood flow, which will eventually abate the crisis,” Dr. Kanter wrote.
The study shows that the infusion center treatment approach can benefit patients across different settings, commented John J. Strouse, MD, PhD, medical director of the adult sickle cell program at Duke University Sickle Cell Center, Durham, N.C., who was not involved in the study.
“They show that they can definitely get closer to the recommendations of guidelines for acute pain management and sickle cell disease” in a setting that is focused on one problem, he said. “The other piece that is really important is that people are much more likely to go home if you follow the guideline.”
Infusion centers are scarce
“These systems need to be built,” Dr. Lanzkron said. “In most places, patients don’t have access to the infusion center model for their care. And in some places, it is not going to be practical.” Still, there may be ways to establish infusion locations, such as at oncology centers. And while there are challenges to delivering sickle cell disease care in EDs, “emergency rooms need to try to meet the needs of this patient population as best as they can,” Dr. Lanzkron said.
“Structural racism has played a role in the quality of care delivered” to patients with sickle cell disease, Dr. Lanzkron said. “The big message is [that] there is a better way to do this.”
The study was funded by the Patient-Centered Outcomes Research Institute. Dr. Lanzkron’s disclosures included grants or contracts with government agencies and companies that are paid to her institution, as well as consulting fees from Bluebird Bio, Novo Nordisk, and Pfizer. Coauthors have disclosed working with sickle cell organizations and various medical companies. Dr. Kanter and Dr. Strouse have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
At infusion centers, patients received pain medication an average of 70 minutes faster compared with patients treated in EDs (62 vs. 132 minutes), according to a study published online in the Annals of Internal Medicine. In addition, patients at infusion centers were 3.8 times more likely to have their pain reassessed within 30 minutes of the first dose. And they were 4 times more likely to be discharged home, the researchers found.
“It’s not that the emergency room doctors don’t want to do the right thing,” study author Sophie Lanzkron, MD, said in an interview. “They do, but they aren’t experts in sickle cell disease. They work in an emergency room, which is an incredibly busy, stressful place where they see trauma and heart attacks and strokes and all of these things that need emergency care. And so it just is not the right setting to treat people with sickle cell disease.”
To assess whether care at specialty infusion centers or EDs leads to better outcomes for patients with sickle cell disease with uncomplicated vaso-occlusive crises, Dr. Lanzkron, director of the Sickle Cell Center for Adults at the Johns Hopkins Hospital, Baltimore, and colleagues conducted the ESCAPED (Examining Sickle Cell Acute Pain in the Emergency vs. Day Hospital) study.
The trial included 483 adults with sickle cell disease who lived within 60 miles of an infusion center in four U.S. cities: Baltimore, Maryland; Cleveland, Ohio; Milwaukee, Wisconsin; and Baton Rouge, Louisiana. Investigators recruited patients between April 2015 and December 2016 and followed them for 18 months after enrollment.
The present analysis focused on data from 269 participants who had infusion center visits or ED visits that occurred during weekdays when infusion centers were open. Two sites had infusion centers solely for adults with sickle cell disease (Baltimore and Milwaukee), and two infusion centers shared infusion space with other hematology-oncology patients. All four sites were in hospitals that also had EDs.
Although participants may have received comprehensive care at one of the sites with an infusion center, those who lived farther from an infusion center were likely to receive care for acute pain at an ED closer to home, the authors explain in the article.
The investigators used propensity score methodology to balance patient characteristics in the study groups.
Quick, effective pain reduction is beneficial
The results suggest that infusion centers “are more likely to provide guideline-based care than EDs,” and this care “can improve overall outcomes,” the authors write.
Although the specialty infusion centers the researchers studied used various models, similar outcomes were seen at all of them.
The study did not include patients who had complications of sickle cell disease in addition to vaso-occlusive crisis, the researchers note.
“[Because] the magnitude of the treatment effects estimated in our study is large and we have captured most of the important potential confounders, an unmeasured confounder that can nullify the treatment effect is unlikely to exist,” the authors write.
“Sickle cell disease is a complicated condition that affects multiple organs. Patients who present with acute pain will have better outcomes being treated under providers who know and understand the disease,” commented Julie Kanter, MD, director of the adult sickle cell disease program and codirector of the Comprehensive Sickle Cell Center at the University of Alabama at Birmingham. “Specialized infusion centers offer the opportunity to both improve outcomes and decrease the cost of care. Most importantly, it is better for the individual with sickle cell disease,” she said.
Dr. Kanter wrote an accompanying editorial about the ESCAPED findings. The editorialist notes that “opioid medications are the only option to reduce the pain caused by microvascular injury” in patients with sickle cell crisis, although these treatments do not reduce the underlying damage and have substantial side effects and risks. Nevertheless, “quick and effective reduction of pain can allow patients to more easily move, stretch, and breathe ... important to increase oxygenation and restore blood flow, which will eventually abate the crisis,” Dr. Kanter wrote.
The study shows that the infusion center treatment approach can benefit patients across different settings, commented John J. Strouse, MD, PhD, medical director of the adult sickle cell program at Duke University Sickle Cell Center, Durham, N.C., who was not involved in the study.
“They show that they can definitely get closer to the recommendations of guidelines for acute pain management and sickle cell disease” in a setting that is focused on one problem, he said. “The other piece that is really important is that people are much more likely to go home if you follow the guideline.”
Infusion centers are scarce
“These systems need to be built,” Dr. Lanzkron said. “In most places, patients don’t have access to the infusion center model for their care. And in some places, it is not going to be practical.” Still, there may be ways to establish infusion locations, such as at oncology centers. And while there are challenges to delivering sickle cell disease care in EDs, “emergency rooms need to try to meet the needs of this patient population as best as they can,” Dr. Lanzkron said.
“Structural racism has played a role in the quality of care delivered” to patients with sickle cell disease, Dr. Lanzkron said. “The big message is [that] there is a better way to do this.”
The study was funded by the Patient-Centered Outcomes Research Institute. Dr. Lanzkron’s disclosures included grants or contracts with government agencies and companies that are paid to her institution, as well as consulting fees from Bluebird Bio, Novo Nordisk, and Pfizer. Coauthors have disclosed working with sickle cell organizations and various medical companies. Dr. Kanter and Dr. Strouse have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
At infusion centers, patients received pain medication an average of 70 minutes faster compared with patients treated in EDs (62 vs. 132 minutes), according to a study published online in the Annals of Internal Medicine. In addition, patients at infusion centers were 3.8 times more likely to have their pain reassessed within 30 minutes of the first dose. And they were 4 times more likely to be discharged home, the researchers found.
“It’s not that the emergency room doctors don’t want to do the right thing,” study author Sophie Lanzkron, MD, said in an interview. “They do, but they aren’t experts in sickle cell disease. They work in an emergency room, which is an incredibly busy, stressful place where they see trauma and heart attacks and strokes and all of these things that need emergency care. And so it just is not the right setting to treat people with sickle cell disease.”
To assess whether care at specialty infusion centers or EDs leads to better outcomes for patients with sickle cell disease with uncomplicated vaso-occlusive crises, Dr. Lanzkron, director of the Sickle Cell Center for Adults at the Johns Hopkins Hospital, Baltimore, and colleagues conducted the ESCAPED (Examining Sickle Cell Acute Pain in the Emergency vs. Day Hospital) study.
The trial included 483 adults with sickle cell disease who lived within 60 miles of an infusion center in four U.S. cities: Baltimore, Maryland; Cleveland, Ohio; Milwaukee, Wisconsin; and Baton Rouge, Louisiana. Investigators recruited patients between April 2015 and December 2016 and followed them for 18 months after enrollment.
The present analysis focused on data from 269 participants who had infusion center visits or ED visits that occurred during weekdays when infusion centers were open. Two sites had infusion centers solely for adults with sickle cell disease (Baltimore and Milwaukee), and two infusion centers shared infusion space with other hematology-oncology patients. All four sites were in hospitals that also had EDs.
Although participants may have received comprehensive care at one of the sites with an infusion center, those who lived farther from an infusion center were likely to receive care for acute pain at an ED closer to home, the authors explain in the article.
The investigators used propensity score methodology to balance patient characteristics in the study groups.
Quick, effective pain reduction is beneficial
The results suggest that infusion centers “are more likely to provide guideline-based care than EDs,” and this care “can improve overall outcomes,” the authors write.
Although the specialty infusion centers the researchers studied used various models, similar outcomes were seen at all of them.
The study did not include patients who had complications of sickle cell disease in addition to vaso-occlusive crisis, the researchers note.
“[Because] the magnitude of the treatment effects estimated in our study is large and we have captured most of the important potential confounders, an unmeasured confounder that can nullify the treatment effect is unlikely to exist,” the authors write.
“Sickle cell disease is a complicated condition that affects multiple organs. Patients who present with acute pain will have better outcomes being treated under providers who know and understand the disease,” commented Julie Kanter, MD, director of the adult sickle cell disease program and codirector of the Comprehensive Sickle Cell Center at the University of Alabama at Birmingham. “Specialized infusion centers offer the opportunity to both improve outcomes and decrease the cost of care. Most importantly, it is better for the individual with sickle cell disease,” she said.
Dr. Kanter wrote an accompanying editorial about the ESCAPED findings. The editorialist notes that “opioid medications are the only option to reduce the pain caused by microvascular injury” in patients with sickle cell crisis, although these treatments do not reduce the underlying damage and have substantial side effects and risks. Nevertheless, “quick and effective reduction of pain can allow patients to more easily move, stretch, and breathe ... important to increase oxygenation and restore blood flow, which will eventually abate the crisis,” Dr. Kanter wrote.
The study shows that the infusion center treatment approach can benefit patients across different settings, commented John J. Strouse, MD, PhD, medical director of the adult sickle cell program at Duke University Sickle Cell Center, Durham, N.C., who was not involved in the study.
“They show that they can definitely get closer to the recommendations of guidelines for acute pain management and sickle cell disease” in a setting that is focused on one problem, he said. “The other piece that is really important is that people are much more likely to go home if you follow the guideline.”
Infusion centers are scarce
“These systems need to be built,” Dr. Lanzkron said. “In most places, patients don’t have access to the infusion center model for their care. And in some places, it is not going to be practical.” Still, there may be ways to establish infusion locations, such as at oncology centers. And while there are challenges to delivering sickle cell disease care in EDs, “emergency rooms need to try to meet the needs of this patient population as best as they can,” Dr. Lanzkron said.
“Structural racism has played a role in the quality of care delivered” to patients with sickle cell disease, Dr. Lanzkron said. “The big message is [that] there is a better way to do this.”
The study was funded by the Patient-Centered Outcomes Research Institute. Dr. Lanzkron’s disclosures included grants or contracts with government agencies and companies that are paid to her institution, as well as consulting fees from Bluebird Bio, Novo Nordisk, and Pfizer. Coauthors have disclosed working with sickle cell organizations and various medical companies. Dr. Kanter and Dr. Strouse have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.