CONCORD, N.C. – A care center for acute sickle cell pain management, which includes a dedicated emergency room and a daytime management unit in the hospital, decreased health system costs and the frequency of acute care visits by sickle cell patients, James Eckman, MD, reported at Sickle Cell Disease Symposium held by Carolinas Health Care System.
“In the first 5 years of the center, acute care visits dropped from 16 per patient per year to 10, and admissions per active patient per year dropped from 2.1 to less than one,” said Dr. Eckman, former medical director of the Georgia Comprehensive Sickle Cell Center at Grady Health System in Atlanta.
James Eckman, MD
By 2011, those numbers had dropped further, falling to less than four acute care visits per patient per year and less than 0.5 admissions per patient per year.
The results Dr. Eckman reported are based on 37 years of his experience at Grady Health System, which included setting up an emergency room dedicated to patients with sickle cell disease (SCD) and the launch of a tertiary care clinic in 1985. The Grady SCD database includes more than 4,500 patients, with about 1,000 adults active at any given time.
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“We really developed a model that was very cost effective for the management of this disease,” said Dr. Eckman, professor emeritus in hematology and medical oncology at Emory University. “We actually consistently turned a profit in our budget.”
Previously, SCD patients went to the regular emergency department for their acute pain crises, and they would often wait for hours without treatment. “You need to initiate treatment rapidly in these patients,” Dr. Eckman said. “It’s really unacceptable now what’s happening in our emergency rooms, where they have to wait 3, 4, or more hours to get treated while they’re in intolerable pain.”
In 2014, an expert panel issued guidelines for pain management in SCD calling for the initiation of pain treatment for acute crisis within 30 minutes of the patient’s arrival in the emergency department (JAMA. 2014 Sep 10;312[10]:1033-48). “Our goal is 20 minutes to have a complete assessment, get a laboratory draw, and have them on therapy,” he said. “And we were relatively successful in being able to do that.”
Each patient at the center was enrolled in a care management program consisting of 35 assessment and intervention elements. Assessment includes a complete medical evaluation, along with social and psychological evaluations. Intervention entails developing a detailed problem list – including medical, social, and psychological issues – a detailed management plan, and a social support plan. The initial assessment can take 4-8 hours.
For the first decade, the program tracked acute care visits and admissions in 166 continuing patients and saw dramatic declines in both. “The data only go through 1995, but they actually look exactly the same after 1995 all the way up to 2015,” Dr. Eckman said. “This sustained a really marked decrease in health care utilization.”
The program also identified a small group of patients – fewer than 75 out of a base of 1,000 – who accounted for 90% of visits, he said.
Although the Georgia experience is based on a dedicated care center for SCD, the results can be replicated without that type of dedicated infrastructure, Dr. Eckman said. “It is not the 24-hour acute care center,” he said. “It’s the carefully thought out and implemented comprehensive care plan by a multidisciplinary care team dedicated to care of the individuals with sickle cell disease that makes the difference.”
Dr. Eckman reported having no financial disclosures.