SAN DIEGO – When caring for patients with sickle cell disease who were hospitalized for vaso-occlusive crisis, hospitalists more often used demand-only patient-controlled analgesia, compared with hematologists.
In addition, symptoms of acute chest syndrome were reported more often among patients cared for by hospitalists than by those cared for by hematologists.
The findings, reported during a poster session at the annual meeting of the American Society of Hematology, underscore the need for improved collaboration between hematologists and hospitalists in the care of patients with sickle cell disease.
Dr. Nirmish Shah
These patients have been "increasingly managed by hospitalists rather than adult hematology specialists," the researchers, led by Dr. Nirmish Shah, wrote in their abstract. "Hospitalists provide efficient inpatient management; however, many possess knowledge gaps and carry biases into their relationship with patients with sickle cell disease."
In an effort to better understand the differences between hematologists and hospitalists in the care practices of this patient population, Dr. Shah and his associates reviewed the records of 298 patients with sickle cell disease who were hospitalized for vaso-occlusive crisis at Duke University Medical Center, Durham, N.C., between Sept. 1, 2008, and Jan. 31, 2011. In November of 2009, all inpatient care for patients with sickle cell disease was moved from the hematologists to the hospitalist service, said Dr. Shah, who directs the medical center’s sickle cell transition program.
Of the 298 patients, 120 were cared for by hematologists over 13 months while 178 were cared for by hospitalists over 13 months. The mean age of patients was 32 years.
There were no significant differences between hematologists and hospitalists in standard ordering practices including incentive spirometry, a bowel regimen, an anti-itching medication, and DVT prophylaxis. However, patients cared for by a hematologist had a higher total number of hours on a patient-controlled analgesia device (212 vs. 171 hours).
Dr. Shah also reported that, compared with hospitalists, hematologists were significantly less likely to use demand-only patient-controlled analgesia (23% vs. 42%) and significantly more likely to use both continuous and demand patient-controlled analgesia (67% vs. 54%).
Transfusions were similarly used by clinicians in both specialties. However, the number of units transfused was higher for hematologists, compared with hospitalists (a mean of 2.6 units vs. 1.9 units).
Erythrocytapheresis was used more often by hematologists than by hospitalists, but this difference did not reach statistical significance (6.7% vs. 2.2%).
No patients cared for by hematologists were diagnosed with acute chest syndrome, but 5.6% of those cared for by hospitalists were. In addition, patients cared for by hematologists had a significantly longer hospitalization, compared with those cared for by hospitalists (a mean of 10 days vs. 8.4 days, respectively) and a nonsignificantly lower 7-day readmission rate (6.7% vs. 7.2%) and 30-day readmission rate (35% vs. 40%).
"There often is a knowledge gap in hospitalist care of sickle cell patients," Dr. Shah said in an interview. "Because they may have a gap, it is our job as hematologists to be available as consultants. In addition, we should decide on the right method for controlling pain in this population of patients. I’m not trying to say that [hospitalists are] doing something in a wrong fashion. I think it brings up the idea that we need to collaborate more. At our hospital we’re assigning a nurse practitioner to round independently and help assist hospitalists now, in an attempt to improve our care for patients with sickle cell disease."
Dr. Shah said that he had no relevant financial disclosures.
(**Corrected: An earlier version of this story referred to "anesthesia" rather than "analgesia.")