Keli Coleman, MD: Predictors of Hospitalization, Return Visits in Children with SCD

Findings from a multicenter retrospective cohort study presented at the 2023 American Society of Hematology (ASH) Annual Meeting and Exposition in San Diego, California showed the final emergency department pain score was the best predictor of hospitalization in children with uncomplicated sickle cell disease (SCD) pain crises.

Of note, no pain score from any point during an emergency department visit predicted a return hospital visit after discharge - rather, fewer opioid doses in the emergency department and receipt of an opioid prescription at discharge were associated with fewer return visits, posing important implications for identifying high-risk patients and developing targeted intervention strategies.

Results were based upon electronic healthcare data from the Pediatric Emergency Care Applied Research Network (PECARN) Registry across 7 sites, which investigators collected to determine the relationship between pain scores and disposition as well as the occurrence of a return emergency department visit.

For the purpose of analysis, investigators defined index emergency department visits as uncomplicated pain crises with no preceding emergency department visits within 14 days between January 2017 and November 2021. Initial, last, and change in scores as measured by a numeric rating scale (0-10) were collected and modeled to assess hospital disposition while adjusting for age, sex, and uncomplicated pain crisis visit admission rate.

When assessing return visits, investigators used the same predictor variables and additionally included both the number of parenteral opioid doses administered in the emergency department and whether or not a prescription for an opioid was given at discharge. Investigators noted all analyses were adjusted for site using generalized estimating equations with an exchangeable correlation structure to account for clustering.

In total, 4985 index visits for uncomplicated SCD pain crises were included in the study, 52% of which resulted in hospitalization. Among the cohort, 39% of study participants were <12 years of age, 54% were female, and 96% were Black. Index emergency department visits per site varied from 157 to 1855. The overall emergency department median initial pain score was 8.0 (interquartile range [IQR], 6.0-10), the median last pain score was 5.0 (IQR, 2.0-8.0), and the median change in pain score was 2.0 (IQR, 0.0-5.0).

Multivariate analyses revealed the last pain score was the best predictor of hospital admission (adjusted rate ratio, 1.16; 95% Confidence interval [CI], 1.12-1.19), while change in pain score was not significant (adjusted rate ratio, 0.98; 95% CI, 0.96-1.00).

More than 80% of participants with a last pain score > 7 were hospitalized, compared to less than 40% whose score was < 4. Of the 2,377 visits originally discharged, 29% had a return visit within 14 days. Of note, none of the pain scores from the initial visit were associated with having a return visit within 14 days. However, investigators pointed out both an increased number of emergency department opioid doses and failure to receive an opioid prescription at discharge were associated with increased return visits.

The editorial team of HCPLive Hematology reached out to Keli Coleman, MD, assistant professor in the department of pediatrics at the Medical College of Wisconsin, for further insight into the study’s design, results, and its contribution to our understanding of hospitalizations and return visits in this patient population.

HCPLive: What burdens do patients with sickle cell disease face, and what is the importance of pain reduction for these patients?

Coleman: Patients with sickle cell disease (SCD) undoubtedly face numerous challenges attributed to the nature of their chronic illness. I cannot, of course, speak to the patient’s perspective of disease burden which is that of a lived experience, individualized, and likely variable based on SCD genotype and other factors.

In SCD, the crescent shape of the red blood cells limits blood flow to an area of the body and attributes to downstream effects including several clinical complications (i.e., vaso-occlusive events, acute chest syndrome, stroke, splenic sequestration, sepsis, etc). SCD calls on the vigilance of patients, families, and clinicians alike to monitor and appropriately evaluate patients with early signs of illness such as fever, respiratory symptoms, and pain to provide evidence-based care.

From the lens of a pediatric emergency medicine clinician with a SCD pain research focus, children with SCD experience sudden onset, severe, excruciating, acute pain called vaso-occlusive events (VOEs) and present to the emergency department (ED) for treatment. VOEs, the hallmark of SCD, are the most common reason for ED visits, hospitalization, and rehospitalization in SCD. Children <19 years old also experience high ED return visit rates after ED discharge for VOE. Patients with SCD have increased acute healthcare utilization, experience acute and chronic pain, and report a lower health-related quality of life (HRQoL).

It is essential to prioritize equitable and prompt pain treatment of VOE through adherence to national guidelines and further research pursuits to improve SCD pain care in the ED and after discharge home to make meaningful changes in outcomes.

HCPLive: Is there a reason you chose to conduct this study among children? How might their experiences differ from those of adults with SCD?

Coleman: Good question. My training is in pediatric emergency medicine with a scholarly interest in improving children’s SCD acute pain experience outcomes in the ED and after their discharge home following VOE treatment.

While not the focus of this particular study, I agree that it would be interesting to know whether the adult population had similar or different results when considering the association between ED pain scores, disposition at index ED visit, and an ED return visit within 14 days.

HCPLive: Can you give an overview of the findings from your research?

Coleman: Our research team is interested in exploring the high ED return visit rates following an uncomplicated, SCD acute VOE. We sought to determine if ED pain scores (first, initial, last ED pain score) were associated with disposition at the initial ED visit and whether ED pain scores could help predict an ED return visit within 14 days. Our results demonstrated that the last ED pain score is a better predictor for hospitalization than change in pain score. We found that none of the ED pain scores predicted an ED return visit after discharge. However, children who receive fewer opioid doses and a prescription for opioids were less likely to return to the ED in 14 days.

HCPLive: Were you surprised to find none of the pain scores predicted a return visit after discharge? Did any of the other results contradict what you may have expected, or confirm expectations about these patients?

Coleman: Yes, I was surprised that none of the ED pain scores predicted a high probability of return to the ED. However, I hypothesized that a high last ED pain score might indicate a higher probability of children with acute SCD pain returning to the ED.

Receipt of an opioid prescription and fewer ED doses of opioids were associated with less ED return visits. These findings were consistent with my expectations. Prescriber practices are inconsistent nationally, and a short course opioid prescription at ED discharge is an important reminder of a modifiable consideration in ED discharge planning to support patients with acute, severe SCD pain.

HCPLive: What is the clinical significance of these results?

Coleman: Our research on ED return visits for uncomplicated SCD pain VOEs in children and acute pain scores provide information to help identify children at the highest risk of a 14-day return visit to the ED which will allow us to target interventions aimed at reducing return visits to the patients most in need.

Reference

Brooks, A. Pain Scores, Opioid Receipt Predict Hospitalization in Children with Sickle Cell Disease. HCPLive. December 12, 2023. Accessed December 14, 2023. https://www.hcplive.com/view/pain-scores-opioid-receipt-predict-hospitalization-in-children-with-sickle-cell-disease