We also report the use of an EDOU to help decrease hospital admission

To the best of our knowledge, this is the first report of healthcare utilization in patients with SCD that includes DH and ED observation visits, in addition to the routinely reported ED visits and hospitalizations. We intentionally “counted” each encounter, and the numbers are significant. We attempted to dissect the “locations” in an effort to more fully understand all healthcare use for treatment of VOC and to begin to understand the potential for all locations as alternatives for treatment of VOC. During the project, several changes at both sites affected healthcare utilization options. Immediately prior to the onset of the study, Site 1 opened a new day hospital, enabling the management of mild episodes of VOC crisis with a DH stay; in contrast, at Site 2, the main provider that admitted patients to the DH took an 18-month medical leave, temporarily limiting the use of the DH at Site 2. Therefore, it is not surprising that the DH was used more for Site 1 patients needing acute pain management of VOC. It should be noted that the percentage of patients with one or more encounters to the DH at each site was not significantly different. The difference in usage reflected the frequency of DH use per patient during the study period rather than the percentage of patients with at least one DH encounter at each site. Another difference in management style is reflected in the hospital admission rate following a DH encounter between sites. Site 1 had a low post-DH encounter hospital admission rate, 8%,garden racks wholesale compared to Site 2, 24%. Dedicated DH management of patients with SCD has been shown to reduce full hospital admissions and total costs.It is clear there was a lower threshold for admission from the DH at Site 2 when compared with Site 1. This reflects practice pattern differences.

Emergency physicians should work with area hematologists to explore expanded use of DH treatment of uncomplicated VOC to reduce hospital admission for those cases where hospital admission is not otherwise warranted.Site 1 placed 67 patients in the observation unit rather than admitting to the hospital after inability to discharge after the ED stay; the admission rate was less than the SCD-VOC ED admission rate. A Brazilian hospital center successfully implemented an EDOU protocol and reduced hospital admissions; however, generalization of findings is limited to the small sample size, as there were less than 30 hospital admissions for sickle cell crisis each year.Two studies proclaiming a 50-55% reduction in hospital admission rates following implementation of a dedicated SCD-VOC observation protocol have been published in abstract form,but the detailed reports have yet to be published. Additional details are required before conclusions can be generalized to other settings. However, emergency physicians with access to an EDOU should consider establishing a SCD-observation protocol to reduce hospital admissions for uncomplicated VOC. Few prior studies assessed sickle cell patients’ use of hospital facilities outside of their specialists’ home institutions. Our finding of 34.5% of SCD patients visiting outside institutions is slightly less than that found by Woods et al. in 1997, who found 39% of SCD patients in the Illinois statewide database used more than one hospital for care.However, our finding of 34.5% outside hospital use is considerably less than Panepinto et. al. study using a database from eight states, which found that 48.7% of adult patients with SCD used more than one hospital.The fact that our patients had access to a hematologist for regular care may have reduced their need to seek care outside of the home institutions, while the other two cited studies reflected a more general SCD patient population, likely with less hematology follow-up care. Furthermore, patients seeking care elsewhere may represent needs unmet by the home institution.Our findings highlight the importance of measuring the cost of outside hospital utilization when studying the financial impact of new treatments or programs initiated at the investigator’s institution. While the majority of patients with sickle cell disease at each study site presented for acute care during the study period, a significant number had no acute care encounters, for a period longer than previously reported previously.

Approximately 40% of clinic patients at Site 1, and 33% of clinic patients at Site 2 had no acute care encounters at their hematologist’s institution, or at hospitals within 20 miles of the hematologist,hydroponic racks during the 2.5-year monitoring period. Our findings should be compared to an eight-state study of statewide inpatient and ED databases that found only 29% of patients had no acute care encounters related to their sickle cell anemia over a 12-month period.Darbari et. al. reported percentages similar to our study, 40%, but the assessment period was only one year.Our findings document 33-40% of two populations of patients with sickle cell disease being managed by hematologists without the need for acute care encounters for period of 30 months. We believe this is an important finding and further refutes the commonly held myth that all patients with SCD are high utilizers. Another important finding is that a greater proportion of patients at Site 2 had one or more hospital admissions , and had one or more ED visits. Furthermore, while the number of patients with acute care encounters at Site 1 was more than twice the number at Site 2 , Site 2 patients had more total ED encounters than Site 1 patients. This again speaks to differences in practice patterns between sites that can be guided with strong input from the patients’ hematologists. It has been documented previously how a minority of patients with SCD account for a disproportionately greater number of encounters;however, the variation in acute care usage between sickle cell populations has not been demonstrated previously within a single study. Clearly, the patients at Site 2 had more acute care encounters per patient. Our study did not assess the differences in methods of sickle cell disease management in the outpatient clinics; future study should investigate differences in all management methods, as well as differences in the patient characteristics, to determine the cause of this difference in acute care utilization. Our study was a prospective observational study, and we did not randomize patients to any specific treatment plan or setting. Although it was our intention to provide optimal and uniform care at both sites, providers at Site 2 were unable to initiate patient-controlled analgesia in the ED.

However, use of patient-controlled analgesia at Site 1 had unique problems, including delays to initiation of pain treatment as the device takes more time to set up than simple, single intravenous injection of pain medicine. Patient satisfaction with pain medication was not significantly different between sites.We did not assess outside hospital use beyond a 20-mile radius of each study site. We learned from discussions with patients that a few had received acute medical care at facilities outside of the 20-mile radius surrounding the home institutions, but we are not able to quantify or comment further on this care as patients were consented for hospitals only within the 20-mile radius. We observed differences in management styles, but we were unable to determine from this data to what extent the differences we observed were due to physician practice, patient disease severity, or other factors. Each site experienced a deficit in hematologist specialty coverage that reduced the use of the DH until a replacement could be found. Our patient population had access to a hematology specialty clinic during the entire study period; our finding may not be applicable to settings without readily available hematology follow-up and hematologist-directed day hospital management for patients with sickle cell disease. Headache is a common complaint in the emergency department.The use of HCT by emergency physicians for evaluation of headache varies widely, and 97% of EPs surveyed felt that at least some of the imaging studies ordered in EDs were medically unnecessary.The American College of Emergency Physicians released its Choosing Wisely Campaign in 2013, which included avoiding HCTs in patients with minor head injury who are at low risk based on validated decision rules.During the 2015 Academy of Emergency Medicine Consensus Conference on diagnostic imaging in the emergency department, participants suggested that allowing providers to influence metrics could produce better quality metrics; they also suggested that knowledge translation for the optimization of diagnostic imaging use should be a core area warranting further research.The Centers for Medicare and Medicaid Services proposed OP-15, “Use of Brain Computed Tomography in the Emergency Department for Atraumatic Headache,” to measure the proportion of HCTs performed on ED patients presenting with a primary complaint of headache that were supported by diagnosis codes; however, its methods were soon questioned.In 2012 while OP-15 was still under consideration, we implemented a quality improvement effort intended to improve the documentation of appropriate diagnoses in support of HCT ordering. As part of this QI effort we addressed some of the criticisms of OP-15 by expanding the indications for HCT and getting input from practicing EPs.

Reviewing this QI effort in 2014 we observed that the proportions of HCT use decreased after EPs had reviewed their individual practice data. The primary objective of our present study was to determine whether the observed decrease in HCT use was associated with changes in proportions of death or missed intracranial diagnosis. Secondarily, we sought to determine whether proportions of subsequent cranial imaging or reevaluation of headache differed when compared between those who did and those who did not undergo HCT in the ED.Our QI effort was structured to fulfill the practice improvement component of the American Board of Emergency Physicians’ Maintenance of Certification requirement.This required collecting data on 10 visits per EP before and after an intervention. We performed two interventions in succession, so our QI effort yielded three epochs: pre-intervention ; post-education ; and post-data review. At the end of each epoch, we sampled 10 visits for headache seen by each EP by searching the EMR for chief complaints of headache, and identifying the 10 most recent ED visits seen by each faculty EP. For our educational intervention we began by soliciting feedback from EPs on OP-15. Using this feedback we expanded the list of appropriate diagnoses supporting HCT. We followed this with a series of emails and lectures explaining CMS OP-15. We also conducted group discussions during educational conferences and faculty meetings to educate EPs on selecting appropriate diagnoses to support HCT ordering and explaining the measurement process, highlighting common pitfalls. During group discussions we invited and answered questions. The explicit goal of education was to improve diagnosis documentation, rather than to decrease HCT ordering. This began in late 2012 and continued through 2013. The data-review phase took place between January and March of 2014 when individual EPs reviewed their own HCT ordering practices based on data collected for the QI effort during the pre-intervention phase. These reviews occurred during individual faculty’s annual reviews with the department chair. In these meetings we presented each EP with his/her individual proportion of HCT ordering and proportion of appropriate diagnosis assignment. In cases where a HCT was ordered without the assignment of an appropriate supporting diagnosis we reviewed the ED chart. In keeping with Schuur et al.’s findings, we found that in the majority of cases a more specific diagnosis than “headache” was clearly supported by information documented in the ED chart, but had not been assigned at the end of the ED visit.During each annual review we informed the EP of the specific cases where HCT was not supported by a diagnosis code and suggested an alternate, more-specific diagnosis or the addition of a secondary diagnosis that would have made this HCT appropriate according to CMS OP-15. This was followed by the post data review phase when we sampled another 10 headache visits per EP. After our QI effort was completed, we were surprised to note that while there was no decrease in HCT use after the educational intervention, we observed a 9.6% reduction in HCT use after data review.In 2016 we decided to use the dataset generated during the QI effort to investigate our study hypothesis: Was a decrease in HCT use followed by an increase in death or missed intracranial diagnosis?