Patterns of healthcare utilization among patients with sickle cell disease hospitalized with pain crises.

BACKGROUND: Vaso-occlusive crises (VOC) are the hallmark of sickle cell disease (SCD). Adults experiencing VOC often have high rates of unexpected healthcare utilization. We characterized prior and future healthcare utilization among adults hospitalized with VOC at an urban, academic medical center. METHODS: We identified 449 VOC hospitalizations among 63 patients from 2013 to 2016. Patients were categorized based on receiving established care at the medical center and prior utilization: (a) not established (n = 21); (b) newly established (n = 10); (c) established with low utilization in past 12 months (<4 VOC hospitalizations) (n = 22); and (d) established with high utilization in past 12 months (≥4 VOC hospitalizations) (n = 10). Patient and hospitalization characteristics and future utilization were compared across categories. RESULTS: Median age was 26 years (Q1 = 22, Q3 = 29) and 55.6% were female. Established patients with high prior utilization tended to have higher median pain scores at admission (10, P = .08). Thirty-day readmissions were highest in established patients with high prior utilization (P = .06), but 30-day clinic visits were highest in established patients with low prior utilization (P = .08). Adjusted linear regression found that newly established patients (ß = -4.6, P < .01) and established patients with low prior utilization (ß = -5.6, P < .01) had fewer VOC hospitalizations in the ensuing 12 months than established patients with high prior utilization. CONCLUSION: Among patients with SCD hospitalized for VOC, there was heterogeneity in healthcare utilization, with persistence in utilization over time for some patients. Efforts are needed to shift care from the acute setting to the outpatient clinic, which may lead to improved outcomes.

Clusters of pain trajectories among patients with sickle cell disease hospitalized for vaso-occlusive crisis: a data-driven approach.

BACKGROUND: Vaso-occlusive crises (VOC) are the hallmark of sickle cell disease (SCD), with higher severity among hospitalized patients. Clustering hospitalizations with similar pain trajectories could identify vulnerable patient subgroups. Aims were to (1) identify clusters of hospitalizations based on pain trajectories; (2) identify factors associated with these clusters; and (3) determine the association between these clusters and 30-day readmissions. METHODS: We retrospectively included 350 VOC hospitalizations from 2013-2016 among 59 patients. Finite mixture modeling identified clusters of hospitalizations from intercepts and slopes of pain trajectories during the hospitalization. Generalized estimating equations for multinomial and logistic models were used to identify factors associated with clusters of hospitalizations based on pain trajectories and 30-day readmissions, respectively, while accounting for multiple hospitalizations per patient. RESULTS: Three clusters of hospitalizations based on pain trajectories were identified: slow (n=99), moderate (n=207), and rapid (n=44) decrease in pain scores. In multivariable analysis, SCD complications, female gender, and affective disorders were associated with clusters with slow or moderate decrease in pain scores (compared to rapid decrease). Although univariate analysis found that the cluster with moderate decrease in pain scores was associated with lower odds of 30-day readmissions compared to the cluster with slow decrease, it was non-significant in multivariable analysis. SCD complications were associated with higher odds of 30-day readmissions and older age was associated with lower odds of 30-day readmissions. CONCLUSIONS: Our results highlight variability in pain trajectories among patients with SCD experiencing VOC and provide a novel approach for identifying subgroups of patients that could benefit from more intensive follow-up.

Assessment of health-related quality of life among adults hospitalized with sickle cell disease vaso-occlusive crisis.

Sickle cell disease (SCD) is characterized by painful vaso-occlusive crises (VOCs). Self-reported pain intensity is often assessed with the Numeric Rating Scale (NRS), whereas newer patient-reported outcome measures (PROMs) assess multidimensional pain in SCD. We describe pain experiences among hospitalized adults with VOCs, using 2 PROMs: the Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health and the Adult Sickle Cell Quality of Life Measurement System (ASCQ-Me). Adults with SCD hospitalized with VOCs at 2 academic centers in Boston, Massachusetts, from April 2016 to October 2017 were eligible. Participants completed the NRS and PROMs at admission and 7 days postdischarge. PROM scores were described and compared with population norms. Length of stay (LOS) and 30-day readmission rates were assessed. Forty-two (96%) of 44 eligible patients consented and completed admission assessments. Mean age was 30.2 years (standard deviation, 9.1), 60% were women, 76% were non-Hispanic black, and 64% had hemoglobin SS. Twenty-seven participants (64%) completed postdischarge assessments. Sixty percent had ≥4 VOCs in the last year. Nearly all PROMIS Global Health and ASCQ-Me scores were worse than population norms. NRS and PROMIS Global Physical Health scores improved after discharge, the latter driven principally by improvements in pain. Overall median LOS was 7 days, and 30-day readmission rate was 40.5%. Administration of PROMs among adults with SCD hospitalized for VOCs is feasible and demonstrates participants experienced recurrent, prolonged, and severe VOCs. PROMIS Global and ASCQ-Me scores indicated substantial suffering, and the striking 30-day readmission rate highlights the vulnerability of these patients.

Timeliness of Treatment Initiation in Newly Diagnosed Patients With Breast Cancer.

BACKGROUND: Evidence-based timeliness benchmarks have been established to assess quality of breast cancer care, as delays in treatment are associated with poor clinical outcomes. However, few studies have evaluated how current breast cancer care meets these benchmarks and what factors may delay the timely initiation of treatment. PATIENTS AND METHODS: Demographic and disease characteristics of 377 newly diagnosed patients with breast cancer who initiated treatment at Tufts Medical Center (2009-2015) were extracted from electronic medical records. Time from diagnosis to initial surgery and time from diagnosis to initiation of hormone therapy were estimated with Kaplan-Meier curves. Multivariable regression analysis was used to identify factors associated with treatment delays. Thematic analysis was performed to categorize reasons for delay. RESULTS: Of 319 patients who had surgery recommended as the first treatment, 248 (78%) met the 45-day benchmark (median, 28 days; 25th-75th %, 19-43). After adjusting for potential confounders, multivariable regression analysis revealed that negative hormone receptor status (odds ratio, 3.48; 95% confidence interval, 1.44-8.43) and mastectomy (odds ratio, 4.07; 95% confidence interval, 2.10-8.06) were significantly associated with delays in surgery. Delays were mostly owing to clinical complexity or logistical/financial reasons. Of 241 patients eligible for hormone therapy initiation, 232 (96%) met the 1-year benchmark (median, 147 days; 25th-75th %, 79-217). CONCLUSION: Most patients met timeliness guidelines for surgery and initiation of hormone therapy, although risk factors for delay were identified. Knowledge of reasons for breast cancer treatment delay, including clinical complexity and logistical/financial issues, may allow targeting interventions for patients at greatest risk of care delays.

Successful Management of Cryptococcal Meningitis and Bone Marrow Infiltration in a Young HIV/AIDS Patient: A Case Report and Review of the Literature.

Bone marrow cryptococcosis has been rarely reported in the literature, and there are no established treatment guidelines specific to this AIDS-related complication. The recommended treatment for AIDS-related invasive fungal treatments include amphotericin B and flucytosine which are associated with an array of complications making optimal treatment recommendations difficult. This case presentation represents an example of a patient with newly diagnosed AIDS and bone marrow cryptococcosis, which was successfully managed with an antifungal regimen adjusted to her comorbidities.