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Adults with sickle cell disease who experienced a vaso-occlusive crisis performed significantly better when treated in specialized infusion centers than those treated in emergency departments (ED), according to a prospective observational study.
In infusion centers, patients received pain relievers on average 70 minutes faster than patients treated in emergency rooms (62 vs. 132 minutes), according to a study published online in the Annals of Internal Medicine. In addition, patients in infusion centers were 3.8 times more likely to have their pain reassessed within 30 minutes of the first dose. And they were 4 times more likely to be sent home, the researchers found.
“It’s not that emergency department doctors don’t want to do the right thing,” study author Sophie Lanzkron, MD, said in an interview. “They do, but they’re not sickle cell experts. They work in an emergency room, which is an incredibly busy and stressful place where they see traumas, heart attacks and strokes and all of that stuff. that require emergency care. And so this is just not the right setting for treating people with sickle cell disease. “
To assess whether care in specialized infusion centers or emergency departments leads to better outcomes for sickle cell patients with uncomplicated vaso-occlusive crises, Lanzkron, director of the Sickle Cell Center for Adults at the hospital Johns Hopkins of Baltimore, Maryland, and his colleagues conducted the Examining Sickle Cell Acute Pain in the Emergency vs Day Hospital (ESCAPED) study.
The trial included 483 adults with sickle cell disease who lived within 60 miles of an infusion center in four US cities: Baltimore, Maryland; Cleveland, Ohio; Milwaukee, Wisconsin; and Baton Rouge, Louisiana. Investigators recruited patients between April 2015 and December 2016 and followed them for 18 months after inclusion.
This analysis focused on data from 269 participants who had visits to the infusion center or emergency room visits that occurred on weekdays when the infusion centers were open. Two sites had infusion centers only for adults with sickle cell disease (Baltimore and Milwaukee), and two infusion centers shared the infusion space with other hematology-oncology patients. All four sites were in hospitals that also had emergency services.
Although participants were able to receive comprehensive care at one of the sites with an infusion center, those who lived further away from an infusion center were likely to receive acute pain care in an emergency department. closer to home, the authors explain in the article.
The investigators used the propensity score methodology to balance the characteristics of the patients in the study groups.
Quick and effective pain reduction is beneficial
The results suggest that infusion centers “are more likely to provide directive-based care than emergency departments,” and such care “may improve overall outcomes,” the authors write.
Although the specialized infusion centers that the researchers studied used a variety of models, similar results were seen in all of them.
The study did not include patients who had complications from sickle cell disease in addition to a vaso-occlusive crisis, the researchers note.
“[Because] the magnitude of the treatment effects estimated in our study is large and we captured most of the important potential confounders, an unmeasured confounding factor that can negate the treatment effect is unlikely to exist, ”write the authors.
“Sickle cell disease is a complicated disease that affects several organs. Patients with acute pain will have better outcomes when treated by providers who know and understand the disease, ”commented Julie Kanter, MD, director of the Sickle Cell Adult Program co-director of the Comprehensive Sickle Cell Center at the University of Alabama. in Birmingham. “Specialized infusion centers offer the opportunity to both improve outcomes and reduce the cost of care. More importantly, it’s better for people with sickle cell disease,” she said.
Kanter wrote an accompanying editorial on ESCAPED’s findings. The columnist notes that “opioid drugs are the only option for reducing pain from microvascular damage” in patients with sickle cell crisis, although these treatments do not reduce the underlying damage and have side effects and symptoms. significant risks. Nonetheless, “rapid and effective pain reduction can make it easier for patients to move, stretch and breathe, which is important for increasing oxygenation and restoring blood flow, which will ultimately alleviate the seizure. “Kanter wrote.
The study shows that the infusion center treatment approach can benefit patients in different settings, commented John J. Strouse, MD, PhD, medical director of the Sickle Cell Adult Program at Duke University Sickle Cell Center in Durham, in North Carolina, which was not involved. in the study.
“They show that they can certainly come close to the guideline recommendations for the management of acute pain and sickle cell disease” in a problem-focused setting, he said. “The other thing that is really important is that people are much more likely to go home if you follow the guidelines.”
Infusion centers are rare
“These systems have to be built,” Lanzkron said. “In most places, patients do not have access to the infusion center model for their care. And in some places it will not be practical.” Still, there may be ways to establish infusion sites, such as at oncology centers. And while there are challenges in providing sickle cell disease care in emergency departments, “emergency rooms must try to best meet the needs of this patient population,” Lanzkron said.
“Structural racism has played a role in the quality of care provided” to patients with sickle cell disease, Lanzkron said. “The big message is that there is a better way to do it.”
The study was funded by the Patient-Centered Outcomes Research Institute. Lanzkron’s disclosures included grants or contracts with government agencies and companies that are paid to his institution, as well as consulting fees from Bluebird Bio, Novo Nordisk and Pfizer. The co-authors revealed that they have worked with sickle cell organizations and various medical companies. Kanter and Strouse did not report any relevant financial relationships.
Ann Intern Med. Published online July 5, 2021. Summary, Editorial
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