Children's hospitals best for sickle cell disease complications
By Megan Brooks
Adolescents and young adults with sickle cell disease (SCD) and acute chest syndrome get different care at general hospitals than at children's hospitals, a retrospective study hints.
The study found higher rates of intubation and longer stays in general hospitals, but no difference in 30-day readmission rates.
"Patients should be sent to the closest hospital to be stabilized, regardless of age. Most important is that the hospital treating the patient have easy access to the prior health records of that particular patient," Dr. Sophia Jan from Children's Hospital of Philadelphia in Pennsylvania, who worked on the study, told Reuters Health by email.
Acute chest syndrome is the leading cause of death in patients with SCD, and after vaso-occlusive pain, the most common reason for hospitalization, the investigators note in Pediatrics online October 28.
They also not that most children with SCD in the U.S. are followed at SCD centers in large academic children's hospitals, but they "age out" of these centers as adolescents and young adults, a time when they are at risk for uninsurance or a lapse in health insurance.
Most of them also may have a tough time finding a provider comfortable managing SCD, leading to fragmented care.
Dr. Jan and her colleagues took a look back at 1,379 SCD patients ages 16 to 25, with 2,178 admissions for acute chest syndrome between 2007 and 2009 at 12 children's hospitals and 244 general hospitals in the United States.
Fourteen of the 1,379 died, and 45% were intubated.
Compared to the children's hospitals, general hospitals had more deaths (13 of 14) and higher intubation rates (48% vs 24% predicted probability, p=0.045). Length of stay was also longer at the general hospitals (predicted mean LOS, 7.6 days vs 6.2 days).
The higher intubation risk and longer LOS in general hospitals "may suggest that children's hospitals have mechanisms and expertise leading to improved outcomes compared with general hospitals," the investigators say.
"This difference may also suggest that adolescent and young adult patients admitted to general hospitals are sicker at presentation because they are aging out of pediatric care and are having difficulty accessing ongoing adult care," the authors write.
In their study, patients in general hospitals did have more complex chronic conditions and more previous ICU admissions than those in children's hospitals.
Nearly half of admissions for acute chest syndrome (46%) received a simple transfusion (42%), exchange transfusion (2%), or both (1%). The researchers didn't see any marked difference by hospital type or provider specialty in rates of simple or exchange transfusion, or 30-day readmission.
"We need to better understand the drivers of these differences, including the role of staff expertise, hospital volume, and quality of ongoing SCD care," the investigators conclude in their article.
"We believe that children's hospitals are outperforming general hospitals for adolescent and young adult patients for a few different reasons," Dr. Jan told Reuters Health. "The patients presenting to children's hospitals are probably being cared for by doctors who have known them their entire lives, and therefore are more familiar with the medical histories and potential complications of individual patients."
"More importantly, the patients admitted to children's hospitals probably still have access to comprehensive and coordinated sickle cell care outside of the hospital. Comprehensive sickle cell disease centers exist primarily in pediatrics, and don't exist in the adult world yet. So those patients presenting to general hospitals are less likely to have access to adequate or coordinated outpatient care, and may actually be sicker when they are finally admitted to general hospitals," Dr. Jan said.
The researchers say general hospitals may improve outcomes through regionalization of SCD care, akin to systems of care for adults with cystic fibrosis.
SOURCE: http://bit.ly/16NuDtI
Pediatrics 2013;132:854-861.