ARTICLE: Treatment of Acute Pain in Adults With Sickle Cell Disease in an Infusion Center Versus the Emergency Department : A Multicenter Prospective Cohort Study

AUTHORS: Sophie Lanzkron, Jane Little, Hang Wang, Joshua J Field, J Ryan Shows, Carlton Haywood Jr, Mustapha Saheed, Marc Proudford, Derek Robertson, Adrienne Kincaid, Lorri Burgess, Charles Green, Rebecca Seufert, Jasmine Brooks, Allie Piehet, Brandi Griffin, Nicole Arnold, Steven Frymark, Marcus Wallace, Nebras Abu Al Hamayel, Chiung-Yu Huang, Jodi B Segal, Ravi Varadhan

JOURNAL: Ann Intern Med. 2021 Jul 6. doi: 10.7326/M20-7171. Online ahead of print.

Abstract

Background: Patients with sickle cell disease (SCD) have vaso-occlusive crises (VOCs). Infusion centers (ICs) are alternatives to emergency department (ED) care and may improve patient outcomes.

Objective: To assess whether care in ICs or EDs leads to better outcomes for the treatment of uncomplicated VOCs.

Design: Prospective cohort. (ClinicalTrials.gov: NCT02411396).

Setting: 4 U.S. sites, with recruitment between April 2015 and December 2016.

Participants: Adults with SCD living within 60 miles of a study site.

Measurements: Participants were followed for 18 months after enrollment. Outcomes of interest were time to first dose of parenteral pain medication, whether pain reassessment was completed within 30 minutes after the first dose, and patient disposition on discharge from the acute care visit. Treatment effects for ICs versus EDs were estimated using a time-varying propensity score adjustment.

Results: Researchers enrolled 483 participants; the 269 who had acute care visits on weekdays are included in this report. With inverse probability of treatment-weighted adjustment, the mean time to first dose was 62 minutes in ICs and 132 minutes in EDs; the difference was 70 minutes (95% CI, 54 to 98 minutes; E-value, 2.8). The probability of pain reassessment within 30 minutes of the first dose of parenteral pain medication was 3.8 times greater (CI, 2.63 to 5.64 times greater; E-value, 4.7) in the IC than the ED. The probability that a participant's visit would end in discharge home was 4.0 times greater (CI, 3.0 to 5.42 times greater; E-value, 5.4) with treatment in an IC than with treatment in an ED.

Limitation: The study was restricted to participants with uncomplicated VOCs.

Conclusion: In adults with SCD having a VOC, treatment in an IC is associated with substantially better outcomes than treatment in an ED.

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