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2378 Return Visit Rates after an Emergency Department Treat-and-Release Visit for Children with Sickle Cell Pain Episodes

Program: Oral and Poster Abstracts
Session: 114. Hemoglobinopathies, Excluding Thalassemia: Clinical and Epidemiological: Poster II
Hematology Disease Topics & Pathways:
Research, epidemiology, Clinical Research, health outcomes research
Sunday, December 11, 2022, 6:00 PM-8:00 PM

Keli C Coleman1*, Kenneth McKinley, MD2*, Angela Ellison3*, Amanda M. Brandow, DO, MS4, Blake Nielsen, MS5*, Lawrence Cook, PhD5*, Elizabeth Alpern, MD, MSCE6*, Selena Hariharan, MD7*, Irina Topoz, MD8*, Morgan Wurtz, MD9*, Claudia R. Morris, MD10,11, Andrew D. Campbell, MD12, Robert Liem, MD13, Rachelle Nuss, MD14*, Charles T. Quinn, MD15, Alexis A. Thompson, MD, MPH16, Anthony Villella, MD9*, Ana Baumann, PhD17*, Allison A. King, MD, PhD, MPH18, Warren Frankenberger, PhD16* and David C Brousseau, MD, MS19

1Medical College of Wisconsin and the Children's Research Institute of Children's Wisconsin, Milwaukee, WI
2Children's National Medical Center, Washington, DC
3Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
4Pediatric Hematology/Oncology, Medical College of Wisconsin and Children’s Research Institute of the Children’s Hospital of Wisconsin, Milwaukee, WI
5University of Utah, Salt Lake City, UT
6Lurie Children's Hospital, Chicago, IL
7Cincinnati Children's Hospital, Cincinnati, OH
8Department of Pediatrics, Children's Colorado, Denver, CO
9Nationwide Children's Hospital, Columbus, OH
10Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
11Childrens Healthcare of Atlanta, Atlanta, GA
12Center for Cancer and Blood Disorders, Childrens National Hospital, Washington, DC
13Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
14Center for Cancer and Blood Disorders, University of Colorado Anschutz Medical Campus, Aurora, CO
15Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Med. Ctr., Cincinnati, OH
16Children's Hospital of Philadelphia, Philadelphia, PA
17Washington University School of Medicine, St Louis, MO
18Pediatric Hematology/Oncology, Washington University School of Medicine, Clayton, MO
19Department of Pediatrics, Medical College of Wisconsin and the Children's Research Institute at Children's Wisconsin, Milwaukee, WI

Background: Children with sickle cell disease (SCD) have high emergency department (ED) visit, hospitalization and rehospitalization rates. With the release of national guidelines, increased emphasis has been placed on ensuring guideline adherent care for the timeliness of ED treatment to decrease pain and reduce hospitalizations. If decreased hospitalizations result, it will be important to ensure that those ED treat-and-release visits do not result in higher ED return visits, yet there are no multicenter studies on ED return visit rates for children with SCD after a pain episode.

Hypothesis: Our aim was to determine the 14-day return visit rate following an ED treat-and-release visit for children with SCD across multiple children’s hospitals. We hypothesized these children would have high return visit rates and that older children would have higher ED return visit rates that younger children.

Methods: This is a multicenter retrospective cohort study of ED visits by children with SCD using data from the Pediatric Emergency Care Applied Research Network (PECARN) Registry. The PECARN Registry contains electronic health record data for all ED visits at seven sites: Lurie Children’s, Children’s Hospital of Philadelphia, Cincinnati Children’s, Children’s National Medical Center, Children’s Colorado, Children’s Wisconsin, and Nationwide Children’s. ED visits for children less than 19 years old presenting with an uncomplicated sickle cell pain episode between January 2017 and December 2021 were included. An uncomplicated pain episode was defined using previously published criteria including: 1) receipt of at least one parenteral opioid in the ED AND 2) at least one of the following: a primary billing diagnosis for SCD (ICD-10 = D57.* except sickle cell trait), a chief complaint of sickle cell pain crisis, or a chief complaint of sickle cell fever. Visits were excluded if the child had a secondary diagnosis of acute chest syndrome or priapism or a fever in the ED higher than 38.5 0C. Index visits were defined as visits for an uncomplicated pain episode, discharged home, with no prior visit within 14 days. The primary outcome was the overall return visit rate within 14 days; secondary outcomes were the overall return visit rates at 3 and 7 days. We also evaluated the return visit rate for the subset of return visits classified as uncomplicated pain episodes. We estimated return visit rates by age, sex, and site. We reported the exact 95% confidence intervals for each return visit rate. We considered estimates not contained in comparison 95% confidence intervals as statistically significant differences. All analyses were conducted at the ED visit level using SAS software version 9.4.

Results: A total of 7,216 visits for SCD uncomplicated pain episodes occurred during the study period; 2,319 (32%) of those visits were ED treat-and-release visits with no prior visit within 14 days and were included as index visits. Approximately 57% of the study population was less than 12 years old, and approximately half were female. Non-Hispanic Black patients accounted for over 95% of the study population. The number of eligible index visits varied by site from 78 visits to 831 over the five-year study. The overall 14-day return visit rate was 29.5% (range 22.9% to 31.4%); the 7-day return visit rate was 22.8% (range 15.4% - 25.3%); the 3-day return visit rate was 16.3% (range 10.9% to 18.3%). Approximately 64% of the return visits at all three time points were uncomplicated pain episodes. Analyzing the disposition of the 29.5% of 14-day return visits, 13.0% of the index visits were followed by an ED treat-and-release visit while 18.8% were followed by a hospitalization (some children had both an ED treat-and release visit and a hospitalization). 14-day return visit rates varied between sites (highest: 31.4% [24.7% - 38.6%], lowest: 22.9% [16.9% - 29.8%]) Patients less than 12 years old had lower 14-day return visit rates than older patients (27.6% [25.2% - 30.2%] vs 31.5% [28.7% - 34.3%]). 14-day return visit rate did not differ by sex.

Conclusions: Almost 30% of ED treat-and-release visits for SCD pain episodes had a return visit within 14 days, of which approximately 75% were within 7 days and half were within 3 days. Older children were more likely to have return ED visits than younger children. Increased efforts are necessary to ensure post-ED discharge pain medication and follow-up care are adequate to reduce these high return visit rates.

Disclosures: Morris: CSL Behring: Consultancy; UCSF Benioff Children's Hospital Oakland: Patents & Royalties: inventor of IP generating Royalties. Campbell: Novartis: Consultancy; Global Blood Therapeutics: Consultancy; Agios: Consultancy; Forma: Consultancy; Vertex: Consultancy. Liem: BlueBird Bio: Research Funding; GBT: Research Funding; Editas: Research Funding; NHLBI: Research Funding. Quinn: Novo Nordisk: Honoraria; FORMA Therapeutics: Honoraria; Dispersol Technologies: Honoraria; Aruvant: Research Funding; Emmaus Medical: Research Funding. Thompson: Editas: Research Funding; Biomarin: Research Funding; Baxalta: Research Funding; CRISPR/Vertex: Consultancy, Research Funding; Bristol Myers Squibb: Consultancy, Research Funding; bluebird bio, Inc.: Consultancy, Research Funding; Beam: Consultancy; Agios: Consultancy; Global Blood Therapeutic: Current equity holder in publicly-traded company, Membership on an entity's Board of Directors or advisory committees; Novartis: Research Funding. Villella: CRISPR Therapeutics: Consultancy. King: Global Blood Therapeutics: Consultancy, Research Funding. Brousseau: CSL Behring: Consultancy.

*signifies non-member of ASH