Lowering Emergency Department Reliance in Patients With Sickle Cell Disease

Thanks to new initiatives to improve care for patients with sickle cell disease (SCD) living in Wisconsin, fewer patients are visiting the emergency department (ED) to manage pain, according to a longitudinal analysis of ED use among patients with SCD. While children and young adults had lower-than-expected ED reliance (EDR), the researchers, led by Ashima Singh, PhD, MS, from the Medical College of Wisconsin in Milwaukee, noted that ED use among patients in the young-adult “transition” age group increased.

In this study, presented at the 2017 ASH Annual Meeting, investigators estimated EDR among 609 patients with SCD over a five-year period to examine the effect of several SCD-related initiatives in the state.

“EDR among the sickle cell population is an indicator of quality of care and access to outpatient settings,” the authors explained. “In the state of Wisconsin, more recent efforts to improve patient care include setting up a sickle cell clinic for adult patients, creating an electronic health records–based registry for children with SCD, and [expanding] hydroxyurea indication to all children ≥1 year of age with sickle cell anemia.”

Patients included in the study were enrolled continuously in Medicaid and had at least one sickle cell pain–related ED visit. The researchers defined EDR for pain as the proportion of ED visits among all ambulatory visits (calculated by dividing the number of ED visits for pain by the number of all hospital visits). Excessive ED use was defined as an EDR ≥0.33.

Participants were categorized into four age groups:

  • children (0-18 years; n=248)
  • transition group (those who turned 19 years old during the 5-year study period; n=54)
  • young adults (19-30 years; n=170)
  • adults (31-45 years; n=137)

Results from a linear mixed model (adjusted for age group and hydroxyurea adherence) demonstrated that the overall EDR was 0.24 for the entire population – lower than the “excessive use” threshold.

According to the study’s findings, EDR for children was significantly lower than adults >30 years old (p=0.0091). However, patients in the transition-age group (p=0.0014) and young adults (p=0.0014) relied more heavily on ED visits than children (p<0.001; see TABLE).

When the researchers examined temporal patterns in EDR among age groups over the study period, they found that EDR was continuously below the established threshold of 0.33, though it significantly increased from 0.17 in 2011 to 0.21 in 2015 (p<0.001).

However, the EDR in the transition age group continued to increase over time, from 0.23 in 2011 to 0.37 in 2015 (p=0.001), suggesting that “further interventions focusing on the transition age group are needed to improve care and ensure smooth transition from the pediatric to adult health-care systems,” the authors concluded.

The study was limited by its retrospective nature, and because it was conducted in a single state, the results may not be generalizable to the larger U.S. patient population.

The authors report no relevant conflicts of interest.


Singh A, Yan K, Brandow AM, Panepinto JA. Longitudinal trend in emergency department reliance for pain among sickle cell disease patients in Wisconsin. Abstract 901. Presented at the 2017 American Society of Hematology Annual Meeting, December 9, 2017; Atlanta, GA.

TABLE. EDR for Pain in SCD Patients Living in Wisconsin Between 2011-2015
Age Group n Outpatient Visit,

Mean (SE)

ED Visit,

Mean (SE)

Pain EDR, Mean (SE)
Children (0-18 years) 248 45.90 (2.41) 8.70 (0.62) 0.18 (0.0093)
Transition group (turned 19 years during study period) 54 61.52 (5.57) 41.22 (9.47) 0.33 (0.030)
Young adults (19-30 years) 170 68.35 (4.73) 49.07 (7.72) 0.33 (0.018)
Adults (31-45 years) 137 71.83 (5.90) 21.15 (2.83) 0.23 (0.017)
EDR = emergency department reliance; SCD = sickle cell disease; SE = standard error; ED = emergency department