Predictors of hospital readmissions in adult patients with sickle cell disease.

Am J Blood Res 2023;13(6):189-197 www.AJBlood.us /ISSN:2160-1992/AJBR0151153 Original Article Predictors of hospital readmissions in adult patients with sickle cell disease Laura H Santiago1,2, Roberto B Vargas1,2, Derek O Pipolo1, Deyu Pan1, Sweta Tiwari1, Kaveh Dehghan1, Shahrzad Bazargan-Hejazi1,2 College of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA; 2David Geffen School of Medicine, UCLA, Los Angeles, CA, USA 1 Received May 9, 2023; Accepted October 3, 2023; Epub December 25, 2023; Published December 30, 2023 Abstract: Background: Sickle cell disease (SCD) is the most common inherited blood disorder, affecting primarily Black and Hispanic individuals. In 2016, 30-day readmissions incurred 95,445 extra days of hospitalization, $152 million in total hospitalization costs, and $609 million in total hospitalization charges. Objectives: 1) To estimate hospital readmissions within 30 days among patients with SCD in the State of California. 2) Identify the factors associated with readmission within 30 days for SCD patients in California. Methods: We conducted a retrospective observational study of adult SCD patients hospitalized in California between 2005 and 2014. Descriptive statistics and logistic regression models were used to examine significant differences in patient characteristics and their association with hospital readmissions. Results: From 2,728 individual index admissions, 70% presented with single admission, 10% experienced one readmission, and 20% experienced ≥ two readmissions within 30 days. Significant predictors associated with zero vs. one readmission were male gender (OR=1.37, CI: 1.06-1.77), Black ethnicity (OR=3.27, CI: 1.71-6.27) and having Medicare coverage (OR=1.89, CI: 1.30-2.75). Lower likelihood of readmission was found in those with a Charlson Comorbidity index of three or more (OR=0.53, CI: 0.29-0.97). For zero vs. ≥ two readmissions, significant predictors were male gender (OR=1.43, CI: 1.17-1.74), Black ethnicity (OR=6.90, CI: 3.4113.97), Hispanic ethnicity (OR=2.33, CI: 1.05-5.17), Medicare coverage (OR=3.58, CI: 2.68-4.81) and Medi-Cal coverage (OR=1.70, CI: 1.31-2.20). Lower likelihood for having two or more readmissions were associated with individuals aged 65+ (OR=0.97, CI: 0.96-0.98) and those with self-payment status (OR=0.32, CI: 0.12-0.54). Conclusions: In California, male, Black, and Hispanic patients, as well as those covered by Medicare or Medi-Cal, were found to have an increased risk of hospital readmissions. Redirecting outpatient goals to address these patient populations and risk factors is crucial for reducing readmission rates. Keywords: Sickle cell disease, health disparity, hospital readmissions, Medi-Cal/Medicare Introduction Sickle cell disease (SCD) is the most common inherited blood disorder, affecting approximately 1 in 2500 births and 100,000 individuals in the United States [1]. It is characterized by the presence of abnormal hemoglobin, known as hemoglobin S (HbS), which causes red blood cells to change their shape from a flexible disc to a rigid sickle-like shape. These sickle-shaped cells can become trapped in blood vessels, leading to vaso-occlusion, tissue damage, and pain crises [2, 3]. Detection and diagnosis of SCD typically involves a comobination of biochemical and molecular tests [4]. The gold standard and most popular methods, how- ever, included the complete count of blood cells (CBC), hemoglobin (Hb) electrophoresis or highperformance liquid chromatography (HPLC), which can distinguish between normal hemoglobin (HbA), hemoglobin S (HbS), and other abnormal hemoglobin variants [5]. Additionally, genetic testing through DNA analysis is important for precise detection, and can confirm specific genetic mutations responsible for SCD, such as the HbS gene [6]. Current treatment options for SCD aim to alleviate symptoms, manage complications, and improve the patient’s quality of life. The evidence-based recommendation by American Society of Hematology (ASH) for blood transfu- https://doi.org/10.62347/ZDET8809 Predictors of hospital readmissions in SCD sion is considering it on an individualized caseby-case bases, considering risk of surgery, complications with prior transfusions, and disease severity to optimize outcomes [7]. For patients with recurrent episodes of ACS, frequent pain, or other complications, ASH suggests, with low certainty, that physicians should consider Hematopoietic stem cell transplantation (HSCT) at an early age, rather than standard of care. Their cautionary recommendation is due to lack of randomized controlled clinical trials for HSCT [8]. In addition to blood transfusion, other management options of SCD involve a combination of pharmacological and non-pharmacological interventions. Key treatment approaches include pain management involving use of analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids; hydroxyurea to reduce the frequency and severity of pain crises; prophylactic antibiotics to prevent infections in SCD patients, and immunization to protect SCD patients from infection [9-11]. However, the efficacy of these treatments remains variable. More specifically, hydroxyurea has shown significant efficacy in managing SCD [12, 13]. Despite advancements in treatment some patients experience better outcomes such as relatively mild disease course, while others experience more frequent complications and hospitalizations, and readmission. In 2004, SCD accounted for 113,000 hospitalizations resulting in $488 million in annual hospitalization costs [14, 15]. Hospital readmissions within 30 days have been used as a metric of quality care by the Centers for Medicare & Medicaid Services (CMS) and are considered critical in reducing healthcare-associated costs for individuals with chronic conditions [16-19]. Since October 1, 2012, CMS began penalizing hospitals with excess readmissions [17, 19]. Notably, in 2016, 30-day readmissions resulted in 95,445 additional days of hospitalization, costing $152 million in total hospitalization costs, and $609 million in total hospitalization charges [19]. Findings from empirical studies reveal that readmission is the highest in SCD patients who live in socio-economically deprived areas, where access to care is limited to the population most in need [20-24]. Among other factors contributing to increased SCD readmissions, particularly among patients from lower socio190 economic status is the number of comorbidities. Specific medical conditions such as asthma, pneumonia, congestive heart failure (CHF) are at higher risk of readmission [19, 25]. There is also empirical evidence suggesting disparities in the prevalence, type, severity, and complications, and cost of care related to SCD based on race/ethnicity [26-28]. For instance, among Black newborns in the United States 1 in 365 is affected by SCD compared to approximately 1 in 16,300 in Hispanic newborns [26, 29]. Recent research con (...truncated)