Background: Sickle cell disease (SCD) is characterized by sickled red blood cells that can cause severely painful vaso-occlusive crises. These crises can cause damage to multiple organs and bring about additional chronic disease, such as avascular necrosis, leg ulcers, pulmonary hypertension, and renal failure. While there are options for disease modification, these are not effective if patients (pts) cannot attend regular doctor visits for their condition to be monitored and for medications to be adjusted. Obstacles to obtaining outpatient primary care include physical disability, environmental factors, transportation, and psychosocial factors. Impaired access to primary care leads to poor clinical outcomes in chronic diseases, such as SCD. This study was conducted to help pts with SCD who had the most barriers to obtaining outpatient primary care. Home based primary care has proven beneficial for pts with chronic illnesses in the past. Utilizing this method, a physician meets with pts in their homes to manage both acute and chronic illnesses. This eliminates many potential barriers for pts with difficulty attending office visits and would provide continuity of care. It also allows physicians to observe other potential factors that could undermine the treatment plans for these pts, and get the correct member of the team to intervene more efficiently. Methods: Outcomes were measured for patient quality of care and health service utilization, both one year prior to and one year after the home visits began. Data was collected from a chart review and included the number of primary care visits, day hospital referrals, and emergency department visits. SCD specific immunizations and the number of prescription refills were also noted. McNemar's test and Wilcoxon signed rank test were used to compare binary and continuous outcomes, respectively, during the years prior to and after home based primary care began. Results: There were 23 SCD pts enrolled in this study, with 13 pts (69% female, 31% male) having completed one full year of home visits. These pts ranged from 26 to 66 years old. Comorbidities include one patient with a history of a myocardial infarction (MI) and two with diabetes mellitus. Other medical history noted were: acute chest syndrome (62%), thrombosis (62%), avascular necrosis (46%), retinopathy (46%), depression (38%), kidney disease (31%), hypertension (31%), pulmonary hypertension (23%), stroke (23%), and iron overload (15%). Most pts had received transfusions (92%), and 77% had taken hydroxyurea. Pts received a median number of 11 home visits (range 7-15) during the 1-year program in which they received home based primary care. The median number of new long term prescriptions increased significantly (p = 0.04) from 1 to 3. Five pts not previously receiving PVC-13 vaccine started to receive it after the initiation of the home visit program (p = 0.06). The total number of immunizations (p = 0.09), months with prescription refills (p = 0.08) both increased slightly. There was no change in the number of new short term prescriptions, breast or colon cancer screening rates, nor influenza, PVC-23, or MenAWCY immunization rates. The median number of reported vaso-occlusive crises per patient decreased from 8 per year to 5 (p = 0.69), and the median number of emergency department visits per patient decreased from 6 visits per year to 3 visits per year (p = 0.80). Conclusion: Overall, home based primary care seems to be a promising alternative for pts with SCD. It had a significant impact on patient quality of care and may improve prescription adherence, but more data are needed to determine if it has an effect on healthcare utilization for pts with SCD. Disclosures Moore: Ohio State University College of Medicine: Research Funding. Desai:FDA: Research Funding; Pfizer: Research Funding; University of Pittsburgh: Research Funding; Selexy/Novartis: Research Funding; NIH: Research Funding; Ironwood: Other: Adjudication Committee.
Background: The median life expectancy of patients with sickle cell disease surpassed 40 years of age in the last two decades. While sickle cell patients overall are known to have high utilization of health services due to vaso-occlusive pain crises (VOC), few studies have focused on the impact of age on utilization pattern. Due to this, our understanding of the patient population is frequently skewed based on data on younger patients. This study examines the utilization of healthcare in patients in two groups: below 40 years of age, and 40 years and over. We also examined the impact on these two cohorts of a home-based primary care program. Methods: All patients were enrolled in a home-based primary care program in which their primary care doctor visited their home every 4-6 weeks. Health utilization data were collected retrospectively, through chart review for one year prior to joining the home-based primary care program, and prospectively for one year after joining the program. Primary care appointments, reported crises, Sickle Cell Day Hospital visits, ED visits, admissions, 30-day readmissions, and total admission days were recorded. Results: A total of 30 patients was enrolled in the study, and 58 years of data were collected. There were 16 patients between 18 and 39, and 14 patients aged 40 and over. 50% of the 40 and over age group was SS genotype and 50% SC compared to only one patient in the below 40 population had genotype SC. The groups were not significantly different regarding gender distribution (57% female in the 40 and over population vs 50% female in the below 40 population). The 40 and over population had on average more comorbidities per patient. The 40 and over population had significantly more primary care visits every year both before and after the start of the home visits compared to the below 40 population,. The 40 and over population, also had significantly lower overall rates of acute care utilization than the patients under 40: number of crises, ED visits, admissions, 30-day readmissions, and total hospital admission days. When comparing pre and post home visiting within the 40 and older population, there was an increase in primary care visits and a decrease in in reported crises, ED visits, admissions and readmissions. There was no change in these parameters in the 18-39 year old patient group. Discussion: As sickle cell patients age, they are more likely to have cumulative co-morbidities due to their sickle cell disease. Despite their more advanced age and their increase in co-morbid conditions, patients 40 and above were shown in our study to have fewer ED visits and admissions than younger patients, and to further reduce ED visits and admissions when provided with home-based primary care. The younger group had higher utilization at baseline, and did not show improvement when receiving home-based primary care. The reduced acute care utilization in the older group could be due to increased use of primary care, which was further enhanced by enrollment in the home-based primary care program; better adherence to medical treatment; more skill and experience in disease self-management; better social support; or fewer vaso-occlusive crises despite a higher number of co-morbid conditions. The higher prevalence of SC disease in the older cohort is a possible confounder. Those patients with higher utilization at a younger age may be higher risk of mortality, thereby leading to a survivor effect in the older population. Research in the general medical population has shown that home-based primary care reduces acute care utilization in high-utilizing patients with multiple chronic conditions, but more research is needed on the impact in sickle cell patients. Conclusion: This is the first study, to our knowledge, of the impact of home-based primary care on adults with sickle cell disease. In this study, sickle cell patients aged 40 and under showed overall more acute care utilization than those over age 40. The older population had an increase in primary care visits, and overall a significant decrease in healthcare utilization after enrollment in the home visiting program. We did not see a significant decrease in utilization in the younger population with home visits. Disclosures Desai: Global Blood Therapeutics: Membership on an entity's Board of Directors or advisory committees, Research Funding; Ironwood: Other: Adjudication Board; University of Pittsburgh: Research Funding; Novartis: Research Funding; Pfizer: Membership on an entity's Board of Directors or advisory committees, Research Funding; Potomac: Speakers Bureau.
Background Multi-system inflammatory syndrome in children (MIS-C) is a rare consequence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). MIS-C shares features with common infectious and inflammatory syndromes and differentiation early in the course is difficult. Identification of early features specific to MIS-C may lead to faster diagnosis and treatment. We aimed to determine clinical, laboratory, and cardiac features distinguishing MIS-C patients within the first 24 hours of admission to the hospital from those who present with similar features but ultimately diagnosed with an alternative etiology. Methods We performed retrospective chart reviews of children (0-20 years) who were admitted to Vanderbilt Children’s Hospital and evaluated under our institutional MIS-C algorithm between June 10, 2020-April 8, 2021. Subjects were identified by review of infectious disease (ID) consults during the study period as all children with possible MIS-C require an ID consult per our institutional algorithm. Clinical, lab, and cardiac characteristics were compared between children with and without MIS-C. The diagnosis of MIS-C was determined by the treating team and available consultants. P-values were calculated using two-sample t-tests allowing unequal variances for continuous and Pearson’s chi-squared test for categorical variables, alpha set at < 0.05. Results There were 128 children admitted with concern for MIS-C. Of these, 45 (35.2%) were diagnosed with MIS-C and 83 (64.8%) were not. Patients with MIS-C had significantly higher rates of SARS-CoV-2 exposure, hypotension, conjunctival injection, abdominal pain, and abnormal cardiac exam (Table 1). Laboratory evaluation showed that patients with MIS-C had lower platelet count, lymphocyte count and sodium level, with higher c-reactive protein, fibrinogen, B-type natriuretic peptide, and neutrophil percentage (Table 2). Patients with MIS-C also had lower ejection fraction and were more likely to have abnormal electrocardiogram. Conclusion We identified early features that differed between patients with MIS-C from those without. Development of a diagnostic prediction model based on these early distinguishing features is currently in progress. Disclosures Natasha B. Halasa, MD, MPH, Genentech (Other Financial or Material Support, I receive an honorarium for lectures - it’s a education grant, supported by genetech)Quidel (Grant/Research Support, Other Financial or Material Support, Donation of supplies/kits)Sanofi (Grant/Research Support, Other Financial or Material Support, HAI/NAI testing) Natasha B. Halasa, MD, MPH, Genentech (Individual(s) Involved: Self): I receive an honorarium for lectures - it’s a education grant, supported by genetech, Other Financial or Material Support, Other Financial or Material Support; Sanofi (Individual(s) Involved: Self): Grant/Research Support, Research Grant or Support James A. Connelly, MD, Horizon Therapeutics (Advisor or Review Panel member)X4 Pharmaceuticals (Advisor or Review Panel member)
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