Emergency Department Quality of Care for Sickle Cell Disease in Ontario, Canada: A Population-Based Matched Cohort Study

Abstract

BackgroundAcute vaso-occlusive crisis (VOC) in sickle cell disease (SCD) often leads patients to seek emergency department (ED) care. The landscape of SCD ED care within Canada’s universal and publicly funded healthcare system remains largely undefined. Here, we sought to address this knowledge gap by characterizing the quality of SCD VOC ED and inpatient care in Ontario, Canada.MethodsWe used population-level health administrative data to identify patients with SCD in Ontario who presented to the ED with SCD VOC (ICD-10-CA code D57.0) from 2006 to 2018. We evaluated ED and inpatient metrics for this population and compared these with a general ED patient population and a validated Crohn’s disease cohort matched by age, sex, neighbourhood income quintile, geography, date range of visit, and ED triage score.ResultsWe identified 2,123 patients who presented to the ED with SCD VOC for a total of 18,712 unscheduled ED visits. Annual ED visit rates ranged from a mean of 2.6 to 14.2 visits per patient, with 4.6% of patients having incurred 38.4% of all SCD VOC ED visits. Subgroup analyses showed that adult patients with SCD VOC visited the ED 2.5 times more than pediatric patients, but their wait times for initial physician assessment were significantly longer (90.6 vs. 51.1 minutes, p < 0.0001) with a difference that was disproportionately larger than the reference cohorts. Males with SCD VOC experienced significantly shorter ED and inpatient stays compared to females (e.g. admission length of stay: 4.4 vs. 5.8 days, p < 0.0001), but their ED return rates within 30-days were significantly higher (0.89 vs. 0.35 times, p < 0.0001) with a difference that was disproportionately larger relative to the reference cohorts. Lower-income neighbourhoods correlated with lower acuity triage scores for SCD VOC visits and increased repeat ED visit rates at more pronounced levels than the reference cohorts. Higher acuity triage scores for adults with SCD VOC correlated with improved metrics for quality of ED and inpatient care with fewer longer-term ED visits.InterpretationPatients with SCD VOC carry a significant burden of acute care needs, with a smaller patient subset whose high ED visit rates have distinctly increased over time in Ontario, Canada. Adults, males and those from lower income quintile neighbourhoods with SCD VOC experienced poorer quality of ED and inpatient care compared to their counterparts, with differences that are disproportionately larger than those found in the general ED population and in patients with Crohn’s disease. Higher acuity triage scoring may improve and standardize the quality of ED care for adult patients with SCD VOC. Future work should address these identified care quality disparities for SCD VOC that remain present within a universal and publicly funded healthcare system.

Empowering patients with sickle cell anemia and their families through innovative educational methods

“…Access to timely and quality emergency care and differences between pediatric and adult populations is becoming recognized as a concern in other provinces as well. In Ontario, one study found that adults are waiting much longer than their pediatric counterparts, despite visiting the ED 2.5 times more frequently (12). This highlights the importance of collaboration for SCA emergency management.…”

Empowering patients with sickle cell anemia and their families through innovative educational methods

“…Access to timely and quality emergency care and differences between pediatric and adult populations are becoming recognized as a concern in other provinces as well. In Ontario, one study found that adults are waiting much longer than their pediatric counterparts, despite visiting the ED 2.5 times more frequently [15]. This highlights the importance of collaboration for SCA emergency management.…”

Costs for Long-Term Health Care After a Police Shooting in Ontario, Canada

“…Prevailing laws during the study mandated medical reporting of all patients with a gun injury . Emergency care was universally available, publicly funded by the Ontario Health Insurance Plan (OHIP), and tracked through encrypted linked records after a lag for data security and collection . Patient-level linked health services data were available to qualified researchers through population-based electronic medical records at the Institute for Clinical Evaluative Sciences (ICES) …”