Transcranial Doppler Screening Adherence among Children with Sickle Cell Anemia Seen in the Emergency Department

Weisman, Julie K.; Diamond, Carrie; Kappa, Sarah; Nickel, Robert Sheppard

doi:10.1016/j.jpeds.2019.10.049

Cited by 9 publications

(14 citation statements)

References 23 publications

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“…A notable strength of this study was that it gathered perspectives from a nationally representative sample of patients/caregivers and providers, which allowed a comprehensive analysis of factors across ecological levels. Findings support previous work examining barriers to TCD screening in SCA [ 15 , 16 , 18 – 26 ]; however, this study highlights several new and important points, including the complexity in barriers and facilitators interacting with one another at multiple ecological levels, the importance of care coordination, and the discrepancy in perceptions of barriers and facilitators between patients/families versus providers.…”

Section: Discussionsupporting

confidence: 85%

“…Despite these advances in care, the implementation of TCD screening remains suboptimal. A follow-up study to the STOP trials (Post STOP) demonstrated wide variation in TCD screening rates, even among sites that participated in the original stroke prevention trials; similar results have been found in smaller-scale studies [ 15 – 18 ]. Reasons for variation are likely multifactorial, occurring at the intersection of multiple ecological levels, including the patient (e.g., child age; caregiver knowledge, education, and self-efficacy; extent of involvement with the health care system), provider (e.g., provider knowledge, self-efficacy, and expectations), and organizational/systems (e.g., access to TCD, insurance status) levels [ 15 , 16 , 18 – 26 ].…”

Section: Introductionmentioning

confidence: 55%

“…Specifically, prior studies supported the importance of patient/family adherence to scheduled appointments and the role of the provider in disseminating knowledge and improving ordering practices. Previous studies also noted organizational factors, such as co-locating TCD screening near the hematology clinic, as methods for improving TCD screening rates [ 15 , 16 , 18 – 26 ]. The current study used a more comprehensive approach to assess how factors influence and compound one another resulting in the novel findings described.…”

Section: Discussionmentioning

confidence: 99%

“…Although the NHLBI guidelines were published in 2014, it has been 20 years since the original STOP trial and implementation remains mediocre. Further, TCD screening rates remain far below the level needed to attain a “stroke-free generation” [ 15 – 18 , 39 ]. Our next step for the DISPLACE project will be implementing interventions based on these findings to improve real-world TCD screening rates for children with SCA.…”

Section: Discussionmentioning

confidence: 99%

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Identified barriers and facilitators to stroke risk screening in children with sickle cell anemia: results from the DISPLACE consortium

Phillips

Schlenz

Mueller

et al. 2021

Implement Sci Commun

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Background Children with sickle cell anemia are at risk for stroke. Ischemic stroke risk can be identified among children ages 2–16 years with sickle cell anemia using transcranial Doppler ultrasound. Despite strong recommendations for transcranial Doppler screening in guidelines released by the National Heart, Lung, and Blood Institute, implementation of transcranial Doppler screening in sickle cell anemia remains suboptimal. The purpose of this study was to identify barriers and facilitators to transcranial Doppler screening in a large national consortium to inform subsequent implementation interventions. Methods A qualitative descriptive approach was used to conduct 52 semi-structured interviews with a sample of patients with sickle cell anemia, their parents or primary caregivers, and healthcare providers dispersed across the United States. Interviews took place from September 2018 through March 2019. Directed content analysis was conducted with an adapted version of the Multilevel Ecological Model of Health as an initial coding framework, completed July 2019. Frequency analysis was conducted to determine predominant barrier and facilitator themes. Results Fourteen barrier themes and 12 facilitator themes emerged representing all levels of the ecological framework. Two barrier themes (Logistical Difficulties and Competing Life Demands and Gaps in Scheduling and Coordination), and 5 facilitator themes (Coordination, Scheduling and Reminders; Education and Information; Provider and Staff Investment and Assistance; Positive Patient Experience; and Convenient Location) were predominant. Conclusions Barriers and facilitators to transcranial Doppler screening in children with sickle cell anemia are complex and occur across multiple ecological levels. One barrier theme and 3 facilitator themes were found to be optimal to address in subsequent implementation interventions.

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Section: Discussionsupporting

confidence: 85%

Section: Introductionmentioning

confidence: 55%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Identified barriers and facilitators to stroke risk screening in children with sickle cell anemia: results from the DISPLACE consortium

Phillips

Schlenz

Mueller

et al. 2021

Implement Sci Commun

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“…Based on our findings, providers at our institution are encouraged to obtain a posttransfusion antibody screen on all transfused patients, but given the low yield of this screening, we no longer devote program resources to ensure this is accomplished considering other important efforts like improving stroke screening rates and uptake of disease-modifying therapies. 34,35 The low yield of our screening in identifying new RBC alloantibodies is due, at least in part, to our institution's prophylactic minor RBC antigen matching policy for patients with SCD. The American Society of Hematology 2020 guidelines for SCD recommend prophylactic antigen matching for Rh (C, E or C/c, E/e) and K antigens over only ABO/RhD matching to decrease the incidence of alloimmunization.…”

Section: Discussionmentioning

confidence: 99%

Screening for new red blood cell alloantibodies after transfusion in patients with sickle cell disease

et al. 2021

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Background Patients with sickle cell disease (SCD) are frequent recipients of red blood cell (RBC) transfusions and are at risk for RBC alloimmunization. RBC alloimmunization is diagnosed by identifying RBC alloantibodies as part of pre‐transfusion testing, but this testing fails to detect alloantibodies that have evanesced. It may be beneficial to screen for new RBC alloantibody development after transfusion before possible antibody evanescence. Study Design and Methods Our institution started a new initiative for episodically transfused patients with SCD to obtain at least one antibody screen 2–6 months after transfusion as part of their clinical care. A database was created to prospectively track all transfused patients for 1 year and their post‐transfusion antibody screen results. Patients received prophylactically CEK‐matched RBC units. Results During the study year, 138 patients with SCD received a total of 242 RBC transfusions. Patients with a history of an RBC alloantibody (n = 13, 9.4%) had previously received more RBC units than non alloimmunized patients (median 11 vs. 2 RBC units, p = .0002). A total of 337 post‐transfusion antibody screens were obtained in 127 patients (92.0%) with 110 patients (79.7%) having at least one antibody screen 2–6 months post‐transfusion. With this prospective testing, two new RBC alloantibodies (anti‐C and ‐M) were identified in two patients. Conclusion It is feasible to test for new RBC alloantibody development in most episodically transfused patients with SCD as part of their routine care. The yield of this screening appears low with CEK matching, but it could still provide important information for individual patients.

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Trends in quality of care among children with sickle cell anemia

Reeves

Freed

Madden

et al. 2021

Pediatric Blood & Cancer

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Introduction:For decades, it has been recommended that children with sickle cell anemia (SCA) receive antibiotic prophylaxis to prevent serious infections and undergo transcranial Doppler (TCD) screening to identify those at highest risk of overt stroke.We assessed recent temporal trends in antibiotic prophylaxis prescription fills and TCD screening among children with SCA using validated quality measures.Procedure: Using validated claims-based definitions, we identified children with SCA who were enrolled in Michigan or New York State (NYS) Medicaid programs (2011)(2012)(2013)(2014)(2015)(2016)(2017)(2018). Among recommended age groups, two outcomes were assessed yearly: (a) filling of ≥300 days of antibiotics, and (b) receipt of greater than or equal to one TCD. The proportion of children with each outcome was calculated by state. Temporal trends in each preventive service were assessed using generalized linear models.Results: A total of 1784 children were eligible for antibiotic prophylaxis (Michigan: 384; NYS: 1400), contributing 3322 person-years. Annual rates of filling ≥300 days of antibiotics ranged from 16% to 22% and were similar by state. There was no change in rates of antibiotic filling over time in Michigan (p-value: .10), but there was a decrease in NYS (p-value: .02). A total of 3439 children with SCA were eligible for TCD screening (Michigan: 710; NYS: 2729), contributing 10,012 person-years. Annual rates of TCD screening ranged from 39% to 45%, were similar by state, and did not change over time (p-values >.05). Conclusions: Most children with SCA do not receive recommended antibiotic prophylaxis and/or TCD screening. New, sustainable, and coordinated interventions across preventive services are urgently needed.

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Transcranial Doppler Screening Adherence among Children with Sickle Cell Anemia Seen in the Emergency Department

Cited by 9 publications

References 23 publications

Identified barriers and facilitators to stroke risk screening in children with sickle cell anemia: results from the DISPLACE consortium

Identified barriers and facilitators to stroke risk screening in children with sickle cell anemia: results from the DISPLACE consortium

Screening for new red blood cell alloantibodies after transfusion in patients with sickle cell disease

Trends in quality of care among children with sickle cell anemia

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