Weekly Article: International ED Utilization and Sickle Cell

by J. Cohen
Glassman JA, et al. Risk factors of increased ED utilization in a multinational cohort of children with sickle cell disease. Acad Emer Med. 2012.
This study seeks to identify modifiable risk factors for increased ED utilization in children with SCD. This is particularly relevant to our ED, as we have high rates of sickle cell disease in our population and high rates of ED utilization. In summary..... 


The data was analyzed, post-hoc, from a database collected as part of a multinational (US, Canada, UK and France) prospective clinical trial, The Silent Cerebral Infarct Transfusion Trial. The authors hypothesize that low income and comorbid asthma are associated with increased ED use. The incidence of ED visits for pain was determined by 3 years of chart review of each. Demographic, clinical and laboratory data were prospectively collected at the time of enrollment. The primary outcome for this study was the number of ED visits for painful episodes. A secondary outcome for this analysis was the number of ED visits for acute chest syndrome. Participants self-reported their yearly household income. 


The sample included 985 children with 2,201 visits for pain and 193 visits for acute chest syndrome. Among U.S. children, more than half (53.7%) of children in the cohort lived below the poverty line, 71% were insured by Medicaid, 33% had private insurance, and 1% were uninsured. Asthma was associated with a 28% increase in the frequency of ED visits for pain. Each $10,000 increase in income was associated with a 5% reduction in ED. Income below the federal poverty line was associated with a 31% increase in ED visits for. 


The two variables associated with increased risk of ED utilization for acute chest syndrome were asthma and environmental tobacco smoke exposure. Exposure to tobacco smoke in the home was associated with a 73% increase in the rate of ED utilization for acute chest and a physician diagnosis of asthma was associated with a 60% increase in ED visits for ACS. 


The authors suggest future targeted interventions including aggressive asthma, more frequent follow-up visits for children with asthma, and targeted support for children who live in poverty.