Median Time to Pain Medication for Patients with a Diagnosis of Sickle Cell Disease (SCD) with Vaso-Occlusive Episode (VOE)

Median time (in minutes) from Emergency Department (ED) arrival to initial administration of pain medication for all patients, regardless of age, with a principal encounter diagnosis of SCD with VOE

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Sickle Cell Disease (SCD) is the most common inherited blood disorder and is estimated to affect approximately 100,000 individuals in the United States.[1] SCD is also most prominent among Black or African American patients—affecting 1 out of 365 Black or African American births—and the average life expectancy of publicly insured individuals with SCD is reported to be approximately 52.6 years of age.[2] Based on a 2022 systematic review, total annual costs (medical and non-medical) were estimated to range from $14,012 to $80,842 per patient per year.[3] 

Evidence suggests that up to 80% of patients with SCD avoid the healthcare system whenever possible and live with chronic pain that is undermanaged.[4] When they do seek emergency care due to an acute severe pain crisis, single-site studies have shown patients wait an average of 90 minutes before analgesics are given,[5,6] and a multi-site study across seven Emergency Departments (EDs) found that half of all pediatric visits had a time to first opioid over one hour.[7]  Updated data from the National Ambulatory Medical Care Survey (NHAMCS) show that from 1999 to 2020, of the 222,612 estimated yearly average number of ED visits by patients with a diagnosis of SCD, three-fourths were due to a complaint of pain.[8] Compared with prior estimates (1997-2007), the overall volume of ED visits has increased by nearly 13%.[8] Individuals with SCD face health inequities stemming from socioeconomic factors, including disease stigma, racial prejudice, and lack of access to specialized care.[9-12] These inequities were demonstrated in a study of adult patients with acute pain from SCD and renal colic in an ED. This study showed that despite higher arrival pain scores and triage acuity levels in patients with SCD, SCD patients experienced longer time to initial analgesia when compared with renal colic patients.[13] 

The implementation of this eCQM targeting timing to administration of pain medication for adult and pediatric patients with SCD presenting to the ED may significantly improve pain management and other outcomes, including admission rates,[14] hospital length of stay,[14-16] length of ED stay,[6,16,17] and patient satisfaction.[18]

This measure is supported by two evidence-based clinical practice guidelines. The clinical recommendation statements from the supporting guidelines are noted below and specifically state the rapid initiation of analgesic medications for patients presenting to the Emergency Department with acute pain associated with a diagnosis of SCD with VOE, which demonstrates a direct relationship to this measure: 

1)	The American Society of Hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain. [19]

Statement: Recommendation 1A. For adults and children with SCD presenting to an acute care setting with acute pain related to SCD, the ASH guideline panel recommends rapid (within 1 hour of emergency department [ED] arrival) assessment and administration of analgesia with frequent reassessments (every 30-60 minutes) to optimize pain control (strong recommendation based on low certainty in the evidence about effects).

2)	The 2014 National Heart, Lung and Blood Institute (NHLBI); Evidence-Based Management of Sickle Cell Disease Expert Panel Report.[20] 

Statement: In adults and children with SCD and a vaso-occlusive crisis (VOC):
  
  a)	Rapidly initiate treatment with parenteral opioids associated with severe pain (Strong Recommendation, High-Quality Evidence) 

OR

  b)	Rapidly initiate analgesic therapy within 30 minutes of triage or within 60 minutes of registration. (Consensus–Panel Expertise – Expert Opinion)

Better quality = Lower score

Reference Type: CITATION

Reference Text: '1.	National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention. Data & statistics on sickle cell disease. Atlanta, GA: US Department of Health and Human Services; 2023. https://www.cdc.gov/ncbddd/sicklecell/data.html#print. Accessed March 13, 2024.'

Reference Type: CITATION

Reference Text: '2.	Jiao B, Johnson KM, Ramsey SD, Bender MA, Devine B, Basu A. Long-term survival with sickle cell disease: a nationwide cohort study of Medicare and Medicaid beneficiaries. Blood Adv. 2023;7(13):3276-3283. doi: 10.1182/bloodadvances.2022009202.'

Reference Type: CITATION

Reference Text: '3.	Baldwin Z, Jiao B, Basu A, et al. Medical and non-medical costs of sickle cell disease and treatments from a US perspective: A systematic review and landscape analysis. Pharmacoecon Open. 2022;6(4):469-481. doi: 10.1007/s41669-022-00330-w.'

Reference Type: CITATION

Reference Text: '4. Ely B, Dampier C, Gilday M, O'Neal P, Brodecki D. Caregiver report of pain in infants and toddlers with sickle cell disease: reliability and validity of a daily diary. J Pain. 2002;3(1):50-57. doi: 10.1054/jpai.2002.xb30064.'

Reference Type: CITATION

Reference Text: '5.	Tanabe P, Myers R, Zosel A, et al. Emergency department management of acute pain episodes in sickle cell disease. Acad Emerg Med. 2007;14(5):419-425. doi: 10.1197/j.aem.2006.11.033.'

Reference Type: CITATION

Reference Text: '6.	Lin SM, Strouse JJ, Whiteman LN, Anders J, Stewart RW. Improving quality of care for sickle cell patients in the pediatric emergency department. Pediatr Emerg Care. 2016;32(1):14-16. doi: 10.1097/PEC.0000000000000369.'

Reference Type: CITATION

Reference Text: '7.	Brousseau DC, Alpern ER, Chamberlain JM, et al. A multiyear cross-sectional study of guideline adherence for the timeliness of opioid administration in children with sickle cell pain crisis. Ann Emerg Med. 2020;76(3S):S6-S11. doi: 10.1016/j.annemergmed.2020.08.006.'

Reference Type: CITATION

Reference Text: '8.	Attell BK, Barrett PM, Pace BS, et al. Characteristics of emergency department visits made by individuals with sickle cell disease in the U.S., 1999-2020. AJPM Focus. 2024;3(1):100158. doi: 10.1016/j.focus.2023.100158.'

Reference Type: CITATION

Reference Text: '9.	Haywood C, Jr., Diener-West M, Strouse J, et al. Perceived discrimination in health care is associated with a greater burden of pain in sickle cell disease. J Pain Symptom Manage. 2014;48(5):934-943. doi: 10.1016/j.jpainsymman.2014.02.002.'

Reference Type: CITATION

Reference Text: '10.	Pokhrel A, Olayemi A, Ogbonda S, Nair K, Wang JC. Racial and ethnic differences in sickle cell disease within the United States: From demographics to outcomes. Eur J Haematol. 2023;110(5):554-563. doi: 10.1111/ejh.13936.'

Reference Type: CITATION

Reference Text: '11.	Telfair J, Haque A, Etienne M, Tang S, Strasser S. Rural/urban differences in access to and utilization of services among people in Alabama with sickle cell disease. Public Health Rep. 2003;118(1):27-36. doi: 10.1093/phr/118.1.27.'

Reference Type: CITATION

Reference Text: '12.	Wahab S, Kelly K, Klingler M, et al. Impact of race, socioeconomic status, and geography on healthcare outcomes for children with sickle cell disease in the United States: A scoping review. Cureus. 2024;16(3):e56089. doi: 10.7759/cureus.56089.'

Reference Type: CITATION

Reference Text: '13.	Lazio MP, Costello HH, Courtney DM, et al. A comparison of analgesic management for emergency department patients with sickle cell disease and renal colic. Clin J Pain. 2010;26(3):199-205. doi: 10.1097/AJP.0b013e3181bed10c.'

Reference Type: CITATION

Reference Text: '14.	Wachnik AA, Welch-Coltrane JL, Adams MCB, et al. A standardized emergency department order set decreases admission rates and in-patient length of stay for adults patients with sickle cell disease. Pain Med. 2022;23(12):2050-2060. doi: 10.1093/pm/pnac096.'

Reference Type: CITATION

Reference Text: '15.	Brandow AM, Nimmer M, Simmons T, et al. Impact of emergency department care on outcomes of acute pain events in children with sickle cell disease. Am J Hematol. 2016;91(12):1175-1180. doi: 10.1002/ajh.24534.'

Reference Type: CITATION

Reference Text: '16.	King H, Albright A, Murry M. Delayed management of sickle cell disease vaso-occlusive episodes and the impact on prolonged hospitalizations at a single academic center. Blood. 2023;142(Supplement 1):7201. doi: 10.1182/blood-2023-190385.'

Reference Type: CITATION

Reference Text: '17.	Mathias MD, McCavit TL. Timing of opioid administration as a quality indicator for pain crises in sickle cell disease. Pediatrics. 2015;135(3):475-482. doi: 10.1542/peds.2014-2874.'

Reference Type: CITATION

Reference Text: '18.	Kim S, Brathwaite R, Kim O. Evidence-based practice standard care for acute pain management in adults with sickle cell disease in an urgent care center. Qual Manag Health Care. 2017;26(2):108-115. doi: 10.1097/QMH.0000000000000135.'

Reference Type: CITATION

Reference Text: '19. Brandow AM, Carroll CP, Creary S, et al. American Society of Hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain. Blood Adv. 2020;4(12):2656-2701. doi: 10.1182/bloodadvances.2020001851'

Reference Type: CITATION

Reference Text: '20. National Institutes of Health, National Heart, Lung, and Blood Institute. Evidence-Based Management of Sickle Cell Disease Expert Panel Report. Bethesda, MD: US Department of Health and Human Services; 2014.'

A qualifying encounter is defined as:
 
-  An ED visit for a patient, regardless of age, for which the arrival time occurred during the two-year measurement period, and 
 - The ED visit requires a principal diagnosis of SCD with VOE, and 
 - The ED visit requires at least one qualifying pain medication administered during the ED encounter.

The measure uses a two-year measurement period from January 1, XXXX through December 31, XXXX.

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Emergency Department (ED) encounters for all patients, regardless of age, who have a principal encounter diagnosis of SCD with VOE who have at least one qualifying pain medication administered during the ED encounter.

Equals Initial Population

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Median time (in minutes) from ED arrival to initial administration of pain medication.

For every patient evaluated by this measure, also identify payer, race, ethnicity and sex.

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