Sickle Cell Care Differs in Style, Not Substance

Historically, hematologists have cared primarily for patients with sickle cell disease, whether as inpatients or outpatients here at Duke University Medical Center. This patient population obviously had grown accustomed to the hematologists’ management styles. However, when the hospitalist service took over their care in November 2009, it took a long time, at least 6-9 months, for the transition process to occur.

Even now, many of my colleagues and I would argue that we still do not have full ownership of many of the care aspects of this patient population. Because of that, I would be very reluctant to apply the findings of this study as a judgment of a hospitalist model vs. a hematologist model of care for sickle cell patients on a wider scale.

In fact, many of the aspects of the care process for sickle cell patients are still largely driven by the hematologists here at Duke. We take the recommendations of our sickle cell providers that they have outlined in their clinic notes as the starting point for pain management upon admission. We have approached the hematology attendings about instituting our own protocol that we have designed for uncomplicated pain crises, but have not arrived at an agreement with them to institute our protocol on a global basis. In general, we do not get hematologists involved in uncomplicated pain crises anymore. We call them when we have complicated cases, including patients with acute chest syndrome, hyperhemolysis, hepatic sequestration, severe pulmonary hypertension, and severe anemia in the setting of multiple alloantibodies, which makes transfusion difficult.

I think this is the model that works best for the physicians and the patients and allows our hematology colleagues to truly operate as specialists, which is what they have indicated to us that they want to do.

In Dr. Shah’s study, he points to some differences in average length of stay (LOS), using November 2009 as a break point. However, as I have alluded to above, this exact break point does not allow for an adequate change in ownership to be properly instituted and measured. If you allow a washout period, I would expect the LOS difference to be magnified even more. When you look at data points now for readmission and for LOS, there is even bigger divergence for LOS in sickle cell patients. We actually have more recent data for hospitalists that suggest an LOS of 5.8 days and a readmission rate of 30% in the last 3 months, which is identical to the readmission rates for hematologists and shows a reduction now in LOS by about 4 days, which is very large.

Philosophical Differences. In any group of physicians, there are going to be differences in practices. The bigger the group, the more differences there are to manage. Our group of hospitalists includes about 25 members. There are only about five hematologists. So if you want consistency in management, certainly the smaller the group of providers you have, the easier it is to maintain a consistent process of management. When you are trying to manage 25 providers, everyone’s going to have a little bit of variation. This could account for some of the different management styles regarding time spent on patient-controlled analgesia and instances of these patients getting demand-only PCA.

My main criticism of the study was that lead researcher Dr. Nirmish Shah did not comment on any hard outcome differences: He reported a trend for readmissions that favored hematologists, but once again, it was just a trend, and it was not statistically significant. He reported a difference for pain-medication management and duration of time on PCA.

However, no one has ever proven that one pain-regimen profile – intermittent alone or continuous plus intermittent – is better for the patient. So in this area there is a difference in style, but not necessarily a difference in hard outcomes, as far as readmission, mortality, pain scores, or adverse drug events are concerned. These hard outcomes would be more interesting to providers who care for sickle cell patients than are the differences in philosophies toward pain management.

The most interesting thing I see in Dr. Shah’s study surrounds his findings for acute chest syndrome. It’s hard for me to imagine that in 13 months of hematologists’ care, there were zero cases of acute chest, but in the same period of hospitalists’ care, there were 5.6% of patients with acute chest.

Acute chest is obviously one of the most severe manifestations that you see with patients who have sickle cell disease. And, obviously, if there were that many more patients with acute chest, we would expect to see that hospitalists’ data would have longer length of stays, higher morbidity, and higher mortality.