Differences Between Hematologist and Hospitalist Caring for Patients with Sickle Cell Disease Hospitalized for Vaso-Occlusive Crisis,

Sickle cell disease (SCD) is a chronic disease characterized by multiple vaso-occlusive complications. Often patients present with episodic pain which can be severe, disabling, and often require opioid treatment. Furthermore, vaso-occlusive crisis (VOC) is the most common cause for hospitalization for patients with SCD. The care for hospitalized patients with SCD has been increasingly managed by hospitalists rather than adult hematology specialists. Our institution recently transitioned the care of inpatients with SCD from the hematology service to the hospitalist group. Initial recommendations to the hospitalist service were given either by informal opinion or formal consultation when requested. Hospitalists provide efficient inpatient management, however, many possess knowledge gaps and carry biases into their relationship with patients with SCD. Therefore, we sought to perform a formal comparison of care practices between hematologist and hospitalist to better understand differences and enhance potential insights for improvement of care of patients with SCD.

We performed a single-institution, retrospective review of patients with SCD hospitalized for vaso-occlusive crisis (VOC) between February 1, 2008 and January 31, 2011.

We found a total of 298 patients with SCD admitted for VOC with a mean age of 32 (range 19 – 58). There were 120 patients cared for by hematologists over ten months and 178 patients cared for by hospitalists over ten months. Patients cared for by a hematologist had a higher total number of hours on a patient controlled analgesia (PCA) device (212 vs. 171 hours, p=0.11). In examining specific ordering practices for PCA, hematologists were significantly less likely to utilize demand only PCA than hospitalists (23% vs. 42%, p=0.002) and had a significantly higher rate of using both continuous and demand PCA (67% vs. 54%, p=0.04). Although non-significant, hematologists also were more likely to use oral opioid medications alone on admission (13% vs 10%) and begin home oral medications prior to discontinuation of PCA (65% vs. 54%, p=0.08). Hematologists and hospitalists equally utilized intravenous fluids on admission and continued patients on their outpatient hydroxyurea dose. There were no significant differences in ordering: incentive spirometry; a bowel regimen; an anti-itching medication; and DVT prophylaxis. Transfusions were utilized similarly by hematologists for 37% of patients for a mean pre-transfusion hemoglobin of 5.7 g/dL and by hospitalists for 31% of patients for a mean pre-transfusion hemoglobin of 5.9 g/dL. Interestingly, patients cared for by hematologists developed acute chest syndrome (ACS) less often (0%) as compared to patients cared for by hospitalists (5.6%, p= 0.02). A formal hematology consultation was requested by hospitalists for 31% of patients and included all patients who developed ACS. Finally, patients cared for by hematologists had a significantly longer hospitalization (10 days) compared to hospitalists (8.4 days, p=0.04) with a non-significant decrease in 7 day readmission rates (6.7% vs.7.2%) and 30 day readmission rates (35% vs. 40%).

We discovered significant differences between hematologists and hospitalists in the care of patients with SCD who were admitted for VOC. On admission, hematologists utilized both continuous and demand PCA more often when compared to hospitalists who utilized both home oral pain medications and demand only PCA. The use of home oral opioid medications with demand only PCA may account for shorter hospitalizations, however it may also lead to a slightly higher 7 day and 30 day readmission rate. Importantly, a formal hematology consult was requested for only 31% of patients. In addition, 5.6% of patients cared for by hospitalists developed ACS which is associated with an increased morbidity and mortality. This study advocates improved collaboration between hematologists and hospitalists to improve the care of patients hospitalized with VOC.

No relevant conflicts of interest to declare.