Health Care Disparities in Sickle Cell Disease : A Population-Based Study of Los Angeles County.

As young adults with Sickle Cell Disease (SCD) age out of comprehensive pediatric coverage, they are left with suboptimal coverage for disease-appropriate comprehensive care, and rely on Emergency Departments (ED). This situation is implied to affect SCD outcome, as review of death certificates suggests that patients cared for outside comprehensive sickle cell centers (CSCC) die earlier on average than patients cared for within CSCCs. Los Angeles County (LAC) poses particular challenges, as even within the CSCC network patients die younger than the national average. There are no data describing LAC SCD patients outside of the tertiary care referral centers, nor are there population-based data describing the effect of access to health care on ED utilization in SCD. In order to eliminate these disparities in health care and health outcomes, the first step is to identify the population and where they receive care. This population-based study assesses the effect of where a patient lives, age, and insurance status on utilization of emergency departments (ED) and rates of inpatient admission.

We conducted a retrospective cohort study using the 2007 LAC data from the California Office of Statewide Healthcare Planning and Development, with all hospital discharges from non-federal emergency departments (ED) and inpatient units. We selected patients based on ICD9 codes indicating SCD (282.60-282.69) or SB-thalassemia (282.41-282.42) as a primary or secondary diagnosis. Unique identifiers longitudinally link multiple visits. One of the 8 service planning areas (SPA) defined by LAC Department of Public Health has very poor health outcomes and access to care as compared to the others. Using Poisson regression, we evaluated the effect of living in this resource-poor SPA on the number of SCD-related ED visits per year. We controlled for age (adult ≥21 years old vs. child), gender (male vs. female), race (African American vs. not), ethnicity (Hispanic vs. not), and socioeconomic status (using insurance as a proxy). Finally, we evaluated the effect of living in the resource-poor SPA on disposition from the ED (admit vs. discharge) using binary logistic regression.

In LAC in 2007, 1088 identified individual patients with SCD visited the ED, leading to 4420 total ED visits. There were 298 children and 790 adults (>21yo). The mean number of visits per patient was 4.06 (SD = 10.84; range 1 to 180). The mean number of annual SCD-related ED visits per hospital was 35.93 (SD = 75.30; range 1 to 414). Children accounted for 18% of the visits and adults 82%. SCD adults had 2 times the rate of ED visits as compared to children. Patients living in the poor-resource SPA had 7% more ED visits than those living in the SPAs with better healthcare resources. Publicly insured SCD patients had a 33% higher rate of ED visits than privately insured patients and a 77% higher rate of visits than self-pay patients. Being male and African American were also significantly associated with an increased rate of ED visits. ED visits by patients from the resource-poor SPA were 13% less likely to result in an inpatient admission than were the ED visits by patients living in the other SPAs. Being female, African American, Hispanic, and having public insurance were also significantly associated with increased likelihood of the ED visit resulting in inpatient admission.

Our data suggest that among SCD patients in LAC, adults ≥ 21 years of age, those living in a resource-poor area of LAC, and the publicly insured all have higher ED utilization rates. ED visits by patients from the resource-poor area of LAC are less likely to result in inpatient admissions whereas visits from publicly insured patients were more likely to result in an inpatient admission. The dramatically higher rate of ED visits by those 21 and over is consistent with the notion that adults with SCD have poor access to appropriate comprehensive care leading them to seek care in the ED. The results also support the premise that poor access to health care and public insurance are associated with suboptimal comprehensive care in SCD, leading to a higher rate of ED use. Considering LAC's population size and diversity, this population-based study substantiates findings from the tertiary care center cohorts. These findings beg further investigation into the outpatient utilization practices of patients with SCD as a means of developing measures of access to care in SCD.

No relevant conflicts of interest to declare.