Return Visit Rates after an Emergency Department Treat-and-Release Visit for Children with Sickle Cell Pain Episodes

Background: Children with sickle cell disease (SCD) have high emergency department (ED) visit, hospitalization and rehospitalization rates. With the release of national guidelines, increased emphasis has been placed on ensuring guideline adherent care for the timeliness of ED treatment to decrease pain and reduce hospitalizations. If decreased hospitalizations result, it will be important to ensure that those ED treat-and-release visits do not result in higher ED return visits, yet there are no multicenter studies on ED return visit rates for children with SCD after a pain episode.

Hypothesis: Our aim was to determine the 14-day return visit rate following an ED treat-and-release visit for children with SCD across multiple children's hospitals. We hypothesized these children would have high return visit rates and that older children would have higher ED return visit rates that younger children.

Methods: This is a multicenter retrospective cohort study of ED visits by children with SCD using data from the Pediatric Emergency Care Applied Research Network (PECARN) Registry. The PECARN Registry contains electronic health record data for all ED visits at seven sites: Lurie Children's, Children's Hospital of Philadelphia, Cincinnati Children's, Children's National Medical Center, Children's Colorado, Children's Wisconsin, and Nationwide Children's. ED visits for children less than 19 years old presenting with an uncomplicated sickle cell pain episode between January 2017 and December 2021 were included. An uncomplicated pain episode was defined using previously published criteria including: 1) receipt of at least one parenteral opioid in the ED AND 2) at least one of the following: a primary billing diagnosis for SCD (ICD-10 = D57.* except sickle cell trait), a chief complaint of sickle cell pain crisis, or a chief complaint of sickle cell fever. Visits were excluded if the child had a secondary diagnosis of acute chest syndrome or priapism or a fever in the ED higher than 38.5 ⁰C. Index visits were defined as visits for an uncomplicated pain episode, discharged home, with no prior visit within 14 days. The primary outcome was the overall return visit rate within 14 days; secondary outcomes were the overall return visit rates at 3 and 7 days. We also evaluated the return visit rate for the subset of return visits classified as uncomplicated pain episodes. We estimated return visit rates by age, sex, and site. We reported the exact 95% confidence intervals for each return visit rate. We considered estimates not contained in comparison 95% confidence intervals as statistically significant differences. All analyses were conducted at the ED visit level using SAS software version 9.4.

Results: A total of 7,216 visits for SCD uncomplicated pain episodes occurred during the study period; 2,319 (32%) of those visits were ED treat-and-release visits with no prior visit within 14 days and were included as index visits. Approximately 57% of the study population was less than 12 years old, and approximately half were female. Non-Hispanic Black patients accounted for over 95% of the study population. The number of eligible index visits varied by site from 78 visits to 831 over the five-year study. The overall 14-day return visit rate was 29.5% (range 22.9% to 31.4%); the 7-day return visit rate was 22.8% (range 15.4% - 25.3%); the 3-day return visit rate was 16.3% (range 10.9% to 18.3%). Approximately 64% of the return visits at all three time points were uncomplicated pain episodes. Analyzing the disposition of the 29.5% of 14-day return visits, 13.0% of the index visits were followed by an ED treat-and-release visit while 18.8% were followed by a hospitalization (some children had both an ED treat-and release visit and a hospitalization). 14-day return visit rates varied between sites (highest: 31.4% [24.7% - 38.6%], lowest: 22.9% [16.9% - 29.8%]) Patients less than 12 years old had lower 14-day return visit rates than older patients (27.6% [25.2% - 30.2%] vs 31.5% [28.7% - 34.3%]). 14-day return visit rate did not differ by sex.

Conclusions: Almost 30% of ED treat-and-release visits for SCD pain episodes had a return visit within 14 days, of which approximately 75% were within 7 days and half were within 3 days. Older children were more likely to have return ED visits than younger children. Increased efforts are necessary to ensure post-ED discharge pain medication and follow-up care are adequate to reduce these high return visit rates.

Morris:CSL Behring: Consultancy; UCSF Benioff Children's Hospital Oakland: Patents & Royalties: inventor of IP generating Royalties. Campbell:Novartis: Consultancy; Global Blood Therapeutics: Consultancy; Agios: Consultancy; Forma: Consultancy; Vertex: Consultancy. Liem:BlueBird Bio: Research Funding; GBT: Research Funding; Editas: Research Funding; NHLBI: Research Funding. Quinn:Aruvant: Research Funding; FORMA Therapeutics: Honoraria; Novo Nordisk: Honoraria; Emmaus Medical: Research Funding; Dispersol Technologies: Honoraria. Thompson:Editas: Research Funding; Biomarin: Research Funding; Baxalta: Research Funding; CRISPR/Vertex: Consultancy, Research Funding; Bristol Myers Squibb: Consultancy, Research Funding; bluebird bio, Inc.: Consultancy, Research Funding; Beam: Consultancy; Agios: Consultancy; Global Blood Therapeutic: Current equity holder in publicly-traded company, Membership on an entity's Board of Directors or advisory committees; Novartis: Research Funding. Villella:CRISPR Therapeutics: Consultancy. King:Global Blood Therapeutics: Consultancy, Research Funding. Brousseau:CSL Behring: Consultancy.