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Infusion Centers or EDs for Sickle Cell Crises?

Infusion Centers or EDs for Sickle Cell Crises? — Adults with SCD treated in infusion centers had improved outcomes in three key measures by Mike Bassett, Staff Writer, MedPage Today July 6, 2021

Adults with sickle cell disease (SCD) had better outcomes when treated for vaso-occlusive crises in infusion centers (ICs) rather than emergency departments (EDs), according to a prospective observational cohort study. Compared with SCD patients presenting to EDs, those seen first in ICs received parenteral pain medication faster, were more likely to have their pain reassessed within 30 minutes after the initial medication dose, and were substantially less likely to be hospitalized, reported Sophie Lanzkron, MD, MPH, of Johns Hopkins University School of Medicine in Baltimore, and colleagues. "These results suggest that ICs are more likely to provide guideline-based care than EDs, and that care can improve overall outcomes," the team wrote in the study online in Annals of Internal Medicineopens in a new tab or window. Among the main findings:

  • The mean time to the first dose of intravenous pain medication was more than twice as fast in ICs (62 vs 132 minutes in EDs)

  • The chance of patients having pain reassessed 30 minutes after their first medication dose was 3.8 times greater in an IC than an ED

  • The probability that a patient's visit for an uncomplicated vaso-occlusive crisis would result in being discharged was four times greater in the IC

The researchers noted that while growing literature supports the role of subspecialty ICs or dedicated SCD day hospitals as an alternative to EDs in delivering care to patients with acute pain, no studies to date had directly compared ICs and EDs in managing pain in SCD patients. The ESCAPED (Examining Sickle Cell Acute Pain in the Emergency Versus Day Hospital) study was conducted at four sites -- one each in Baltimore; Cleveland; Milwaukee; and Baton Rouge, Louisiana. Two of the sites had ICs dedicated solely to the care of adults with SCD, while the other two shared infusion space with other hematology/oncology patients. All were located in hospitals with adjoining EDs. Lanzkron and colleagues enrolled a total of 483 adults who lived within 60 miles of a study site who were followed for 18 months with the expectation that each would have at least one or two acute care visits per year. The researchers said that since ICs are open only on weekdays, the analysis included only the 269 patients who had acute care visits on weekdays in order to achieve a valid comparison between EDs and ICs. Among those, there were 1,441 eligible visits -- 241 in an ED, 1,200 in an IC -- with a median number of three visits per patient. The investigators suggested that structural problems -- such as overcrowding and providers' limited knowledge about a particular patient's illness -- can limit the effectiveness of care in the ED. "Adequacy of pain management in the ED has also been a well-recognized problem despite guidelines to assist with management," Lanzkron and co-authors added. "In contrast, ICs are staffed by clinicians and staff with experience caring for people with SCD." Given the limitations of EDs, the authors suggested that ICs may provide the best options for treating SCD, particularly in regions where large groups of patients live with the disease. "Future studies should evaluate the cost-effectiveness of IC versus ED care and assess the size of the local population that would justify the expense of investing in a dedicated center versus a shared model," the researchers wrote. "Cost notwithstanding, the most important goal that ICs can achieve is to address structural racism in health care by alleviating suffering that affects this historically underserved population," Lanzkron and co-authors concluded. In an accompanying editorialopens in a new tab or window, Julie Kanter, MD, of the University of Alabama at Birmingham, also touched on the issue of cost effectiveness, noting that the IC model reduces hospitalizations, and subsequently hospital-related morbidity and cost of care. In addition, all the patients in the study were those "fortunate enough to be in the care of a SCD specialist." Studies have shown that fewer than 30% of adults with SCD see specialists, and because there is no national funding for SCD centers, few exist, Kanter noted. "Compared with other conditions, SCD is very behind."

  • Mike Bassett is a staff writer focusing on oncology and hematology. He is based in Massachusetts.

Disclosures Lanzkron reported personal or institutional financial relationships with Imara, Global Blood Therapeutics, Shire, Novartis, Bluebird Bio, Novo Nordisk, and Forma; co-authors also reported relationships with industry. Kanter reported no disclosures. Primary Source Annals of Internal Medicine Source Reference: opens in a new tab or windowLanzkron S, et al "Treatment of acute pain in adults with sickle cell disease in an infusion center versus the emergency department" Ann Intern Med 2021; DOI: 10.7326/M20-7171. Secondary Source Annals of Internal Medicine Source Reference: opens in a new tab or windowKanter J "One small step for sickle cell disease: many more to go" Ann Intern Med 2021; DOI: 10.7326/M21-2650.

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