Emergency Department Quality of Care for Sickle Cell Disease in Ontario, Canada: A Population-Based Matched Cohort Study

Abstract Importance Acute vaso-occlusive crisis (VOC) in sickle cell disease (SCD) often leads patients to seek emergency department (ED) care. The landscape of SCD ED care within Canada’s universal and publicly funded healthcare system remains largely undefined. Objective To characterize the quality of SCD VOC ED and inpatient care in Ontario, Canada. Design, Setting and Participants We used population-level health administrative data to identify patients with SCD in Ontario, Canada who presented to the ED with SCD VOC (ICD-10-CA code D57.0) from 2006 to 2018. We derived two reference patient cohorts from the general population and separately from a validated Crohn’s disease cohort matched at the level of ED visits by age, sex, neighbourhood income quintile, geography, date range of visit, and ED triage score. Main Outcomes and Measures Quality of care metrics included the number of ED visits, triage scores, time to physician initial assessment, time from triage to disposition, type of disposition, number of hospital admissions, length of admission for those admitted to hospital, number of repeat ED visits within a 14- and 30-day time window, and number of ED visits within any 1-year period. Stratifying variables and sociodemographic data included the month and year of ED visit, age bracket, triage scores, sex, rurality, Ontario’s marginalization indices (neighbourhood income, dependency, deprivation, ethnic concentration, instability), and number of ED visits within any 1-year period. Results We identified 2,123 patients who presented to the ED with SCD VOC for a total of 18,712 unscheduled ED visits. Annual ED visit rates ranged from a mean of 2.6 to 14.2 visits per patient, with 4.6% of patients having incurred 38.4% of all SCD VOC ED visits. Subgroup analyses showed that adult patients with SCD VOC visited the ED 2.5 times more than pediatric patients, but their wait times for initial physician assessment were significantly longer (90.6 vs. 51.1 minutes, p < 0.0001) with a difference that was disproportionately larger than the reference cohorts. Males with SCD VOC experienced significantly shorter ED and inpatient stays compared to females (e.g. admission length of stay: 4.4 vs. 5.8 days, p < 0.0001), but their ED return rates within 30-days were significantly higher (0.89 vs. 0.35 times, p < 0.0001) with a difference that was disproportionately larger relative to the reference cohorts. Lower-income neighbourhoods correlated with lower acuity triage scores for SCD VOC visits and increased repeat ED visit rates at more pronounced levels than the reference cohorts. Higher acuity triage scores for adults with SCD VOC correlated with improved metrics for quality of ED and inpatient care with fewer longer-term ED visits. Conclusions and Relevance Patients with SCD VOC carry a significant burden of acute care needs, with a smaller patient subset whose high ED visit rates have distinctly increased over time in Ontario, Canada. Adults, males and those from lower income quintile neighbourhoods with SCD VOC experienced lower quality of care metrics compared to their counterparts, with differences that were disproportionately larger than those found in the general ED population and in patients with Crohn’s disease. Higher acuity ED triage scores reflected improved downstream quality of care metrics for adult patients with SCD VOC. Future work should address these identified care quality disparities for SCD VOC that remain present within a universal and publicly funded healthcare system. Key Points Question What is the quality of emergency department (ED) and inpatient care for patients with sickle cell disease (SCD) vaso-occlusive crisis (VOC) in Ontario, Canada? Findings This population-based matched cohort study of 2,123 patients with 18,712 ED visits for SCD VOC identified that adults, males and those from lower-income neighbourhoods experienced lower quality of care metrics compared to their counterparts, with differences that were disproportionately larger than those in two reference patient cohorts. Meaning Disparities in the quality of SCD VOC care with their associated outcomes remain pronounced and present within a universal and publicly funded healthcare system.

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