Author: Michael Vlessides
Patients with sickle cell disease who present for abdominal surgery experience vastly increased odds for blood transfusion, major and minor postoperative complications, longer hospital stay and total hospital charges, a New York–based research team found.
According to John Brumm, MD, a resident at NewYork-Presbyterian Hospital/Weill Cornell Medical College in New York City, sickle cell disease has been estimated to cost the U.S. health care system about $1.6 billion each year. Although previous research has shown that the blood disorder is associated with increased postoperative complications, prolonged hospital stays and higher hospital cost, these trials are limited and mostly in the orthopedic surgery literature. But knowledge of these outcomes may help anesthesiologists better manage and counsel this unique patient population, he added.
“The purpose of our study was to update the existing literature on sickle cell disease’s role in influencing postoperative complications and hospital resource utilization after three common abdominal surgeries: cholecystectomy, appendectomy and hysterectomy,” said Dr. Brumm. “In addition to caring for these patients intraoperatively, regional anesthesiologists and acute pain specialists are sure to encounter sickle cell disease patients as acute pain consults; therefore, it is beneficial to better understand this high-risk population.”
The researchers analyzed data from 1,934,562 adult patients in five states (California, Florida, Kentucky, Maryland and New York) in the State Inpatient Databases between 2007 and 2014. Some patients were undergoing inpatient cholecystectomy (n=788,216), appendectomy (n=467,910) or hysterectomy (n=678,436), The primary outcomes of the analysis were hospital length of stay and total hospital charges. Secondary outcomes included blood transfusion, major complications and minor complications.
There were 1,702 patients (0.1%) who had sickle cell disease. Of this group, 1,319 underwent cholecystectomy, 208 underwent hysterectomy and 175 underwent appendectomy. Perhaps not surprisingly, these individuals were demographically distinct from the rest of the study population: Sickle cell disease patients were younger; more likely to be black; have Medicaid; be in the lowest median household income quartile based on zip code; have an emergency procedure; and have comorbidities present on admission, such as pulmonary circulatory disorders, complicated hypertension, renal failure, liver disease, coagulopathy, fluid and electrolyte disorders, anemia or drug abuse.
“These patients were at risk of worse outcomes simply based on their demographics,” Dr. Brumm said while presenting the research at the 2018 World Congress on Regional Anesthesia and Pain Medicine and 2018 annual meeting of the American Society of Regional Anesthesia and Pain Medicine (abstract 4937). “This obviously raises the potential for a confounding effect, making our data analysis more difficult.”
Nevertheless, after adjusting for any effects of patient, hospital and operative factors, sickle cell disease was still found to incur a 1,700% increase in the odds for blood transfusion (odds ratio [OR], 18.00), a 118% increase in the odds for a minor complication (OR, 2.18) and a 234% increase in the odds for a major complication (OR, 3.34).
Multivariate linear regression models revealed that sickle cell disease was associated with increases in hospital length of stay (OR, 1.67; 95% CI, 1.60-1.74) and total hospital charges (OR, 1.36; 95% CI, 1.32-1.41). Stratified logistic regression analysis for each type of surgery yielded similar results as the three surgeries combined. No differences were found in mortality. “Total hospital charges totaled approximately $10,000 more per admission for sickle cell patients,” Dr. Brumm said.
Readmission and Cost Adjustment
The researchers conducted a similar study with the same data set, this time looking at hospital readmissions in the sickle cell patients. In his presentation (abstract 5225), which is featured in the video, Neel Mehta, MD, an anesthesiologist, assistant professor of anesthesiology and the director of pain management at Weill Cornell Medicine, in New York City, reported that sickle cell disease was found to be associated with an increased risk for readmission at 30 days (OR, 2.7; 95% CI, 2.34-3.10) and 90 days (OR, 3.93; 95% CI, 3.47-4.46).
“Our study highlights the clinical risk and hospital resource utilization of sickle cell patients in the postoperative period,” Dr. Brumm said. “We believe this knowledge can be used to consult these patients on the risks of their hospital course, and to inform anesthesiologists, surgeons and other physicians as well.”
William F. Urmey, MD, a clinical associate professor of anesthesiology at the Hospital for Special Surgery, in New York City, and the session moderator, thought the study’s cost estimates may have been lower than in real-world situations. “You mentioned that these patients are from lower socioeconomic populations,” he said. “If this is the case and they’re on Medicaid, chances are they’re going to be billed a lot less than the general population. So if your study found a $10,000 difference, you might expect it to be even more, because a person with private insurance would be billed that much more. So it might be nice to stratify according to the type of insurance.”