Second National Conference on
Quality Health Care for Culturally Diverse Populations:
Strategy and Action for Communities, Providers, and a Changing Health System

Sickle Cell Disease: Inpatient Cost Analysis and Government Expenditure

Sickle cell disease is one of the most common genetic diseases in the United States, affecting one out of four hundred African Americans. However, this population is usually undeserved with a lack of specialty care available in the communities where the disease is prevalent (Platt, 1998). No doubt that this leads to increased emergency room utilization, and subsequent inpatient admission. The chronicity of Sickle Cell disease is daunting, and therefore calls for routine care to lessen or prevent recurring life threatening episodes. On June 17, 1998, Vice President Al Gore launched the planning committee that would create the Forum for Health Care Quality Measurement and Reporting in the private sector. This forum was created as the vehicle to highlight the potential for quality measurement activities to yield improved health care (Gov., 2000). The reports goes on to say that poor quality care leads to sicker patients, more disabilities, higher costs, and lower confidence in the health care industry. It is estimated that in 1997, California (Medicaid) reported expenditures of 2,976 Sickle Cell Anemia related discharges, averaging $13,205.00 per average length of stay (5.2 days). National (Medicaid) averages of 6,977,169 discharges had mean charges of $9,466.00 per average length of stay of 4.9 days (HPUC, 2000), Figure 1. Nationally, total health care cost exceed $3 billion annually (Woods, 1997). These numbers are staggering given the fact that African Americans make up only 7% of the population of California, and 12% of the national population (Gov., 2000). In addition, government statistics referenced in 1991, that 20,000 African American discharges were avoidable (CDC, 1990). The United States cannot effectively address escalating health care cost without addressing the problem of chronic diseases which account for 70% of all deaths, and 60% of the nations medical care costs (Johnson, 1994). Therefore, we as health care clinicians must ask ourselves, what approaches can be utilized to effectively manage these clients? Perhaps, in order to achieve clinically significant decreases in morbidity, and inpatient expendituresÌ, agencies and institutions should pilot the interventions of Sickle Cell Center Prototypes that have documented successes.

The Georgia Comprehensive Sickle Cell Center at Grady Health System is one such model, operating 24 hours a day, managing pediatric and adult clients. Figure 2 demonstrates how this approach has decreased inpatient expenditures while improving client outcomes over time (Eckman, 2000). Many clinicians do not report their operations based on GradyÌs prototype, but have similar approaches that foster client wellness including; Follow-up by teams of physicians, nurses, and social workers dedicated to educating the family, thus opting to decrease avoidable complications. Standardized protocols involving the emergency room, and acute care staff, eliminating unnecessary delays in triaging clients. Online protocols via the www help to hasten pain treatment modalities, eliminating or decreasing actual lengths of stays. Staff in-service, promoting non-judgmental client rights, because all too often, cultural differences between staff and client can minimize the team effort. Transitional teams are necessary as the pediatric client advances chronologically into young adulthood, breaking away from the trusted Pediatrician.

Although we have seen palliative management, challenges remain constant, particularly with the young to middle age adult. These clients are aware of their disease, and the accompanying processes unique to their situation. They are no longer the trusting child of years before. They comprise an estimated 66% of hospital discharges as seen in Figure 3. This age group for varying reasons loses the secure continuity of care associated with the pediatric years, and subsequently become the statistical data encountered in numerous publications. Without the respect of a collaborative, comprehensive, and consistent approach to follow-up, these clients often experience a lack of continuity in care, resulting in increased morbidity, while their affiliate agencies incur escalating costs, and avoidable expenditures.

Current data supports the use of specialized care to effectively treat this population, paying attention to areas of geographical concentration. Clinicians (rural and urban settings) should avail themselves of the latest protocols to ensure proper treatment utilization for these vulnerable clients. Therefore, all institutions should have an online Internet database of Sickle Cell Centers of Excellence, equipped for accessing treatment options, and current research protocols. Piloting the generalized interventions as mentioned earlier can be a supportive infrastructure to optimizing client care, while minimizing inpatient expenditures. Also, clinicians must consider cultural differences between staff and clientsÌ as a dependent variable when undesirable outcomes are present. Perhaps, validating the existence of clinical and / or statistical significance as it relates to the lack of treatment options, and variable outcomes with cultural differences, should be the subject of future research.

My sincerest gratitude of thanks to the Sickle Cell Disease Research Foundation for its supportive efforts of providing informative handouts, and the Sickle Cell Information Center on the world wide web for its worldwide guide to resourcesÌ.

References:

Center for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey. US Bureau of the Census, 1991 Census.

National Center for Chronic Disease Prevention and Health Promotion, Chronic Disease Prevention. About Chronic Disease; http://www.cdc.gov/nccdphp/about.htm, 2000.

Eckman, J., The Sickle Cell Information Center. Sickle Cell Research and Publications from the Staff of The Georgia Comprehensive Sickle Cell Center at Grady Health System in Atlanta, Georgia. History of the Research Effort; http://www.emory.edu?PEDS/SICKLE/ctresrch.htm, 2000.

Gore, A., Department of Health and Human Services Report. The Challenge and Potential for Assuring Quality Health Care for the 21^st Century; http://www.ahrq.gov/qual/21stcena.htm, 2000.

Platt, P.A., Eckman, J. Sickle Cell Research - Web Update - August 1999, http://www.emory.edu/PEDS/SICKLE/Research.htm, 2000.

HCUPnet, Healthcare Cost and Utilization Project. Agency for Healthcare Research and Quality, Rockville, MD; http://www.ahrq.gov/data/hcup/, 2000.

Statewide Data Organizations Participating in the HCUP State Inpatient Database. Healthcare Information Resource Center, Office of Statewide Health; http://www.oshpd.cahwnet.gov, 2000.

US Census Bureau, State and County QuickFacts; 2000.

Woods, K., et al, Hospital Utilization Patterns and Costs for Adult Sickle Cell Patients in Illinois. Public Health Reports; Jan-Feb 1997. Vol 112.

Colleen Jackson, RN, BSN received her BSN from California State University at Los Angeles, and is currently a second year graduate student in the Family Nurse Practitioner Program at the University of California, Los Angeles. She works as an Apheresis Specialist in a large, level -1, tertiary medical center, providing expert care, compassion, and empathy to a diverse group of patients fighting genetic, and auto-immune disorders. Her persistence as a patient advocate is well known by colleagues. Patient advocacy has remained consistent throughout her career in Pediatrics, Med-Surg, CICU, and most recently as Apheresis Specialist within the Division of Pathology and Laboratory Medicine. Colleen maintains membership with Sigma Theta Tau International, and various nursing organizations promoting political empowerment for patient rights. In addition, she volunteers to a diverse group of challenged young adults, advising health issues, self-esteem building, and anger management.

Colleen Jackson, RN, BSN
Second year graduate student, candidate for FNP/MSN June 2001
Apheresis Specialist
Cedars Sinai Medical Center
8700 Beverly Boulevard
Los Angeles, CA 90048
Phone: (310) 423-5347
Fax: (310) 423-0174

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