Trends and hospital practice variation for analgesia for children with sickle cell disease with vaso-occlusive pain episodes: An 11-year analysis

Mohamed Eltorki; Matt Hall; Sriram Ramgopal; Pradip P Chaudhari; Oluwakemi Badaki-Makun; Chris A Rees; Kelly R Bergmann; Daniel J Shapiro; Frank Gonzalez; Timothy Phamduy; Mark I Neuman

doi:10.1016/j.ajem.2024.10.028

Trends and hospital practice variation for analgesia for children with sickle cell disease with vaso-occlusive pain episodes: An 11-year analysis

Am J Emerg Med. 2024 Oct 13:86:129-134. doi: 10.1016/j.ajem.2024.10.028. Online ahead of print.

Authors

Affiliations

¹ Section of Pediatric Emergency Medicine, Department of Pediatrics, Cumming School of Medicine, Alberta Children's Hospital Research Institute, University of Calgary, 28 Oki Drive NW, Calgary, Alberta T3B 6A8, USA; Division of Pediatric Emergency Medicine, Department of Pediatrics, Faculty of Health Sciences, McMaster University, 1200 Main St W, Hamilton, Ontario L8S 4L8, Canada. Electronic address: mmeltork@ucalgary.ca.
² Children's Hospital Association, 6803 W 64th St, Overland Park, Kansas 66202, USA.
³ Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, 225 E Chicago Ave, Chicago, IL 60611, USA.
⁴ Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine of the University of Southern California, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, California 90027, USA.
⁵ Division of Pediatric Emergency Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Center for Data Science in Emergency Medicine, Johns Hopkins University, Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD 21287, USA.
⁶ Division of Pediatric Emergency Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta at Egleston, 1405 Clifton Rd NE, Atlanta, GA 30322, USA.
⁷ Department of Emergency Medicine, Children's Minnesota, 915 E 25th St, Minneapolis, MN, USA.
⁸ Division of Pediatric Emergency Medicine, University of California, UCSF Benioff Children's Hospital, 1825 Fourth St, San Francisco, California 94158, USA.
⁹ Division of Pediatric Emergency Medicine, Dayton Children's Hospital, Department of Pediatrics, Wright State University, Dayton Children's Hospital, 1 Children's Plaza, Dayton, OH 45404, USA.
¹⁰ Division of Emergency Medicine, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA.

PMID: 39427500
DOI: 10.1016/j.ajem.2024.10.028

Abstract

This cross-sectional analysis of 86,111 visits for sickle cell disease and vaso-occlusive episodes (VOE) in U.S. pediatric emergency departments between 2013 and 2023 shows increased use of NSAIDs, ketamine, and acetaminophen, with unchanged opioid use. Hospitals with a higher volume of VOE visits more frequently administered opioids.

Background: Vaso-occlusive episodes (VOEs) are a hallmark of sickle cell disease (SCD), leading to frequent emergency department (ED) visits. Effective pain management is crucial, with guidelines recommending routine use of non-steroidal anti-inflammatory drugs (NSAIDs) with opioids, and emerging evidence supporting ketamine use. However, these recommendations are based on low-certainty evidence, and the impact of these guidelines on analgesia use over time remains unclear.

Objective: This study aimed to analyze trends in analgesia use over an 11-year period in pediatric SCD patients presenting to U.S. EDs with VOE and assess variations in treatment across hospitals.

Methods: A cross-sectional study was conducted using data from the Pediatric Health Information System covering 34 U.S. children's hospitals from January 1, 2013, to December 31, 2023. The primary outcomes were the proportions of visits where opioids, NSAIDs, acetaminophen, and/or ketamine were administered on the first calendar day of the initial visit. Secondary outcomes included the co-administration of NSAIDs with opioids. Logistic and linear regression models were used to assess trends and hospital-level variations.

Results: A total of 86,111 ED visits for VOE were analyzed. Opioids were administered in 82 % of encounters, NSAIDs in 72 %, acetaminophen in 17 %, and ketamine in 1 %. Co-administration of NSAIDs with opioids occurred in 59 % of the visits. Among discharged patients, there was a positive trend for NSAID use (slope: 1.68 %/year, 95 % CI: 0.91 %, 2.45 %) and NSAID-opioid co-administration (slope: 1.03 %/year, 95 % CI: 0.37 %, 1.69 %) over time. Acetaminophen use also increased over the study period (slope: 0.99 %/year, 95 % CI: 0.80 %, 1.17 %). In hospitalized patients, there was a significant upward trend for acetaminophen (slope: 1.29 %/year, 95 % CI: 0.69 %, 1.89 %) and ketamine (slope: 0.36 %/year, 95 % CI: 0.27 %, 0.45 %), while opioid use remained unchanged. Significant hospital-level variations were observed, with larger hospitals more likely to administer opioids but less likely to co-administer NSAIDs with opioids compared to medium-volume hospitals.

Conclusion: Over the past decade, the use of NSAIDs, acetaminophen, and ketamine has increased in the management of VOE in pediatric SCD patients, while opioid use remains consistent. The co-administration of NSAIDs and opioids has also increased, reflecting guideline adherence. Variations in analgesia practices across hospitals underscore the need for standardizing pain management strategies in this population.

Keywords: Analgesic trends; Hospital practice patterns; Multimodal analgesia; Non-steroidal anti-inflammatory drugs (NSAIDs); Opioid use; Pain management; Pediatric emergency medicine; Vaso-occlusive crisis.