Median time (in minutes) from Emergency Department (ED) arrival to initial administration of pain medication for all patients, regardless of age, with a principal encounter diagnosis of sickle cell disease (SCD) with vaso-occlusive episode (VOE)

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Sickle Cell Disease (SCD) is the most common inherited blood disorder and is estimated to affect approximately 100,000 individuals in the United States (Hassell, 2010). SCD is also most prominent among Black or African American patients—affecting 1 out of 365 Black or African American births (Hassell, 2010)—and the average life expectancy of publicly insured individuals with SCD is reported to be approximately 52.6 years of age (Jiao et al., 2023). Based on a 2022 systematic review, total annual costs (medical and non-medical) were estimated to range from $14,012 to $80,842 per patient per year (Baldwin et al., 2022).

Evidence suggests that up to 60% of patients with SCD surveyed reported avoiding care in the ED (Crego et al., 2021). When they do seek emergency care due to an acute severe pain crisis, studies have shown patients wait an average of 90 minutes before analgesics are given (Tanabe, 2007; Lin, Strouse, Whiteman, Anders, & Stewart, 2016), and in another study across seven EDs found that half of all pediatric visits had a time to first opioid over one hour (Brousseau et al., 2020). Updated data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) show that from 1999 to 2020, of the 222,612 estimated yearly average number of ED visits by patients with a diagnosis of SCD, three-fourths were due to a complaint of pain (Attell et al., 2024). Compared with prior estimates (1999-2007), the overall volume of ED visits has increased by nearly 13% (Attell et al., 2024). Individuals with SCD face health inequities stemming from socioeconomic factors, including disease stigma, racial prejudice, and lack of access to specialized care (Haywood et al., 2014; Pokhrel, Olayemi, Ogbonda, Nair, & Wang, 2023; Telfair, Haque, Etienne, Tang, & Strasser, 2003; Wahab et al., 2024). These inequities were demonstrated in a study of adult patients with acute pain from SCD and renal colic in an ED. This study showed that despite higher arrival pain scores and triage acuity levels in patients with SCD, SCD patients experienced longer time to initial analgesia when compared with renal colic patients (Lazio et al., 2010).

To promote rapid, effective, and safe analgesic management and resolution of VOE, the 2014 National Heart, Lung, and Blood Institute (NHLBI) Evidence-Based Management of Sickle Cell Disease Expert Panel Report recommends the use of an individualized prescribing and monitoring protocol or an SCD-specific protocol whenever possible (National Institutes of Health [NIH] & NHLBI, 2014). Individualized care plans, developed by the patient’s SCD clinician, are based on the patient’s home opioid consumption and effective dosing from previous ED visits. The plan is made available to ED clinicians via the electronic health record and provides direction on pain management. Individualized prescribing and monitoring protocols in patients with SCD have demonstrated decreased time to first opioid, shorter ED and hospital length of stay, and more rapid reduction in pain scores, when compared with weight-based dosing (Della-Moretta et al., 2020; Tanabe et al., 2023a; Tanabe et al., 2023b; Welch-Coltrane et al., 2021).

The implementation of this eCQM targeting timing to administration of pain medication for adult and pediatric patients with SCD presenting to the ED may significantly improve pain management and other outcomes, including admission rates (Wachnik et al., 2022), hospital length of stay (Wachnik et al., 2022; Brandow et al., 2016; King, Albright, & Murry, 2023), length of ED stay (Lin et al., 2016; King et al., 2023; Mathias & McCavit, 2015), and patient satisfaction (Kim, Brathwaite, & Kim, 2017).

This measure is supported by two evidence-based clinical practice guidelines. The clinical recommendation statements from the supporting guidelines are noted below and specifically recommend the rapid initiation of analgesic medications for patients presenting to the ED with acute pain associated with a diagnosis of SCD with VOE, which demonstrates a direct relationship to this measure:

1. The American Society of Hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain (Brandow et al., 2020) Statement: Recommendation 1A - For adults and children with SCD presenting to an acute care setting with acute pain related to SCD, the ASH guideline panel recommends rapid (within 1 hour of emergency department [ED] arrival) assessment and administration of analgesia with frequent reassessments (every 30-60 minutes) to optimize pain control (strong recommendation based on low certainty in the evidence about effects).

2. The 2014 National Heart, Lung, and Blood Institute (NHLBI): Evidence-Based Management of Sickle Cell Disease Expert Panel Report (NIH & NHLBI, 2014) Statement: In adults and children with SCD and a vaso-occlusive crisis (VOC):

   a) Rapidly initiate treatment with parenteral opioids associated with severe pain (Strong Recommendation, High-Quality Evidence) OR

   b) Rapidly initiate analgesic therapy within 30 minutes of triage or within 60 minutes of registration. (Consensus–Panel Expertise – Expert Opinion).

Attell, B. K., Barrett, P. M., Pace, B. S., McLemore, M. L., McGee, B. T., Oshe, R., . . . Snyder, A. B. (2024). Characteristics of emergency department visits made by individuals with sickle cell disease in the U.S., 1999-2020. AJPM Focus, 3(1), 100158. doi:10.1016/j.focus.2023.100158

Baldwin, Z., Jiao, B., Basu, A., Roth, J., Bender, M. A., Elsisi, Z., . . . Devine, B. (2022). Medical and non-medical costs of sickle cell disease and treatments from a US perspective: A systematic review and landscape analysis. PharmacoEconomics Open, 6(4), 469-481. doi:10.1007/s41669-022-00330-w

Brandow, A. M., Carroll, C. P., Creary, S., Edwards-Elliott, R., Glassberg, J., Hurley, R. W., . . . Lang, E. (2020). American Society of Hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain. Blood Advances, 4(12), 2656-2701. doi:10.1182/bloodadvances.2020001851

Brandow, A. M., Nimmer, M., Simmons, T., Charles Casper, T., Cook, L. J., Chumpitazi, C. E., . . . Brousseau, D. C. (2016). Impact of emergency department care on outcomes of acute pain events in children with sickle cell disease. American Journal of Hematology, 91(12), 1175-1180. doi:10.1002/ajh.24534

Brousseau, D. C., Alpern, E. R., Chamberlain, J. M., Ellison, A. M., Bajaj, L., Cohen, D. M., . . . Pediatric Emergency Care Applied Research Network. (2020). A multiyear cross-sectional study of guideline adherence for the timeliness of opioid administration in children with sickle cell pain crisis. Annals of Emergency Medicine, 76(3S), S6-S11. doi:10.1016/j.annemergmed.2020.08.006

Crego, N., Masese, R., Bonnabeau, E., Douglas, C., Rains, G., Shah, N., & Tanabe, P. (2021). Patient perspectives of sickle cell management in the emergency department. Critical Care Nursing Quarterly, 44(2), 160-174. doi:10.1097/CNQ.0000000000000350

Della-Moretta, S., Delatore, L., Purcell, M., Huang, Y., Heinlein, M., Adkins, E., & Desai, P. (2020). The effect of use of individualized pain plans in sickle cell patients presenting to the emergency department. Annals of Emergency Medicine, 76(3S), S21-S27. doi:10.1016/j.annemergmed.2020.08.008

Hassell, K. L. (2010). Population estimates of sickle cell disease in the U.S. American Journal of Preventive Medicine, 38, S512–S521. doi:10.1016/j.amepre.2009.12.022

Haywood, C., Jr., Diener-West, M., Strouse, J., Carroll, C. P., Bediako, S., Lanzkron, S., . . . IMPORT Investigators. (2014). Perceived discrimination in health care is associated with a greater burden of pain in sickle cell disease. Journal of Pain and Symptom Management, 48(5), 934-943. doi:10.1016/j.jpainsymman.2014.02.002

Jiao, B., Johnson, K. M., Ramsey, S. D., Bender, M. A., Devine, B., & Basu, A. (2023). Long-term survival with sickle cell disease: a nationwide cohort study of Medicare and Medicaid beneficiaries. Blood Advances, 7(13), 3276-3283. doi:10.1182/bloodadvances.2022009202

Kim, S., Brathwaite, R., & Kim, O. (2017). Evidence-based practice standard care for acute pain management in adults with sickle cell disease in an urgent care center. Quality Management in Health Care, 26(2), 108-115. doi:10.1097/QMH.0000000000000135

King, H., Albright, A., & Murry, M. (2023). Delayed management of sickle cell disease vaso-occlusive episodes and the impact on prolonged hospitalizations at a single academic center. Blood, 142(Supplement 1), 7201. doi:10.1182/blood-2023-190385

Lazio, M. P., Costello, H. H., Courtney, D. M., Martinovich, Z., Myers, R., Zosel, A., & Tanabe, P. (2010). A comparison of analgesic management for emergency department patients with sickle cell disease and renal colic. The Clinical Journal of Pain, 26(3), 199-205. doi:10.1097/AJP.0b013e3181bed10c

Lin, S. M., Strouse, J. J., Whiteman, L. N., Anders, J., & Stewart, R. W. (2016). Improving quality of care for sickle cell patients in the pediatric emergency department. Pediatric Emergency Care, 32(1), 14-16. doi:10.1097/PEC.0000000000000369

Mathias, M. D., & McCavit, T. L. (2015). Timing of opioid administration as a quality indicator for pain crises in sickle cell disease. Pediatrics, 135(3), 475-482. doi:10.1542/peds.2014-2874

National Institutes of Health, & National Heart, Lung, and Blood Institute. (2014). Evidence-based Management of Sickle Cell Disease Expert Panel Report. Bethesda, MD. Retrieved from https://www.nhlbi.nih.gov/health-topics/evidence-based-management-sickle-cell-disease

Pokhrel, A., Olayemi, A., Ogbonda, S., Nair, K., & Wang, J. C. (2023). Racial and ethnic differences in sickle cell disease within the United States: From demographics to outcomes. European Journal Haematology, 110(5), 554-563. doi:10.1111/ejh.13936

Tanabe, P., Bosworth, H. B., Crawford, R. D., Glassberg, J., Miller, C. N., Paice, J. A., & Silva, S. (2023). Time to pain relief: A randomized controlled trial in the emergency department during vaso-occlusive episodes in sickle cell disease. European Journal of Haematology, 110(5), 518–526. doi:10.1111/ejh.13924

Tanabe, P., Ibemere, S., Pierce, A. E., Freiermuth, C. E., Bosworth, H. B., Yang, H., . . . Barnhart, H. X. (2023). A comparison of the effect of patient-specific versus weight-based protocols to treat vaso-occlusive episodes in the emergency department. Academic Emergency Medicine, 30(12), 1210-1222. doi:10.1111/acem.14805

Tanabe, P., Myers, R., Zosel, A., Brice, J., Ansari, A. H., Evans, J., . . . Paice, J. A. (2007). Emergency department management of acute pain episodes in sickle cell disease. Academic Emergency Medicine, 14(5), 419-425. doi:10.1197/j.aem.2006.11.033

Telfair, J., Haque, A., Etienne, M., Tang, S., & Strasser, S. (2003). Rural/urban differences in access to and utilization of services among people in Alabama with sickle cell disease. Public Health Reports, 118(1), 27-36. doi:10.1093/phr/118.1.27

Wachnik, A. A., Welch-Coltrane, J. L., Adams, M. C. B., Blumstein, H. A., Pariyadath, M., Robinson, S. G., . . . Hurley, R. W. (2022). A standardized emergency department order set decreases admission rates and in-patient length of stay for adults patients with sickle cell disease. Pain Medicine, 23(12), 2050-2060. doi:10.1093/pm/pnac096

Wahab, S., Kelly, K., Klingler, M., Pirovic, A., Futch, K., Rennie, C., . . . Costin, J. M. (2024). Impact of race, socioeconomic status, and geography on healthcare outcomes for children with sickle cell disease in the United States: A scoping review. Cureus: Journal of Medical Science, 16(3), e56089. doi:10.7759/cureus.56089

Welch-Coltrane, J. L., Wachnik, A. A., Adams, M. C. B., Avants, C. R., Blumstein, H. A., Brooks, A. K., . . . Hurley, R. W. (2021). Implementation of individualized pain care plans decreases length of stay and hospital admission rates for high utilizing adults with sickle cell disease. Pain Medicine (Malden, Mass.), 22(8), 1743–1752. doi:10.1093/pm/pnab092

This eCQM is an episode-based measure. An episode is defined as a qualifying encounter is defined as an emergency department (ED) visit for a patient, regardless of age, for which the discharge time occurred during the two-year measurement period and the following criteria are met:

• The ED visit requires a principal diagnosis of SCD with VOE, and

• The ED visit requires at least one qualifying pain medication administered during the ED encounter.

The measure uses a two-year measurement period from January 1, XXXX through December 31, XXXX.

This version of the eCQM uses QI-CORE version 6.0. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QI-CORE.

Median

ED encounters with a discharge time during the two-year measurement period for all patients, regardless of age, who have a principal encounter diagnosis of SCD with VOE and who have at least one qualifying pain medication administered during the ED encounter

Equals Initial Population

Median time (in minutes) from ED arrival to initial administration of pain medication

Stratification 1: Pain medication administered via parenteral route

Stratification 2: Pain medication administered via non-parenteral route

For every patient evaluated by this measure also identify payer, race, ethnicity and sex