Cognitive, Emotional Measures Linked to Sickle Cell Healthcare Utilization

Cognitive and emotional functions in pediatric patients should not be overlooked when assessing potential for sickle cell disease self-management practices and healthcare utilization.

A study, presented at the American Society of Hematology (ASH) 2020 Annual Meeting, specifically investigated the extent to which these functions contribute to rates of pain-related visits to the hospital or emergency department.

A team led by Zaria Williams, Howard University College of Medicine, conducted an analysis of pediatric patients representing all genotypes of sickle cell disease. Using existing data from a previous study on computerized working memory training, they gathered cognitive abilities, socioeconomic status, and emotional functioning to determine whether such variables were predictive of healthcare utilization.

Cognitive measures were based on the Wechsler Intelligence Scale for Children (WISC-V) Full Scale IQ as well as a computerized cognitive assessment.

Williams and team measured emotional functioning using the Worry and Emotions domains of the child- and parent-rated Pediatric Quality of Life Inventory Sickle Cell Disease Module.

And finally, they measured heartcare utilization according to chart review—which they separated into emergency department visits for pain and hospitalizations for pain 1 year and 3 years following study enrollment.

Thus, they assessed a total of 112 children, where the mean age was 10.61 years. A majority (58%) were female. Further, 74% had sickle cell anemia (HbSS or HbSβ0 thalassemia).

For the entire population, the median number of emergency department visits was 1 across 1 year (IQR, 2) following enrollment. After 3 years, the median was 3 visits (IQR, 6).

In terms of hospital admissions, the median number of visits was 0 after 1 year (IQR, 1) and 1 after 3 years (IQR, 4).

Cognitive, Emotional Abilities and Healthcare Visits

Linear regression models indicated that there was a significant association between attentional abilities and emergency department visits and hospitalizations for pain—both for 1 year and 3 years following enrollment (P<.009 for both). 

According to the investigators, better performance on the Constate attention task was associated with fewer emergency department visits and hospitalizations.

Furthermore, child-rated emotional quality of life significantly predicted emergency department visits for pain over 1 year (P = .004) and hospitalizations for pain over 3 years (P = .013). Similarly, higher emotional quality of life was predictive of fewer emergency department and hospital visits.

Parent-rated emotional quality of life was predictive of hospitalizations for pain over 3 years (P = .020).

Lastly, the investigators noted that neither sickle cell disease genotype nor socioeconomic status had any significant influence on healthcare utilization.

“Results demonstrate that children’s cognitive and emotional functioning play an important role in pain management and should be an integral part of comprehensive pain management plans for children with sickle cell disease,” they wrote.

Implications and New Perspectives on Sickle Cell Care

Williams and colleagues indicated that attentional abilities appeared to be a reliable predictor of pain-related healthcare utilization. Poor attention may make it difficult to implement strategies that could distract the child from pain.

Further, these findings can be suggestive of the fact that children with poor attention may struggle with behavioral aspects of disease-self management, such as medication adherence and avoidance of pain triggers.

They believed that these considerations should be taken seriously in the treatment of this already high-risk population.

“Clinicians and researchers should consider cognitive and emotional factors when evaluating risk for pain in sickle cell disease and incorporate these factors when developing strategies to reduce healthcare utilization and costs,” the team concluded.

The study, “Cognitive and Emotional Factors and Pain-Related Outcomes in Youth with Sickle Cell Disease,” was presented at ASH 2020.