Pain Scores, Opioid Receipt Predict Hospitalization in Children with Sickle Cell Disease

Keli Coleman, MD

Credit: Medical College of Wisconsin

Findings from a multicenter retrospective cohort study are providing clinicians with an overview of the role of emergency department pain scores, opioid doses in the emergency department, and receipt of an opioid prescription at discharge for predicting hospitalization and return visits among children with uncomplicated sickle cell disease (SCD) pain crises.

Presented at the 2023 American Society of Hematology (ASH) Annual Meeting and Exposition in San Diego, California, study results showed the final emergency department pain score was the best predictor of hospitalization, although no pain score predicted return visit after discharge - rather, fewer opioid doses in the emergency department and receipt of an opioid prescription at discharge were associated with fewer return visits.¹

“Reducing pain through prompt administration of pain medication in the emergency department is a primary driver of national guidelines for sickle cell disease, yet there are few data on how pain scores and changes in pain scores are associated with both the disposition at the initial visit and the likelihood of a return visit,” wrote Keli Coleman, MD, assistant professor in the department of pediatrics at the Medical College of Wisconsin, and colleagues.¹

A group of inherited red blood cell disorders in which abnormal hemoglobin causes a constant shortage of red blood cells, SCD affects millions of people around the world and is estimated to affect approximately 100,000 people in the US. Intravenous fluids, pain-reducing medicine, and hospitalization for severe pain crises are included in the clinical management of SCD. Despite these guidelines, little research has explored the impact of this approach on pain scores, hospitalization, and subsequent return visits.^2,3

Investigators sought to determine the relationship between pain scores and disposition as well as the occurrence of a return emergency department visit among children with uncomplicated sickle cell disease pain crises. To do so, they collected electronic healthcare data from the Pediatric Emergency Care Applied Research Network (PECARN) Registry across 7 sites.¹

For the purpose of analysis, investigators defined index emergency department visits as uncomplicated pain crises with no preceding emergency department visits within 14 days between January 2017 and November 2021. Initial, last, and change in scores as measured by a numeric rating scale (0-10) were collected.¹

When assessing disposition, investigators modeled the relationship between the 3 pain scores and hospital disposition adjusting for age, sex, and uncomplicated pain crisis visit admission rate. When assessing return visits, investigators used the same predictor variables and added both the number of parenteral opioid doses administered in the emergency department and whether or not a prescription for an opioid was given at discharge. Investigators noted all analyses were adjusted for site using generalized estimating equations with an exchangeable correlation structure to account for clustering.¹

In total, 4985 index visits for uncomplicated SCD pain crises were included in the study, 52% of which resulted in hospitalization. Overall, 39% of the study participants were <12 years of age, 54% were female, and 96% were Black. Index emergency department visits per site varied from 157 to 1855. The overall emergency department median initial pain score was 8.0 (interquartile range [IQR], 6.0-10), the median last pain score was 5.0 (IQR, 2.0-8.0), and the median change in pain score was 2.0 (IQR, 0.0-5.0).¹

In univariate analyses, greater initial and last pain scores and a smaller change in pain scores were all associated with increased hospitalization rates. Multivariate analyses revealed the last pain score was the best predictor of hospital admission (adjusted rate ratio, 1.16; 95% Confidence interval [CI], 1.12-1.19). Investigators pointed out change in pain score was no longer significant (adjusted rate ratio, 0.98; 95% CI, 0.96-1.00).¹

More than 80% of participants with a last pain score > 7 were hospitalized, compared to less than 40% whose score was < 4. Of the 2,377 visits originally discharged, 29% had a return visit within 14 days. Of note, none of the pain scores from the initial visit were associated with having a return visit within 14 days. However, investigators pointed out both an increased number of emergency department opioid doses and failure to receive an opioid prescription at discharge were associated with increased return visits.¹

“We found that for a child with SCD presenting to the ED with an uncomplicated pain crisis, the last ED pain score was a better predictor of hospitalization than initial or change in pain score. None of those pain scores predicted a return visit after discharge; however, fewer opioid doses in the ED and receipt of an opioid prescription at discharge were associated with fewer return visits,” investigators concluded.¹

References:

1. Coleman KD, McKinley K, Ellison AM, et al. 3874 Association between Acute Pain Scores in Children with Sickle Cell Disease and Emergency Department Disposition and Return Visit Rates. Presented at: ASH Annual Meeting and Exposition. San Diego, CA. December 9-12, 2023.
2. US Centers for Disease Control and Prevention. Data & Statistics on Sickle Cell Disease. Sickle Cell Disease (SCD). July 6, 2023. Accessed December 11, 2023. https://www.cdc.gov/ncbddd/sicklecell/data.html
3. US Centers for Disease Control and Prevention. What is Sickle Cell Disease? Sickle Cell Disease (SCD). July 6, 2023. Accessed December 11, 2023. https://www.cdc.gov/ncbddd/sicklecell/facts.html