Multicenter evaluation of guideline adherence for the timeliness of pain medication for acute sickle cell disease pain Free

Background

Recurrent pain episodes are the leading cause of emergency department (ED) visits among patients with sickle cell disease (SCD). Effective treatment of SCD pain episodes requires the prompt administration of opioid-based pain medications.

To optimize patient outcomes and mitigate the burden of untreated pain, the American Society of Hematology (ASH) and the National Heart, Lung, and Blood Institute (NHLBI) published guidelines recommending the administration of the first opioid pain medication within 60 minutes of ED arrival, with subsequent evaluations and dosing given within 30-minute intervals according to the NHLBI and 30 to 60 minutes according to ASH. Despite these guidelines, studies involving small numbers of sites, and mainly involving children, suggest that guideline adherence is poor. Studies evaluating the timeliness of opioid pain medication administration across both pediatric and adult populations are lacking.

We conducted a comprehensive assessment of guideline adherence of opioid pain medication administration for SCD patients treated for acute pain across multiple EDs, including pediatric and adult populations.

Methods

We analyzed de-identified electronic health records (EHR) of patients from over 200 health systems participating in EPIC's Cosmos research platform, a multisystem collaboration across EPIC users in the US. We included all ED visits with a primary International Classification of Diseases (ICD-10) diagnosis code indicating SCD pain crisis, where at least one opioid pain medication was administered. We included EHR data from 1/1/2019 to 12/31/2024 and excluded visits with diagnosis codes of any SCD complication. Our primary outcome was the timeliness of ED opioid pain medication for acute, uncomplicated SCD pain expressed as the percentage of guideline adherence for first and second opioid doses.

Guideline adherence for the first dose was calculated as a percentage of overall visits where the first opioid dose was given within 60 minutes of arrival. For visits with multiple opioid doses, the second dose guideline adherence was calculated as the percentage of visits where the second dose was administered within 30 minutes of the first dose. We calculated overall guideline adherence and 95% CIs for the first two opioid doses stratified by route of administration (parenteral vs. oral). We also explored patient, visit, and facility factors, including age, sex, type of healthcare setting, payer, and acuity level, associated with guideline-adherent administration of the first two opioid pain medications using a chi-squared test.

Results

There were a total of 228 sites with a combined 394,725 ED visits from 40,977 unique patients in this study. The median (IQR) age was 31 (24 – 38), and females accounted for 55.2% of the visits. For 75% of visits, the payment method was public insurance.

Across the overall visits, 32.5% were guideline adherent for the first opioid dose within 60 minutes of ED arrival [95% CI: 32.4% - 32.6%]. For the 302,738 (76.6 %) visits with multiple doses, guideline adherence for the second dose was 9.0% [95%CI: 8.9% - 9.1%]. Stratification by the route of administration did not change guideline adherence for the first dose; however, for the second dose, orally administered opioids had higher guideline adherence, 24.3% [95%CI: 23.7% - 24.8%] compared to parenteral doses 7.7% [95%CI: 7.6% - 7.8%] (X²: p < 0.001).

In the univariate analysis, guideline adherence for the first opioid dose was higher among SCD patients aged ≤19 years, 52.0% [95%CI: 51.6% - 52.5%], compared to patients aged >19 years, 29.6% [95%CI: 29.5% - 29.8%] (X2: p < 0.001); the relationship held for the second dose within 30 minutes. Similarly, compared to female patients, visits by male patients were more likely to be guideline-adherent for the first dose: 36.9% [95%CI: 36.7% - 37.1%] vs. 28.9% [95%CI: 28.7% - 29.1%] (X2: p < 0.001), and the second dose: 10.6% [95%CI: 10.4% - 10.8%] vs. 7.7% [95%CI: 7.6% - 7.9%] (X2: p < 0.001). Guideline adherence did not differ according to the payment method, patient's historical ED utilization, and acuity levels.

Conclusion

Guideline-adherence for the timely delivery of opioid pain medication for acute SCD pain is inadequate. Fewer than one-third of visits were guideline-adherent for the administration of the first opioid pain medication, and fewer than one in ten were guideline-adherent for the second dose. Children were more likely to receive guideline-adherent care.