Background: SCD patients are often scrutinized by healthcare providers during acute illness: their pain is often doubted, and they experience delays in receiving pain medications. To improve the care of SCD patients hospitalized for vasoocclusive events (VOE) and improve residents' education, [redacted] hospital developed a model whereby SCD patients with VOEs are under a hematologist's care, supervising a team of internal medicine residents. Previously, SCD patients were admitted to general medicine or oncology services, with hematology in consultation and input from outpatient providers. Few studies explore the inpatient care of adult patients with SCD qualitatively. The goal of this study was to explore how the consolidation of inpatient SCD services under a specialized service affected the quality of care for SCD patients and the education of trainees.

Methods: We conducted in-depth semi-structured qualitative interviews with hospitalized SCD patients, residents, hematology/oncology fellows, attending physicians, advanced practice providers (APPs), and nurses involved in the care of hospitalized SCD patients in June 2024. Interviews were tailored to participants' positionality and focused on each participant's insights regarding the evolution of the quality of the care provided and factors affecting said care, the quality of trainees' education, and patients' experiences as the care model evolved. Patient participants were identified during hospitalization, and all other participants were identified by purposeful sampling, based on active or historical participation in inpatient SCD care during the service's evolution. All interviews were conducted by 1 team member, recorded, and transcribed. We used a primarily deductive coding approach in NVIVO, beginning with an initial codebook developed by the lead investigator based on analytic memos & close reading of transcripts. This initial framework included parent and child codes informed by the interview context, reflexive engagement during data collection, and preliminary thematic insights. To enhance trustworthiness and consistency of the coding process, a second coder independently applied the initial codebook to a subset of transcripts. The coding team then met to compare coding decisions, resolve discrepancies, and iteratively refine code definitions by consensus. This adjudication process supported the development of a stable codebook, which was subsequently applied to the full dataset.

Results: We conducted twenty-two interviews until thematic saturation was achieved. Participants consisted of 4 nurses, 8 trainees, 2 attendings, 3 APPs, and 5 patients. Participants highlighted a historical fragmentation of inpatient SCD care, marked by a lack of coordination of care, inconsistent practices, diluted accountability, and poor education for trainees. Implementation of the consolidated service significantly influenced perceptions of care quality among participants, who described the shift as transformative, enabling more consistent and compassionate care. This model enhanced educational continuity, standardized pain management approaches, and increased time at patients' bedside, fostering deeper provider-patient relationships and more cohesive multidisciplinary collaborations. The consistency brought by this new model allowed clinicians to anticipate needs and advocate for patients effectively. However, this continuity also brought emotional strain, particularly when patients were dissatisfied or when longstanding rapport broke down during moments of high stress. Participants reflected on how anti-Black racism & SCD-related stigma shape SCD care. Clinicians highlighted the impact of resource allocation on the quality of care they provide, while patients were attuned to delays in care, often perceiving them as interpersonal slights. These dynamics highlight a cyclical relationship between institutional resource allocation as a manifestation of institutional and structural racism, and individuals' perceptions and experiences of interpersonal racism.

Conclusion: The consolidation of inpatient adult SCD care under a hematologist's purview positively shifted participants' perception of the quality of care as well as residents' education. Such resource re-allocation shaped participants' perspectives on the intertwined role of structural and interpersonal racism in SCD care. Future work will assess the impact of this model on patient outcomes and acute utilization.

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2025
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