More than 75% with sickle cell crises don’t get hydroxyurea
BY MARY ANN MOON
FROM JAMA
Vitals Key clinical point: More than 75% of adults with sickle cell anemia who have frequent pain crises fail to get hydroxyurea therapy as recommended. Major finding: Only 15.1% of adults with sickle cell anemia received hydroxyurea within 3 months of their third pain crisis, only 18.2% received the agent within 6 months, and only 22.7% received it within 12 months. Data source: An analysis of information in a large nationwide insurance claims database involving 570 adults with frequent hospitalizations for sickle cell pain crises. Disclosures: This study was funded by the Lewin Group, a health care consulting firm. Dr Stettler and his associates reported having no relevant financial disclosures. |
More than 75% of adults with sickle cell anemia who have frequent pain crises fail to receive hydroxyurea therapy as strongly recommended in National Heart, Lung, and Blood Institute clinical guidelines, according to a Research Letter to the Editor published online April 28 in JAMA.
Despite proven benefits in decreasing pain crises, hospitalizations, blood transfusions, and possibly mortality, hydroxyurea, a “safe and inexpensive drug,” is thought to be underused. To document the actual use of the drug when indicated, investigators analyzed information in a nationwide insurance claims database covering nearly 27 million patients per year. They focused on the records of 570 adults hospitalized or treated in an emergency department for a sickle cell pain crisis at least three times during a 1-year period, said Dr Nicolas Stettler of the Lewin Group, a health care consulting firm in Falls Church, Va., and his associates.
Only 15.1% of these patients received hydroxyurea within 3 months of their third crisis, only 18.2% received the agent within 6 months, and only 22.7% received it within 12 months. These figures likely represent a conservative estimate of the hydroxyurea treatment gap, since the study didn’t include the large uninsured and publicly insured populations who have more limited access to health care, Dr Stettler and his associates noted (JAMA 2015;313:1671-2).
Several barriers to this treatment have been identified in previous research, including fear of adverse events, lack of clinician training, and failure to use shared decision making. “To address this gap, it may be necessary to enhance patient outreach and clinician training and develop health care quality measures aimed at increasing the use of hydroxyurea for all patients who would benefit,” they added.
Recognizing human trafficking victims
BY ALICIA GALLEGOS
AT THE AMWA ANNUAL MEETING
CHICAGO – Emergency physicians encounter nearly 40% of human trafficking victims who come in contact with health providers, according to Dr Holly G. Atkinson.
In a 2014 survey of domestic sex-trafficking victims, 88% said they encountered one or more health professions during the period in which they were being trafficked, yet none was identified as a victim by physicians during the visits. In another 2014 survey of survivors, 39% of victims reported having contact with emergency departments; 29%, with primary care physicians; 17%, with ob.gyns.; 17%, with dentists; and 3%, with pediatricians.
Key indicators for potential victimization include discrepancies between history and clinical presentation, multiple sexually transmitted diseases, and the accompaniment of a controlling third-party who is not a guardian, said Dr Atkinson, director of the human rights program at Arnhold Global Health Institute at the Icahn School of Medicine at Mount Sinai in New York City, said at the annual meeting of the American Medical Women’s Association.
In 2014, the National Human Trafficking Resource Center, operated by the antislavery organization Polaris, received 3,598 reports of sex-trafficking cases inside the United States. The National Center for Missing & Exploited Children estimates that between 100,000 and 300,000 U.S. children are at risk of being sexually trafficked each year.
Physical signs that could denote the possibility of patients being trafficked include visible tattoos with “daddy,” “property of,” or a trafficker’s street name. Perpetrators often brand their victims so that they are easily recognizable and can be returned if they escape, Dr Atkinson explained.
Dehydration, malnutrition, multiple sexually transmitted infections, and multiple pregnancies or abortions could also be clues. The inability to provide an address, confusion about their current location, an appearance younger than the stated age, avoidance of eye contact, and answers that sound scripted are potential signs of human trafficking, as is the presence of a controlling third party who does not let the patient answer questions or who interrupts or corrects the patient.
The Via Christi Health system in Wichita, Kan., recently published guidance for clinicians on how to proceed if they suspect a patient is a victim of human trafficking. Steps include following child abuse or domestic violence protocols; separating the patient from the controlling third party; providing the patient a comfortable, safe area; and ensuring a patient interview is performed by a trauma-informed social worker or nurse.