227 - Improving Transcranial Doppler Rates Among Medicaid-Insured Patients with Sickle Cell Anemia; A Collaborative Quality Improvement Project

Publication Number: 2218.227

Gregory Stewart, Nationwide Childrens Hospital, Columbus, OH, United States; Meghann B. Rice, Nationwide Childrens' Hospital Partners for Kids, Grove City, OH 43123-1189, OH, United States; jennifer Young, Nationwide Children's Hospital, Columbus, OH, United States; Timothy S. Crabtree, Nationwide Children's Hospital/ Partners For Kids, Columbus, OH, United States; Randall Brown, Nationwide Children's Hospital, Pickerington, OH, United States; Heather E. Irvin Hauser, Partners for Kids - Nationwide Children's Hospital, Columbus, OH, United States; Anthony Villella, Nationwide Childrens Hospital, Columbus, OH, United States

Background: Children with sickle cell anemia (SCA) have 10 times the risk of developing cerebrovascular injury within their lifetime. It is estimated by the age of 18 that 39 percent of children with SCA will have either a clinically significant or silent stroke. Treatments, such as transfusion/apheresis can decrease the occurrence of stroke in high-risk children by 90%. The American Hematology Society recommends that children under 16 years with SCA have a TCD annually to assess their risk for stroke. Unfortunately, it has been consistently shown that children with SCA who are of lower socioeconomic status have a lower TCD than the rest of the population with sickle cell anemia.

Objective: Partners for kids (PFK) is an accountable care organization that covers 47 counties in Ohio and supports approximately 470,000 children on Medicaid. Under an Ohio Department of Medicaid directive, PFK and the Nationwide Children's Hospital Hematology Department begin a quality improvement project focused on improving the rates of TCDs for the children with SCA.

Design/Methods: Key stakeholders were chosen from NCH Hematology, Ultrasound, Care Navigation Coordinators from Hematology, and Partners for Kids. After reviewing current state process maps and past interventions implemented, a Key Driver Diagram was developed using IHI methodology with the aim of improving TCD rates to over 90% over a 12 mos period - well beyond the national average of 50%.
The team routinely reviewed groups of patient cases that had no TCD for over 24 months to identify potential barriers. Improved communication between service lines identified several interventions and three were implemented: a flexible scheduling option that aligns a TCD with another - already scheduled - healthcare touchpoint, a Friday TCD time slot to coincide with one of the busiest SCA clinic days, and a child-life specialist added to TCDs for children under 4 years old.

Results: Implementation of flexible scheduling to align the TCD with healthcare touchpoints, adding a Friday TCD to busy SCA clinic days, and improving TCD success rates for children 3 years and under, we were able to achieve > 90% TCD rate in a Medicaid-insured population.

Conclusion(s): By combining TCD visit with already scheduled healthcare touchpoints, several social determinants of health barriers were eliminated. Kids missed less school, parents did not have to miss work, and transportation arrangements were not needed. Focusing the healthcare on the family's schedule instead of fitting the family into what works for the healthcare should be considered in more public health interventions.

TCD KDD
TCD KDD PAS.pdfKey Driver Diagram of Transcranial Doppler screenings for Sickle Cell Anemia

TCD rates and count over a rolling 12 mos period
TCD Rates Figure 1.pdfThe rates of Transcranial Doppler Ultrasounds increased as patient-focused interventions were implemented.