Background: Hydroxyurea is an FDA approved medication for use in adults with sickle cell disease. Clinical guidelines, based on high quality evidence, recommend its use in all adults with sickle cell anemia and 3 or more moderate to severe pain crises within one year. Studies suggest its use to be inappropriately low. We assessed local physician trends and the usage of hydroxyurea in the management of sickle cell anemia and pain crises.
Methods: We retrospectively reviewed a database of patients with sickle cell anemia who were being followed in a hematology clinic. Patients were identified based on ICD codes for HbSS disease along with the following: pain crises, sickle cell crises, acute chest syndrome, pain in limbs, and splenic sequestration. Selected patients had 3 or more hospitalizations or emergency department visits within one year of chart review. We evaluated treatment and prescriptions for hydroxyurea following the third episode. A p-value of <0.05 was statistically significant.
Results: 28 patients had at least 3 pain-related hospitalizations or ED visits within 12 months. Among them, 12 were treated with hydroxyurea on follow-up subsequent to their third hospitalization. Barriers to use, as identified in the electronic medical record, included physician concern of side effects, concerns regarding contraception status, and problem with cost. It was unclear whether limited use of hydroxyurea stemmed from provider attitudes regarding treatment or patient preference. Consultation to a specialty hematology clinic occurred for only 10% of visits. The most frequent cited reasons for hydroxyurea use were frequent painful crises, chronic pain with frequent narcotic use, and acute chest syndrome.
Conclusions: Hydroxyurea is an important and effective therapy for patients with sickle cell disease. Despite its documented evidence demonstrating benefit in sickle cell patients with frequent pain crises, our results suggest underuse in by physicians in our studied health care facility. Prior studies showed similar trends. Further research is needed to identify barriers to treatment, including lack of comfort from prescribing physicians, lack of subspecialty hematology referral, cost, and/or physician beliefs regarding treatment efficacy. Our data includes a largely insured population, with more access to specialty care. We hypothesize that hydroxyurea use would be less in an underserved region, such as a major academic medical center. We hope to institute a quality improvement initiative to enhance patient outreach, clinical training, and quality measures to increased hydroxyurea use for sickle cell patients with frequent crises.