Relative value of different outcomesAdmission rate and mean length of stay were considered to be important outcomes, and drove the GDG discussions and recommendations.
The GDG agreed that where statistical testing was not reported, the overall direction of trends appeared to show a beneficial effect after a sickle cell intervention (this may involve education for staff, a pain protocol or other specialised input) that would be clinically important.
Trade off between benefits and harmsThe GDG recognised that there are geographical areas where there is a high prevalence of sickle cell disease, and that the demand for treatment and management differs across England and Wales. The GDG agreed that daycare facilities are not necessarily already in place in low-prevalence areas, and models of care would need to reflect differing demands and potential changes in prevalence.
The GDG discussed the structure and nature of a daycare setting and suggested that this may facilitate a high concentration of expertise and education. It was agreed that providing training and protocols to staff in emergency departments would increase the quality of care received by patients compared with current practice, and this is reflected in the evidence. It was also proposed that the quality of care may be increased further if these interventions are carried out in a daycare setting.
The GDG agreed that education of healthcare professionals needs to be regular and ongoing, because the evidence shows that reductions in readmission rates were not significant when the educational component was removed.
Economic considerationsVery limited evidence was available to explore the economic impact of providing daycare facilities (see ‘Quality of evidence’, below). An exploratory cost-minimisation analysis based on the UK data reported by Wright et al. (2004) suggested that, by reducing the requirement for hospital inpatient care, daycare units may provide cost savings of up to £1000 per acute painful sickle cell episode. However, this analysis was unable to account for the set-up costs of units, which will be extremely variable, depending on the extent and nature of current provision in each locality, as well as the size of the population that is expected to benefit from the facility.
Quality of evidenceThe GDG agreed that, overall, the evidence was of very low quality. However, it was also acknowledged that it would not be possible to conduct a blinded RCT for this question.
The GDG discussed the value of a body of evidence in other areas that suggests that providing specialist care is in general beneficial compared with non-specialist care, and agreed that this could be applied to patients with sickle cell disease.
The GDG noted that many of the studies were conducted in the USA, where facilities and clinical practice may differ from those in the UK. The GDG discussed the value of the UK-based study (Wright et al. 2004) and felt that evidence from that study was more generalisable than that from the other studies.
Other considerationsSubgroups (children and young people, and pregnant women)
The GDG discussed the treatment of children and young people presenting to hospital with an acute painful sickle cell episode, and agreed that specialist healthcare professionals caring for adults and children would differ. For adults these would include haematologists, pain specialists and other healthcare professionals with expertise in sickle cell disease. For children these would include paediatricians who have haematology as a sub-speciality. Therefore a recommendation was made that patients should be cared for in an age-appropriate setting.
The GDG also discussed the treatment of pregnant women, and agreed that there is generally little difference in the management of an acute painful sickle cell episode in women who are pregnant compared with those who are not pregnant. However, it was agreed that in all cases it will be necessary to seek advice from the obstetrics team.

From: 2, Evidence review and recommendations

Cover of Sickle Cell Acute Painful Episode
Sickle Cell Acute Painful Episode: Management of an Acute Painful Sickle Cell Episode in Hospital.
NICE Clinical Guidelines, No. 143.
Centre for Clinical Practice at NICE (UK).
Copyright © 2012, National Institute for Health and Clinical Excellence.

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