P3.076: Assessing Care for Pediatric Sickle Cell Warriors in a Kenyan Referral Hospital: A Vital Step Toward Improvement

Purpose/Objectives: Over 75% of infants with sickle cell disease (SCD) are born in Sub-Saharan Africa. Despite healthcare advances, many die before age five. Kenya published national SCD guidelines to standardize clinical practice, but achieving these standards can be challenging. We undertook a quality assessment of outpatient pediatric SCD management at a Kenyan teaching and referral hospital to identify targets for quality improvement (QI).

Design/Methods: We performed a retrospective chart review at Obama Children’s Hospital (OCH) in Kisumu, Kenya. Children who attended the pediatric SCD clinic from May 2022 to May 2023 were identified in a clinic logbook. Paper charts were obtained from medical records and manually reviewed by 4 Kenyan research assistants. Demographics, clinical characteristics, and treatments described in the Kenyan SCD guidelines were transcribed onto paper case report forms, then entered into an electronic REDCap database. Key stakeholders were interviewed to contextualize the data summary. Opportunities to align pediatric SCD care at OCH with national guidelines were identified.

Results: Charts for 260 unique patients were obtained. Half (53%) were male; median age was 4 years (interquartile range (IQR) 2-7); and median number of clinic visits since birth was 4 (IQR 2-6). Less than half of charts (39%, 100/260) documented a prior hospitalization, and 21% (54/260) documented prior malaria infection. Other clinical complications are shown in Table 1. Penicillin and folate prescription rates were high at 77% (105/136 of children < 5 years old) and 93% (242/260) respectively, and proguanil was prescribed to >90% of children for malaria prophylaxis, but 92% (239/260) lacked any immunization documentation. A majority (68% (179/260)) of patients were described as receiving hydroxyurea. Prior to initiation, a complete blood count was reported in 85% (152/179), baseline hemoglobin F in 45% (81/179), and < 20% had renal or hepatic panels. A weight-based hydroxyurea dose could be calculated for 58% (104/179) of those prescribed HU therapy, and 35% (36/104) were outside the recommended range (20-35 mg/kg/day). During interviews, a common theme discussed was the inability of patients/families to obtain medications despite high prescription rates. Providers described significant cost and availability barriers for both proguanil and hydroxyurea, but were more confident about the availability and use of folic acid and penicillin. They also reflected upon the high cost of additional immunizations that were not part of the national immunization program.

Conclusion/Discussion: Providers at OCH were aware of Kenyan SCD guidelines, and prescription of recommended preventive measures was high. Several discrepancies exist between documented care and guideline recommendations (Table 2). Hydroxyurea treatment and objective measures of patient adherence could be improved. Local stakeholders identified consistent documentation and high-quality counseling as appropriate goals for the first iteration of a QI initiative to align care with evidence-based recommendations.