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Published on: January 18, 2018
Utilization of TCD screening for primary stroke prevention in children with sickle cell disease
J Armstrong-Wells1, B Grimes, S Sidney
1University of California, San Francisco, Department of Neurology, Box 0114, 505 Parnassus Avenue, San Francisco, CA 94143-0114, USA.
Insights
Transcranial Doppler ultrasonography (TCD) screening for sickle cell disease (SCD) increased sixfold after a key trial. TCD screening significantly reduced stroke rates in children, though distance to labs remains a barrier.
Area of Science:
- Pediatric Neurology
- Hematology
- Medical Imaging
Background:
- The Stroke Prevention Trial in Sickle Cell Anemia demonstrated over 90% stroke reduction in high-risk children with sickle cell disease (SCD) using blood transfusions guided by transcranial Doppler ultrasonography (TCD) screening.
- This trial established TCD as a critical tool for identifying children with SCD who are at high risk for stroke.
Purpose of the Study:
- To evaluate the utilization trends of TCD screening in children with SCD within a large managed care plan.
- To assess the impact of TCD screening on stroke incidence rates in this pediatric population.
Main Methods:
- Retrospective cohort study of children with SCD from January 1993 to December 2005.
- Life table methods were used to estimate TCD screening rates.
- Cox proportional hazards regression identified predictors of TCD screening; stroke incidence was compared pre- and post-TCD.
Main Results:
- The annual rate of TCD screening in children with SCD increased sixfold from 1.8 per 100 person-years pre-1998 to 11.4 per 100 person-years after 1999.
- Proximity to a vascular laboratory was the sole independent predictor of TCD screening.
- The annualized stroke rate decreased from 0.44 per 100 person-years pre-TCD to 0.19 per 100 person-years post-TCD.
Conclusions:
- TCD screening utilization has significantly increased in children with SCD following the Stroke Prevention Trial in Sickle Cell Anemia.
- Geographic barriers, specifically distance to vascular laboratories, limit screening accessibility.
- Enhancing TCD screening availability is crucial for improving the implementation of this effective primary stroke prevention strategy in SCD.
Background:
In 1998, the Stroke Prevention Trial in Sickle Cell Anemia showed a >90% reduction in stroke rates after blood transfusion therapy in children with sickle cell disease (SCD) identified as high risk with transcranial Doppler ultrasonography (TCD) screening.
Methods:
We studied the utilization of TCD screening in a retrospective cohort of all children with SCD within a large managed care plan from January 1993 to December 2005. Rates of first TCD screening were estimated using life table methods; predictors of TCD were evaluated using Cox proportional hazards regression. Stroke incidence rates were estimated in person-time before (pre-TCD) and after (post-TCD) first TCD.
Results:
The average annual rate of TCD screening in 157 children with SCD was 1.8 per 100 person-years pre-1998, 5.0 from January 1, 1998, to December 31, 1999, and 11.4 after 1999. The only independent predictor of TCD screening was proximity to the vascular laboratory. The annualized stroke rate pre-TCD was 0.44 per 100 person-years, compared to 0.19 post-TCD.
Conclusions:
Since the Stroke Prevention Trial in Sickle Cell Anemia, the rate of transcranial Doppler ultrasonography (TCD) screening in sickle cell disease (SCD) has increased sixfold within a large health care plan. Children living farther from a vascular laboratory are less likely to be screened. Increased availability of TCD screening could improve the utilization of this effective primary stroke prevention strategy.
