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Updated: Mar 15, 2026
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Personalized Reminders Increase Screening for Stroke Risk in Children with Sickle Cell Anemia
Devin S Muntz1, David G Bundy1, John J Strouse1
1From the Department of Pediatrics, Division of Pediatric Hematology, Johns Hopkins University School of Medicine, Baltimore, Maryland, the Department of Pediatrics, Medical University of South Carolina, Charleston, and the Division of Hematology, Duke University School of Medicine, Durham, North Carolina.
Insights
A quality improvement intervention significantly increased Transcranial Doppler (TCD) screening for children with sickle cell anemia (SCA), reducing stroke risk. This low-cost approach is effective for smaller sickle cell programs.
Area of Science:
- Neurology
- Pediatrics
- Public Health
Background:
- Sickle cell anemia (SCA) poses a significant stroke risk in children.
- Transcranial Doppler (TCD) ultrasound is crucial for identifying children with SCA at high risk of stroke.
- Increasing TCD screening rates is essential for stroke prevention in pediatric SCA patients.
Purpose of the Study:
- To evaluate a low-cost quality improvement (QI) intervention designed to boost TCD screening rates in children with SCA.
- To assess the effectiveness of a QI program in increasing the proportion of children with SCA receiving timely TCD screenings.
Main Methods:
- A QI program was implemented, involving personalized reminder letters, screening information, and refrigerator magnets with recommended screening dates.
- Screening proportions were compared before (April 2009-July 2010) and after (October 2010-January 2012) the QI intervention.
- Statistical analysis examined the association between age, travel time, distance, and TCD screening rates.
Main Results:
- TCD screening rates increased from 54% at baseline to 79% after QI implementation (P = 0.0001).
- The QI intervention eliminated the negative association between older age and screening rates observed at baseline.
- Travel time and distance were not significant factors influencing screening rates before or after the intervention; the number needed to treat was four.
Conclusions:
- A low-cost QI intervention effectively and feasibly increased TCD screening in children with SCA.
- This QI approach proved more successful than other intervention models and is suitable for smaller sickle cell programs.
- The intervention's success highlights the potential for scalable strategies to improve stroke risk assessment in pediatric SCA.
Objectives:
Transcranial Doppler ultrasound (TCD) effectively identifies children with sickle cell anemia (SCA) who are at increased risk of stroke. We evaluated a low-cost quality improvement (QI) intervention to increase the proportion of children screened by TCD.
Methods:
We measured the proportion of children with SCA receiving appropriate TCD screening for increased cerebral blood velocity, a marker of stroke risk, for time periods before (April 1, 2009-July 1, 2010) and after (October 1, 2010-January 1, 2012) the implementation of a QI program. We sent eligible families personalized reminder letters, information on screening, and a refrigerator magnet imprinted with the recommended date of TCD screening.
Results:
Only 54% (60/112) of children (median age 8 years, range 2.2-16.7 years) had a TCD in the baseline period compared with 79% (87/110; P = 0.0001) after implementation of the QI initiative. The odds of appropriate TCD screening decreased with older age in the baseline period (odds ratio 0.86, 95% confidence interval 0.78-0.94/year; P = 0.001), but not after implementation. Neither predicted travel time by car (median 20 minutes, range 2-164) nor distance traveled (median 9.7 mi, range 0.4-132) was significantly associated with appropriate TCD screening before or after QI implementation. The number needed to treat was four.
Conclusions:
We demonstrated the feasibility and effectiveness of a low-cost QI intervention to increase TCD screening. This approach was more successful than other related intervention models and is easily implemented by smaller sickle cell programs without full-time personnel.
