The Association between Educational Attainment and Patterns of Emergency Department Utilization among Adults with Sickle Cell Disease

  • C. R. JonassaintEmail author
  • M. C. Beach
  • J. A. Haythornthwaite
  • S. M. Bediako
  • M. Diener-West
  • J. J. Strouse
  • S. Lanzkron
  • G. Onojobi
  • C. P. Carroll
  • C. HaywoodJr.



Patients with low educational attainment may be at increased risk for unplanned health care utilization. This study aimed to determine what factors are related to emergency department (ED) visits in hopes of guiding treatments and early interventions.


At two medical centers in the Mid-Atlantic United States, 258 adults with sickle cell disease aged 19–70 years participated in a retrospective study where we examined whether education level is independently associated with ED visits after accounting for other socioeconomic status (SES) variables, such as pain and disease severity and psychosocial functioning.


The data showed that patients without a high school education visited the ED three times as frequently as patients with post secondary education. Controlling for poverty and employment status decreased the effect of education on ED visits by 33.24 %. Further controlling for disease severity and/or psychosocial functioning could not account for the remaining association between education and ED visits, suggesting that education is independently associated with potentially avoidable emergency care.


Early interventions addressing disparities in academic performance, especially for those children most at risk, may lead to improved long-term health outcomes in this population.


Sickle cell disease Socioeconomic status Education Health care utilization Health disparities Chronic illness Emergency care Blood disorders 



The primary author would like to thank Andrea Ball for her indispensible intellectual contributions and editing assistance in the preparation of this manuscript.

Study data were collected and managed using REDCap electronic data capture tools hosted at The Johns Hopkins University. REDCap (Research Electronic Data Capture) is a secure, Web-based application designed to support data capture for research studies, providing (1) an intuitive interface for validated data entry; (2) audit trails for tracking data manipulation and export procedures; (3) automated export procedures for seamless data downloads to common statistical packages; and (4) procedures for importing data from external sources.


This study was funded by NHLBI grant no. 5R01HL088511-04

Dr. Haywood is funded by a career development award from the NHLBI: 5 K01 HL108832 02.

Dr. Jonassaint was supported by grant number K12HS022989 from the Agency for Healthcare Research and Quality.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the NHLBI or the Agency for Healthcare Research and Quality.

Compliance with ethical standards

Conflict of Interest

The authors declare that they have no competing interests.

Ethical Approval

This study was approved by the Howard University and the Johns Hopkins Hospital Institutional Review Boards.

All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Williams TN, Weatherall DJ. World Distribution, Population Genetics, and Health Burden of the Hemoglobinopathies. Cold Spring Harbor Perspectives in Medicine. 2012;2(9). doi: 10.1101/cshperspect.a011692.
  2. 2.
    Hassell KL. Population estimates of sickle cell disease in the U.S. Am J Prev Med. 2010;38(4 Suppl):S512–21. doi: 10.1016/j.amepre.2009.12.022.CrossRefPubMedGoogle Scholar
  3. 3.
    Platt OS, Brambilla DJ, Rosse WF, et al. Mortality in sickle cell disease. Life expectancy and risk factors for early death. N Engl J Med. 1994;330(23):1639–44.CrossRefPubMedGoogle Scholar
  4. 4.
    Lanzkron S, Carroll CP, Haywood Jr C. The burden of emergency department use for sickle-cell disease: an analysis of the national emergency department sample database. Am J Hematol. 2010;85(10):797–9. doi: 10.1002/ajh.21807.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Brousseau DC, Owens PL, Mosso AL, Panepinto JA, Steiner CA. Acute care utilization and rehospitalizations for sickle cell disease. JAMA. 2010;303(13):1288–94. doi: 10.1001/jama.2010.378.CrossRefPubMedGoogle Scholar
  6. 6.
    Wolfson JA, Schrager SM, Khanna R, Coates TD, Kipke MD. Sickle cell disease in California: sociodemographic predictors of emergency department utilization. Pediatr Blood Cancer. 2012;58(1):66–73. doi: 10.1002/pbc.22979.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Yusuf HR, Atrash HK, Grosse SD, Parker CS, Grant AM. Emergency department visits made by patients with sickle cell disease: a descriptive study, 1999–2007. Am J Prev Med. 2010;38(4 Suppl):S536–41. doi: 10.1016/j.amepre.2010.01.001.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Lanzkron S, Haywood Jr C, Segal JB, Dover GJ. Hospitalization rates and costs of care of patients with sickle-cell anemia in the state of Maryland in the era of hydroxyurea. Am J Hematol. 2006;81(12):927–32. doi: 10.1002/ajh.20703.CrossRefPubMedGoogle Scholar
  9. 9.
    Steiner CA, Miller JL. Sickle cell disease patients in U.S. hospitals, 2004. Rockville, MD: Agency for Health Care Quality; 2006.Google Scholar
  10. 10.
    Epstein RM, Shields CG, Franks P, Meldrum SC, Feldman M, Kravitz RL. Exploring and validating patient concerns: relation to prescribing for depression. Ann Fam Med. 2007;5(1):21–8.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Wolfson JA, Schrager SM, Coates TD, Kipke MD. Sickle-cell disease in California: a population-based description of emergency department utilization. Pediatr Blood Cancer. 2011;56(3):413–9. doi: 10.1002/pbc.22792.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Carroll CP, Haywood C, Fagan P, Lanzkron S. The course and correlates of high hospital utilization in sickle cell disease: evidence from a large, urban Medicaid managed care organization. Am J Hematol. 2009;84(10):666–70. doi: 10.1002/ajh.21515.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Herron S, Bacak SJ, King A, DeBaun MR. Inadequate recognition of education resources required for high-risk students with sickle cell disease. Arch Pediatr Adolesc Med. 2003;157(1):104.CrossRefPubMedGoogle Scholar
  14. 14.
    King A, Herron S, McKinstry R, et al. A multidisciplinary health care team's efforts to improve educational attainment in children with sickle-cell anemia and cerebral infarcts. J Sch Health. 2006;76(1):33–7. doi: 10.1111/j.1746-1561.2006.00064.x.CrossRefPubMedGoogle Scholar
  15. 15.
    Smith KE, Patterson CA, Szabo MM, Tarazi RA, Barakat LP. Predictors of academic achievement for school age children with sickle cell disease. Adv Sch Ment Health Promot. 2013;6(1):5–20. doi: 10.1080/1754730X.2012.760919.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Jonassaint CR, Beach MC, Lanzkron S, Haywood Jr C. How is patient socioeconomic status related to health care utilization in sickle cell disease? Annual National Sickle Cell Disease Scientific Meeting. 2011.Google Scholar
  17. 17.
    Arendt JN. In sickness and in health–till education do us part: education effects on hospitalization. Econ Educ Rev. 2008;27(2):161–72.CrossRefGoogle Scholar
  18. 18.
    Woods K, Karrison T, Koshy M, Patel A, Friedmann P, Cassel C. Hospital utilization patterns and costs for adult sickle cell patients in Illinois. Public Health Rep. 1997;112(1):44–51.PubMedPubMedCentralGoogle Scholar
  19. 19.
    Haque A, Telfair J. Socioeconomic distress and health status: the urban–rural dichotomy of services utilization for people with sickle cell disorder in North Carolina. J Rural Health. 2000;16(1):43–55.CrossRefPubMedGoogle Scholar
  20. 20.
    Telfair J, Haque A, Etienne M, Tang S, Strasser S. Rural/urban differences in access to and utilization of services among people in Alabama with sickle cell disease. Public Health Rep. 2003;118(1):27–36.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Ellison AM, Bauchner H. Socioeconomic status and length of hospital stay in children with vaso-occlusive crises of sickle cell disease. J Natl Med Assoc. 2007;99(3):192–6.PubMedPubMedCentralGoogle Scholar
  22. 22.
    Aisiku IP, Smith WR, McClish DK, et al. Comparisons of high versus low emergency department utilizers in sickle cell disease. Ann Emerg Med. 2009;53(5):587–93. doi: 10.1016/j.annemergmed.2008.07.050.CrossRefPubMedGoogle Scholar
  23. 23.
    Smith WR, Penberthy LT, Bovbjerg VE, et al. Daily assessment of pain in adults with sickle cell disease. Ann Intern Med. 2008;148(2):99–101.CrossRefGoogle Scholar
  24. 24.
    Reese FL, Smith WR. Psychosocial determinants of health care utilization in sickle cell disease patients. Ann Behav Med. 1997;19(2):171–8.CrossRefPubMedGoogle Scholar
  25. 25.
    Edwards CL, Scales MT, Loughlin C, et al. A brief review of the pathophysiology, associated pain, and psychosocial issues in sickle cell disease. Int J Beh Med. 2005;12(3):171–9. doi: 10.1207/s15327558ijbm1203_6.CrossRefGoogle Scholar
  26. 26.
    Start EH, Assistance EL-IPT. The 2011 Health & Human Services (HHS) Poverty Guidelines. Fed Regist. 2011;76(13):3637–8.Google Scholar
  27. 27.
    Edwards R, Telfair J, Cecil H, Lenoci J. Reliability and validity of a self-efficacy instrument specific to sickle cell disease. Behav Res Ther. 2000;38(9):951–63.CrossRefPubMedGoogle Scholar
  28. 28.
    Kohout FJ, Berkman LF, Evans DA, Cornoni-Huntley J. Two shorter forms of the CES-D (Center for Epidemiological Studies Depression) depression symptoms index. J Aging Health. 1993;5(2):179–93. Scholar
  29. 29.
    Grant MM, Gil KM, Floyd MY, Abrams M. Depression and functioning in relation to health care use in sickle cell disease. Ann Behav Med. 2000;22(2):149–57.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Edwards R, Telfair J, Cecil H, Lenoci J. Self-efficacy as a predictor of adult adjustment to sickle cell disease: one-year outcomes. Psychosom Med. 2001;63(5):850–8.CrossRefPubMedGoogle Scholar
  31. 31.
    Maxwell K, Streetly A, Bevan D. Experiences of hospital care and treatment seeking for pain from sickle cell disease: qualitative study. BMJ. 1999;318(7198):1585–90.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Schwartz LA, Radcliffe J, Barakat LP. Associates of school absenteeism in adolescents with sickle cell disease. Pediatr Blood Cancer. 2009;52(1):92–6. doi: 10.1002/pbc.21819.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Wang W, Enos L, Gallagher D, et al. Neuropsychologic performance in school-aged children with sickle cell disease: a report from the Cooperative Study of Sickle Cell Disease. J Pediatr. 2001;139(3):391–7. doi: 10.1067/mpd.2001.116935.CrossRefPubMedGoogle Scholar
  34. 34.
    Day S, Chismark E. The cognitive and academic impact of sickle cell disease. J Sch Nurs. 2006;22(6):330–5.CrossRefPubMedGoogle Scholar
  35. 35.
    Farber MD, Koshy M, Kinney TR. Cooperative study of sickle cell disease: demographic and socioeconomic characteristics of patients and families with sickle cell disease. J Chronic Dis. 1985;38(6):495–505.CrossRefPubMedGoogle Scholar
  36. 36.
    Taras H, Potts-Datema W. Chronic health conditions and student performance at school. J Sch Health. 2005;75(7):255–66. doi: 10.1111/j.1746-1561.2005.00034.x.CrossRefPubMedGoogle Scholar
  37. 37.
    van Heesch MM, Bosma H, Traag T, Otten F. Hospital admissions and school dropout: a retrospective cohort study of the 'selection hypothesis'. Eur J Public Health. 2012;22(4):550–5. doi: 10.1093/eurpub/ckr129.CrossRefPubMedGoogle Scholar
  38. 38.
    Chua-Lim C, Moore RB, McCleary G, Shah A, Mankad VN. Deficiencies in school readiness skills of children with sickle cell anemia: a preliminary report. South Med J. 1993;86(4):397–402.CrossRefPubMedGoogle Scholar
  39. 39.
    Schatz J, Brown RT, Pascual JM, Hsu L, DeBaun MR. Poor school and cognitive functioning with silent cerebral infarcts and sickle cell disease. Neurology. 2001;56(8):1109–11.CrossRefPubMedGoogle Scholar
  40. 40.
    Vichinsky EP, Neumayr LD, Gold JI, et al. Neuropsychological dysfunction and neuroimaging abnormalities in neurologically intact adults with sickle cell anemia. JAMA. 2010;303(18):1823–31. doi: 10.1001/jama.2010.562.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Mayes S, Wolfe-Christensen C, Mullins LL, Cain JP. Psychoeducational screening in pediatric sickle cell disease: an evaluation of academic and health concerns in the school environment. Child Health Care. 2011;40(2):101–15. doi: 10.1080/02739615.2011.566465.CrossRefGoogle Scholar
  42. 42.
    Dyson SM, Atkin K, Culley LA, Dyson SE, Evans H, Rowley DT. Disclosure and sickle cell disorder: a mixed methods study of the young person with sickle cell at school. Soc Sci Med. 2010;70(12):2036–44. doi: 10.1016/j.socscimed.2010.03.010.CrossRefPubMedGoogle Scholar
  43. 43.
    Dyson SM, Atkin K, Culley LA, Dyson SE. The educational experiences of young people with sickle cell disorder: a commentary on the existing literature. Disabil Soc. 2007;22(6):581–94. doi: 10.1080/09687590701560196.CrossRefGoogle Scholar
  44. 44.
    Koontz K, Short AD, Kalinyak K, Noll RB. A randomized, controlled pilot trial of a school intervention for children with sickle cell anemia. J Pediatr Psychol. 2004;29(1):7–17.CrossRefPubMedGoogle Scholar
  45. 45.
    Dyson SM, Atkin K, Culley LA, Dyson SE, Evans H. Sickle cell, habitual dys-positions and fragile dispositions: young people with sickle cell at school. Sociol Health Illn. 2011;33(3):465–83. doi: 10.1111/j.1467-9566.2010.01301.x.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Muennig P, Schweinhart L, Montie J, Neidell M. Effects of a prekindergarten educational intervention on adult health: 37-year follow-up results of a randomized controlled trial. Am J Public Health. 2009;99(8):1431–7. doi: 10.2105/AJPH.2008.148353.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© International Society of Behavioral Medicine 2016

Authors and Affiliations

  • C. R. Jonassaint
    • 1
    Email author
  • M. C. Beach
    • 2
  • J. A. Haythornthwaite
    • 2
  • S. M. Bediako
    • 4
  • M. Diener-West
    • 3
  • J. J. Strouse
    • 2
  • S. Lanzkron
    • 2
  • G. Onojobi
    • 1
  • C. P. Carroll
    • 2
  • C. HaywoodJr.
    • 2
  1. 1.School of MedicineUniversity of PittsburghPittsburghUSA
  2. 2.School of MedicineJohns Hopkins UniversityBaltimoreUSA
  3. 3.Johns Hopkins Bloomberg School of Public HealthBaltimoreUSA
  4. 4.Department of PsychologyUniversity of Maryland, Baltimore CountyBaltimoreUSA

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