A multidisciplinary care pathway for sickle cell pain crises was associated with far fewer emergency visits, hospital admissions and opioid exposure at a Saudi tertiary hospital, according to a retrospective study. During the year after the pathway was introduced, sickle cell-related emergency department visits fell 69.7%, from 14,273 to 4,319. Utilization also dropped from 45.2 to 11.5 visits per patient-year, with the study reporting P<.001 for the comparison.
The pathway was introduced in May 2017 and revised in July after an interim evaluation. It remained in continuous use at the hospital, backed by hospital-wide staff training, a 30-minute target for giving analgesia and an Adult Sickle Cell Unit for stable isolated crises during daytime hours.
Fewer admissions and shorter stays
Annual hospital admissions fell from 520 before implementation to 349 afterward, a reduction of 171 admissions, or 32.9%. Seven-day readmissions fell from 151 to 46, a 69.5% reduction. The readmission rate declined from 29.1% to 13.2%, an absolute drop of 15.9 percentage points. The median hospital stay also shortened, from 11 days to 4.3 days. The study reported P<.001 for the admission and readmission comparisons.
A shift in the drugs used
The changes were not simply a reduction in every opioid. Meperidine and tramadol consumption fell by between 33.4% and 54.1%, with tramadol capsules showing the largest reported decline. At the same time, morphine use increased 41.2%. The formulation comparisons all had P<.001.
Researchers standardized opioid use to oral morphine milligram equivalents, or MME, by converting dispensed units and injectable doses into oral equivalents. Total annual exposure fell from approximately 1,287,865 to 1,007,580 MME, a 21.8% reduction. Exposure per patient-year fell from approximately 4,075 to 2,694 MME, a 33.9% reduction.
Estimated savings, with a narrow accounting
The researchers estimated annual direct savings of 410,709 Saudi Riyals, approximately 109,522 US dollars. The estimate included 342,000 Riyals attributed to fewer admissions and 68,709 Riyals attributed to lower opioid use. The admission calculation used 171 fewer admissions at an estimated direct cost of 2,000 Riyals each.
The estimate covered gross direct costs and excluded overhead, so it was not a comprehensive calculation of the pathway's full economic value.
What the comparison can, and cannot, show
The study compared two consecutive 12-month periods at a 500-bed tertiary referral hospital: May 2016 to April 2017, before implementation, and May 2017 to April 2018, afterward. It included patients aged 12 years or older with confirmed HbSS, HbSC or HbS/beta-thalassemia who presented with an isolated vaso-occlusive crisis. The final cohorts contained 316 unique patients before the pathway and 374 afterward.
Researchers used emergency department registration records, electronic forms and the OASIS hospital information system. They analyzed the before-and-after differences with t-tests and chi-square tests, described monthly emergency trends and calculated 95% confidence intervals for readmission rates. No multivariable adjustment was performed for genotype distribution or broader changes over time.
Because this was an uncontrolled before-and-after comparison, it cannot show that the pathway alone caused the changes. The cohorts also differed in genotype mix: HbSS accounted for 67.7% of the pre-pathway group and 85.3% of the post-pathway group, a difference reported as P<.001. The analysis did not adjust for that imbalance.
The study reported incomplete pathway adherence and did not collect patients' own assessments of pain relief, satisfaction or quality of life. Its single-hospital setting and uncontrolled design limit causal attribution and generalizability.
The next test
The findings point to an association between the pathway and lower emergency use, admissions, readmissions, length of stay, direct costs and overall opioid exposure. Prospective, multicenter studies with genotype-adjusted analyses would be needed to determine whether the pattern is reproducible and whether it extends to other hospitals.
No funding was reported.
Paper data and sources
Original title: Clinical pathway implementation for adult sickle cell vaso-occlusive crises: Impact on healthcare utilization, opioid prescribing, and costs.
Authors: Alhartani AM, Binmahfouz LS, Alhazmi I, Jambi A
Journal/Repository: Annals of Saudi medicine
Status: Peer-reviewed
First online: 2026-10-01
DOI: 10.5144/0256-4947.2026.319
Original paper · Full text