Consistent with our primary hypothesis, our study showed significantly greater health care utilization as indexed by more frequent emergency department visits and hospitalizations among patients with SCD who reported higher perceived discrimination (perceived discrimination) and trait optimism, whereas among patients who reported low optimism, increasing perceived discrimination was associated with a decrease in health care utilization. For length of hospital stay, low optimism was still protective but only in the presence of high discrimination, as the high perceived discrimination and low optimism group reported fewer days per hospitalization.
Patients reporting higher perceived discrimination and optimism may be exhibiting unrealistic levels of optimism, and, ultimately, a greater need for medical assistance to cope with SCD crises. As described above, this style of coping may be associated with adverse health consequences.38,39
We also found that older patients with SCD in the sample reported significantly fewer number of emergency department visits and number of days spent in the hospital. Very little work has compared functioning in older and younger patients, although one study also found that older patients with SCD reported significantly fewer number of emergency department visits than younger patients.54
This study also reported that older patients utilized greater outpatient services. Together, these data suggest that older patients may have different patterns of health care utilization than younger ones. It is possible that survival bias accounts for this discrepancy; older patients with SCD may be hardy survivors who are able to cope more effectively with their disease. These findings may also reflect a treatment preference that changes with age or that has changed over time along with health care structure and availability—creating a culture that encourages younger adults to seek care in an emergency department rather than an outpatient clinic. Possible societal and/or individual moderating variables that change over time or with age should be explored in future prospective studies.
We found a nonsignificant trend for men to report more discrimination than women. This finding is difficult to interpret both because it was only marginally significant and because of the small number of men in our sample. However, this trend does reflect similar findings in national studies that men across races are nearly twice as likely as women to report frequent day-to-day discrimination.55
There are several limitations of the current study that must be acknowledged. First of all, these findings are based on retrospective self-reports for both predictor (eg, perceived discrimination, optimism) and outcome (eg, number of emergency department visits, number of hospitalizations, and number of days spent in the hospital) variables. To confirm that high perceived discrimination is indeed causing a more adverse clinical course in patients with SCD who have high levels of optimism, it will be necessary to conduct a prospective study showing that the perceived discrimination × optimism interaction predicts subsequent number of emergency department visits, number of hospitalizations and number of days spent in the hospital in a larger sample of patients with SCD who are followed over a period of time.
While our indicators of health care utilization approximate the current knowledge regarding progressive SCD severity, these measures may not necessarily represent a valid construct of SCD severity given the potential for confounders in self-reported report data. Moreover, patients who, for example, visit the emergency department regularly or undergo regular hospitalizations may not necessarily be those who are in the greatest need of these services. However, with a paucity of literature on SCD disease progression and a lack of a standard indicator of disease severity, we are limited in our measures. Fortunately, our measures were adapted from previous literature and created alongside SCD physicians who witness and track clinically the real-life difficulties facing patients with SCD.9,53
Since no standard disease indicators exist as they do for other conditions (eg, hypertension, diabetes, or heart disease), the measures of health care utilization may more effectively capture a patient’s SCD-related disability than more objective measures (eg, measure of tissue damage).
In conclusion, the present study’s findings suggest that patients with SCD who have greater optimism but who also report higher levels of perceived discrimination may be susceptible to a more adverse clinical course and greater utilization of medical services. We believe that the current findings require replication in a larger prospective study. Further, to help decrease the cost of patient health care utilization, more studies examining behavioral interventions in the sickle cell population are needed—specifically those targeting psychological factors such as optimism and perceived discrimination.