Quality Improvement Project Increased Stroke Screening in Children with SCD


A quality improvement initiative exhibited a sustained increase in transcranial Doppler screening rates over an 8-year intervention period.

Jeffrey G. Edwards, MD, MPH | Image Credit: LinkedIn

Jeffrey G. Edwards, MD, MPH

Credit: LinkedIn

A dedicated quality improvement initiative at Boston Children's Hospital led to a sustained increase in transcranial Doppler (TCD) screening adherence among children with sickle cell disease (SCD).1

Medical guidelines, including those from the National Heart, Lung, and Blood Institute, recommend patients with the SCD subtype, sickle cell anemia (SCA), undergo annual TCD screening, which can identify the risk of stroke by measuring major cerebral artery blood velocity.2

“While other quality improvement initiatives have been able to increase adherence to health maintenance investigations for patients with SCD, this is the first study to collect data over such a prolonged period of time and to maintain their improvements over an extended time period,” wrote the investigative team, led by Jeffrey G. Edwards, MD, MPH, division of hematology and oncology at Boston Children’s Hospital.

Although guidelines recommend annual TCD screening, less than half of all eligible patients with SCA nationwide in the United States routinely undergo annual screening.3 Low TCD adherence can be due to factors, including lack of knowledge by both patient and caregiver, access to the procedure, and individuals who were trained to perform the procedure.4

Approximately 500 patients with SCD are followed longitudinally at the institution’s SCD Program, of whom nearly 300 are eligible for any TCD screening.1 However, a limited number of individuals are trained to perform TCD at the institution and eligible patients do not always experience routine TCD screening within 1 year of their previous visit.

As a result, Edwards and colleagues created a unique quality improvement project using automated electronic health record (EHR) data to evaluate the improvement in adherence to TCD screening. Three plan–do–study–act (PDSA) cycles were designed and implemented during the study.

A Specific, Measurable, Achievable, Relevant, and Time-Bound (SMART) aim of the quality improvement initiative was to raise the proportion of eligible patients receiving a TCD within 15 months of the last TCD to ≥95% by January 2021. Once that was met, the analysis set a second SMART aim to maintain TCD adherence at ≥95% for six consecutive months by January 2023.

Patients with conditional TCDs require a shortened interval for repeat TCDs (3–6 months) and those with confirmed abnormal TCDs need a repeat TCD in approximately 2 weeks. This analysis assessed only the adherence to TCD screening for patients with normal/low-risk TCDs.

An interrupted time series (ITS) analysis compared TCD adherence from PSDA cycle 1 to the rates from PDSA Cycles 2 and 3 while accounting for pre-existing trends in TCD adherence. Patients who were nonadherent to TCD screening from April 2022 to March 2023 were categorized as ‘nonadherent.’

Upon analysis, the mean TCD adherence increased from 67% in the first PDSA cycle (January 2015 to September 2020) to 77% in the second PDSA cycle (October 2020 to April 2021) and 92% in the third PDSA cycle (May 2021 to March 2023).

The first SMART aim of a TCD adherence rate ≥95% was achieved in October 2021, with the second SMART aim of sustained TCD adherence ≥95% for six months in a row in March 2022.

Across the ITS analysis of TCD adherence rates, Edwards and colleagues observed a significant difference in the final TCD adherence rate achieved compared with the predicted adherence rate (P <.001). The ITS model estimated a total increase in adherence of 17.9% (95% CI, 5.4–30.3; P = .006) attributed to the interventions from PSDA cycles 2 and 3.

Edwards and colleagues also identified the potential patient and family factors that play a role in the likelihood of missing annual TCD screenings. After multivariate analysis, accounting for sociodemographic variables, was performed, a drive ≥25 miles from the hospital was associated with an increased risk of being overdue for their TCD (odds ratio [OR], 3.05; 95% CI, 1.31 – 7.09).

“These findings, while not unexpected, can be used to support targeted initiatives for families with difficulties maintaining annual screens,” Edwards and colleagues added.


  1. Edwards JG, Yan AP, Yim R, et al. Sustained increase in annual transcranial Doppler screening rates in children with sickle cell disease: A quality improvement project. Pediatr Blood Cancer. Published online May 29, 2024. doi:10.1002/pbc.31088
  2. DeBaun MR, Jordan LC, King AA, et al. American Society of Hematology 2020 guidelines for sickle cell disease: prevention, diagnosis, and treatment of cerebrovascular disease in children and adults. Blood Adv. 2020;4(8):1554-1588. doi:10.1182/bloodadvances.2019001142
  3. Kanter J, Phillips S, Schlenz AM, et al. Transcranial Doppler Screening in a Current Cohort of Children With Sickle Cell Anemia: Results From the DISPLACE Study. J Pediatr Hematol Oncol. 2021;43(8):e1062-e1068. doi:10.1097/MPH.0000000000002103
  4. Cabana MD, Kanter J, Marsh AM, et al. Barriers to Pediatric Sickle Cell Disease Guideline Recommendations. Glob Pediatr Health. 2019;6:2333794X19847026. Published 2019 May 3. doi:10.1177/2333794X19847026
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