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Cao L, Huang YS, Getz KD, Seif AE, Ruiz J, Miller TP, Fisher BT, Aplenc R, Li Y. Applying machine learning to identify pediatric patients with newly diagnosed acute lymphoblastic leukemia using administrative data. Pediatr Blood Cancer 2024; 71:e30858. [PMID: 38189744 DOI: 10.1002/pbc.30858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/22/2023] [Accepted: 12/24/2023] [Indexed: 01/09/2024]
Abstract
Case identification in administrative databases is challenging as diagnosis codes alone are not adequate for case ascertainment. We utilized machine learning (ML) to efficiently identify pediatric patients with newly diagnosed acute lymphoblastic leukemia. We tested nine ML models and validated the best model internally and externally. The optimal model had 97% positive predictive value (PPV) and 99% sensitivity in internal validation; 94% PPV and 82% sensitivity in external validation. Our ML model identified a large cohort of 21,044 patients, demonstrating an efficient approach for cohort assembly and enhancing the usability of administrative data.
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Affiliation(s)
- Lusha Cao
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Yuan-Shung Huang
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kelly D Getz
- Department of Biostatistics, Epidemioloy and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Alix E Seif
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jenny Ruiz
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Division of Hematology-Oncology, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Tamara P Miller
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Brian T Fisher
- Department of Biostatistics, Epidemioloy and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Richard Aplenc
- Department of Biostatistics, Epidemioloy and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yimei Li
- Department of Biostatistics, Epidemioloy and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Schladerer SP, Otth M, Scheinemann K. Quality criteria for pediatric oncology centers: A systematic literature review. Cancer Med 2023; 12:18999-19012. [PMID: 37584279 PMCID: PMC10557895 DOI: 10.1002/cam4.6452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 07/20/2023] [Accepted: 08/03/2023] [Indexed: 08/17/2023] Open
Abstract
INTRODUCTION Survival of children and adolescents diagnosed with cancer improved over the last decades due to better diagnostics, treatment, and supportive care. Quality criteria that measure, compare, and make the quality of care of individual pediatric oncology centers more transparent are heterogeneous and inconsistent. AIM With this systematic review, we aimed to summarize existing quality criteria for pediatric oncology centers in countries with highly developed health-care systems. METHODS We searched three databases for publications, and websites for guidelines about quality criteria for pediatric oncology centers in February 2022. We considered all types of publications except expert opinions. We excluded publications not focusing on highly developed health-care systems, addressing the certification of professionals, or focusing on subspecialties (e.g., pediatric neuro-oncology). We discarded quality criteria if they were too specific (e.g., for a specific treatment center), too broad (e.g., national 5-year overall survival), or if the aspect was covered by standardized clinical procedures or at the national level. We grouped the identified criteria thematically. RESULTS We identified 18 publications and guideline documents with 530 criteria, of which 201 fulfilled the inclusion criteria. The combination of similar criteria resulted in 90 overarching criteria, which we assigned to the following categories: facilities and networks, multidisciplinary team and other experts, supportive care, treatment, long-term care, and volume and numbers. CONCLUSION Our results provide a comprehensive overview of existing quality criteria for pediatric oncology in countries with highly developed health-care systems. These criteria can serve as a basis to develop national quality criteria in pediatric oncology.
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Affiliation(s)
- Sarah P. Schladerer
- Faculty of Health Sciences and MedicineUniversity of LucerneLucerneSwitzerland
| | - Maria Otth
- Faculty of Health Sciences and MedicineUniversity of LucerneLucerneSwitzerland
- Pediatric Hematology‐Oncology CenterChildren's Hospital of Eastern SwitzerlandSt GallenSwitzerland
- Department of Oncology, Hematology, Immunology, Stem Cell Transplantation and Somatic Gene TherapyUniversity Children's Hospital Zurich‐Eleonore FoundationZurichSwitzerland
| | - Katrin Scheinemann
- Faculty of Health Sciences and MedicineUniversity of LucerneLucerneSwitzerland
- Pediatric Hematology‐Oncology CenterChildren's Hospital of Eastern SwitzerlandSt GallenSwitzerland
- Department of PediatricsMcMaster Children's Hospital and McMaster UniversityHamiltonCanada
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Rees CA, Neuman MI, Monuteaux MC, Michelson KA, Duggan CP. Mortality During Readmission Among Children in United States Children's Hospitals. J Pediatr 2022; 246:161-169.e7. [PMID: 35364094 PMCID: PMC9233053 DOI: 10.1016/j.jpeds.2022.03.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/28/2022] [Accepted: 03/24/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To identify demographic, clinical, and hospital factors associated with mortality on readmission within 180 days following an inpatient hospitalization. STUDY DESIGN We conducted a retrospective cohort study including 33 US children's hospitals in the Pediatric Health Information System from January 2010 to June 2020. Our primary outcome was death during readmission within 180 days of an index hospitalization among children aged 0-18 years. Illness severity during the index hospitalization was defined according to the All Patient-Refined Diagnosis-Related Group-categorized illness severity (ie, minor, moderate, or major/extreme). We performed multivariable logistic regression analysis to identify factors during the index hospitalization associated with mortality during readmission. RESULTS Among 2 677 111 children discharged, 337 385 (12.6%) were readmitted within 180 days of the index hospitalization and 2913 (0.8%) died during readmission. More than one-quarter (26.2%) of deaths among children who were readmitted and died occurred within 10 days after discharge from the index hospitalization. Factors independently associated with mortality during readmission included multiple complex chronic conditions, index admissions lasting >7 days, moderate or severe/extreme illness during the index hospitalization, and public insurance. Children whose race was reported as Black had greater odds of mortality during readmission compared with children of other races. CONCLUSIONS Among hospitalized children, several demographic and clinical factors present during index hospitalizations were associated with mortality during readmission. Greater odds of mortality during readmission among children whose race was reported as Black likely reflects disparities in social determinants of health and clinical care. Interventions to reduce mortality during readmission may target high-risk populations in the period immediately following discharge.
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Affiliation(s)
- Chris A. Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America,Children's Healthcare of Atlanta, Atlanta, Georgia, United States of America
| | - Mark I. Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Michael C. Monuteaux
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Kenneth A. Michelson
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Christopher P. Duggan
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America,Center for Nutrition, Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, Massachusetts, United States of America
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Tan O, Schofield DJ, Shrestha R. An Analysis of Hospital Costs for Childhood Cancer Care. J Natl Compr Canc Netw 2021; 20:126-135. [PMID: 34359019 DOI: 10.6004/jnccn.2020.7802] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 12/23/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND This study used a linked dataset consisting of all childhood cancers recorded over the course of 10 years in New South Wales (NSW), Australia, to evaluate the hospital and emergency department costs (from a payer perspective) and resources used by patients with childhood cancer. We also analyzed determinants responsible for high-frequency hospital admissions, hospital length of stay (LoS), and hospital costs. METHODS We analyzed linked data at the individual patient level for a retrospective cohort of 2,966 patients with cancer aged <18 years with a diagnosis date between 2001 and 2012 from the NSW Central Cancer Registry, Australia. We reported costs and use of hospitalization and emergency department presentation 1 year before the date of diagnosis, 1 year after diagnosis, and 2 to 5 years after diagnosis. We also examined the association between cancer types and hospital admission and hospital costs from the payer perspective. Patient characteristics associated with the frequency of hospital admissions, hospital LoS, and hospital costs were also determined using a generalized linear model. RESULTS Most hospital admission costs occurred in the first year after diagnosis, accounting for >70% of hospital costs within 5 years after diagnosis. The estimated median annual cost of hospitalization in the first year after diagnosis was A$88,964 (interquartile range [IQR], A$34,399-A$163,968) for patients diagnosed at age 0 to 14 years and A$23,384 (IQR, A$5,585-A$91,565) for those diagnosed at age 15 to 17 years. Higher frequency of hospital admissions, hospital LoS, and hospital costs were significantly associated with younger age at cancer diagnosis, cancer metastases, and living in remote/disadvantaged socioeconomic areas. CONCLUSIONS Our study represents one of the first in Australia to include detailed hospitalization cost information for all childhood cancer cases. This study highlights the high hospital use by pediatric patients and the importance of early diagnosis. Our findings also demonstrate the health inequities experienced by patients from remote areas and the lowest socioeconomic areas.
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Affiliation(s)
- Owen Tan
- 1GenIMPACT: Centre for Economic Impacts of Genomic Medicine, Macquarie Business School, Macquarie University, Sydney, Australia
| | - Deborah J Schofield
- 1GenIMPACT: Centre for Economic Impacts of Genomic Medicine, Macquarie Business School, Macquarie University, Sydney, Australia
| | - Rupendra Shrestha
- 1GenIMPACT: Centre for Economic Impacts of Genomic Medicine, Macquarie Business School, Macquarie University, Sydney, Australia
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Agulnik A, Cárdenas A, Carrillo AK, Bulsara P, Garza M, Alfonso Carreras Y, Alvarado M, Calderón P, Díaz R, de León C, Del Real C, Huitz T, Martínez A, Miralda S, Montalvo E, Negrín O, Osuna A, Perez Fermin CK, Pineda E, Soberanis D, Juárez Tobias MS, Lu Z, Rodriguez-Galindo C. Clinical and organizational risk factors for mortality during deterioration events among pediatric oncology patients in Latin America: A multicenter prospective cohort. Cancer 2021; 127:1668-1678. [PMID: 33524166 PMCID: PMC8248122 DOI: 10.1002/cncr.33411] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/02/2020] [Accepted: 12/03/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hospitalized pediatric hematology-oncology (PHO) patients have frequent clinical deterioration events (CDE) requiring intensive care unit (ICU) admission, particularly in resource-limited settings. The objective of this study was to describe CDEs in hospitalized PHO patients in Latin America and to identify event-level and center-level risk factors for mortality. METHODS In 2017, the authors implemented a prospective registry of CDEs, defined as unplanned transfers to a higher level of care, use of ICU-level interventions on the floor, or nonpalliative floor deaths, in 16 PHO centers in 10 countries. PHO hospital admissions and hospital inpatient days were also reported. This study analyzes the first year of registry data (June 2017 to May 2018). RESULTS Among 16 centers, 553 CDEs were reported in PHO patients during 11,536 admissions and 119,414 inpatient days (4.63 per 1000 inpatient days). Event mortality was 29% (1.33 per 1000 inpatient days) but ranged widely across centers (11%-79% or 0.36-5.80 per 1000 inpatient days). Significant risk factors for event mortality included requiring any ICU-level intervention on the floor and not being transferred to a higher level of care. Events with organ dysfunction, a higher severity of illness, and a requirement for ICU intervention had higher mortality. In center-level analysis, hospitals with a higher volume of PHO patients, less floor use of ICU intervention, lower severity of illness on transfer, and lower rates of floor cardiopulmonary arrest had lower event mortality. CONCLUSIONS Hospitalized PHO patients who experience CDEs in resource-limited settings frequently require floor-based ICU interventions and have high mortality. Modifiable hospital practices around the escalation of care for these high-risk patients may contribute to poor outcomes. Earlier recognition of critical illness and timely ICU transfer may improve survival in hospitalized children with cancer.
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Affiliation(s)
- Asya Agulnik
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee.,Division of Critical Care, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Adolfo Cárdenas
- Critical Care Medicine, Hospital Infantil Teletón de Oncología, Queretaro, Mexico
| | - Angela K Carrillo
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Purva Bulsara
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Marcela Garza
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee
| | | | - Manuel Alvarado
- Critical Care, Hospital del Niño Dr. José Renán Esquivel, Panama City, Panama
| | - Patricia Calderón
- Oncology, Hospital Infantil Manuel de Jesús Rivera, Managua, Nicaragua
| | - Rosdali Díaz
- Pediatric Oncology, Instituto Nacional de Enfermedades Neoplásicas, Lima, Peru
| | - Claudia de León
- Pediatric Critical Care, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | - Claudia Del Real
- Pediatric Oncology, Benemérito Hospital General con Especialidades ¨Juan María de Salvatierra", La Paz, Mexico
| | - Tania Huitz
- Pediatric Oncology, Centro Estatal de Oncología de Campeche, Campeche, Mexico
| | | | - Scheybi Miralda
- Pediatric Critical Care, Hospital Escuela Universitario, Tegucigalpa, Honduras
| | - Erika Montalvo
- Pediatric Critical Care, Sociedad de Lucha contra el Cáncer Núcleo de Quito, Quito, Ecuador
| | - Octavia Negrín
- Hematology, Hospital Infantil Dr. Robert Reid Cabral, Santo Domingo, Dominican Republic
| | - Alejandra Osuna
- Hematology/Oncology, Hospital Pediátrico de Sinaloa, Sinaloa, Mexico
| | - Clara Krystal Perez Fermin
- Hematology/Oncology, Hospital Infantil Regional Universitario Dr. Arturo Guillón, Santiago, Dominican Republic.,Biomedical and Clinical Research Center, Santiago, Dominican Republic
| | - Estuardo Pineda
- Oncology, Hospital Nacional de Niños Benjamín Bloom, San Salvador, El Salvador
| | - Dora Soberanis
- Hematology/Oncology, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | | | - Zhaohua Lu
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Carlos Rodriguez-Galindo
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee
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6
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Elgarten CW, Li Y, Getz KD, Hemmer M, Huang YSV, Hall M, Wang T, Kitko CL, Jagasia MH, Nishihori T, Murthy HS, Hashem H, Cairo MS, Sharma A, Hashmi SK, Askar M, Beitinjaneh A, Kelly MS, Auletta JJ, Badawy SM, Mavers M, Aplenc R, MacMillan ML, Spellman SR, Arora M, Fisher BT. Broad-Spectrum Antibiotics and Risk of Graft-versus-Host Disease in Pediatric Patients Undergoing Transplantation for Acute Leukemia: Association of Carbapenem Use with the Risk of Acute Graft-versus-Host Disease. Transplant Cell Ther 2020; 27:177.e1-177.e8. [PMID: 33718896 DOI: 10.1016/j.jtct.2020.10.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Variation in the gastrointestinal (GI) microbiota after hematopoietic cell transplantation (HCT) has been associated with acute graft-versus-host disease (aGVHD). Because antibiotics induce dysbiosis, we examined the association of broad-spectrum antibiotics with subsequent aGVHD risk in pediatric patients undergoing HCT for acute leukemia. We performed a retrospective analysis in a dataset merged from 2 sources: (1) the Center for International Blood and Marrow Transplant Research, an observational transplantation registry, and (2) the Pediatric Health Information Services, an administrative database from freestanding children's hospitals. We captured exposure to 3 classes of antibiotics used for empiric treatment of febrile neutropenia: (1) broad-spectrum cephalosporins, (2) antipseudomonal penicillins, and (3) carbapenems. The primary outcome was grade II-IV aGVHD; secondary outcomes were grade III-IV aGVHD and lower GI GVHD. The adjusted logistic regression model (full cohort) and time-to-event analysis (subcohort) included transplantation characteristics, GVHD risk factors, and adjunctive antibiotic exposures as covariates. The full cohort included 2550 patients at 36 centers; the subcohort included 1174 patients. In adjusted models, carbapenems were associated with an increased risk of grade II-IV aGVHD in the full cohort (adjusted odds ratio [aOR], 1.24; 95% confidence interval [CI], 1.02 to 1.51) and subcohort (sub hazard ratio [HR], 1.31; 95% CI, 0.99 to 1.72), as well as with an increased risk of grade III-IV aGVHD (subHR, 1.77; 95% CI, 1.25 to 2.52). Early carbapenem exposure (before day 0) especially impacted aGVHD risk. For antipseudomonal penicillins, the associations with aGVHD were in the direction of increased risk but were not statistically significant. There was no identified association between broad-spectrum cephalosporins and aGVHD. Carbapenems, more than other broad-spectrum antibiotics, should be used judiciously in pediatric HCT recipients to minimize aGVHD risk. Further research is needed to clarify the mechanism underlying this association.
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Affiliation(s)
- Caitlin W Elgarten
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Yimei Li
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA
| | - Kelly D Getz
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA
| | | | - Yuan-Shung V Huang
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Tao Wang
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
| | - Carrie L Kitko
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | | | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Hemant S Murthy
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL
| | - Hasan Hashem
- Division of Pediatric Hematology/Oncology and Bone Marrow Transplantation, King Hussein Cancer Center, Amman, Jordan
| | - Mitchell S Cairo
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Department of Pediatrics, New York Medical College, Valhalla, NY
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN
| | - Shahrukh K Hashmi
- Department of Internal Medicine, Mayo Clinic, Rochester, MN.,Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Medhat Askar
- Department of Pathology and Laboratory Medicine, Baylor University Medical Center, Dallas, TX
| | - Amer Beitinjaneh
- Division of Transplantation and Cellular Therapy, University of Miami, Miami, FL
| | - Matthew S Kelly
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, NC
| | - Jeffery J Auletta
- Blood and Marrow Transplant Program and Host Defense Program, Divisions of Hematology/Oncology/Bone Marrow Transplant and Infectious Diseases, Nationwide Children's Hospital, Columbus, OH
| | - Sherif M Badawy
- Division of Hematology, Oncology and Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Melissa Mavers
- Division of Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Bass Center for Childhood Cancer and Blood Diseases, Stanford University School of Medicine, Palo Alto, CA
| | - Richard Aplenc
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA
| | - Margaret L MacMillan
- Blood and Marrow Transplant Program, Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | | | - Mukta Arora
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, MN
| | - Brian T Fisher
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA.,Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA
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West ZE, Castellino SM, Monroe C, Thomas AS, McCracken C, Miller TP. Quantifying the difference in risk of adverse events by induction treatment regimen in pediatric acute lymphoblastic leukemia. Leuk Lymphoma 2020; 62:899-908. [PMID: 33258395 DOI: 10.1080/10428194.2020.1852471] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The differences in overall morbidity by induction treatment regimen for pediatric acute lymphoblastic leukemia (ALL) are unknown. We examined a cohort of children with ALL who received induction chemotherapy between January 2010 and May 2018. We evaluated 20 clinically relevant adverse events (AEs) and readmission and ICU admission rates. Outcomes were compared between standard 3- and 4-drug treatment regimens in multivariate analyses using Cox proportional hazard ratios. Among 486 eligible patients, the risks of sepsis (HR = 2.16, 95% CI = 1.11-4.19), hypoxia (HR = 2.08, 95% CI = 1.03-4.18), hyperbilirubinemia (HR = 2.48, 95% CI = 1.07-5.74), hyperglycemia (HR = 2.65, 95% CI = 1.29-5.42), thromboembolic event (HR = 4.50, 95% CI = 1.30-15.6), and hyponatremia (HR = 7.88, 95% CI = 1.26-49.4) were significantly higher during 4-drug induction. Despite no differences in readmission or ICU admission rates, 4-drug induction patients had greater total inpatient days (12 vs. 4 days; p<.0001). In conclusion, pediatric patients receiving 4-drug induction for ALL experience higher morbidity. These results inform care practices and patient guidance during induction therapy.
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Affiliation(s)
- Zachary E West
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Sharon M Castellino
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Caitlin Monroe
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Amanda S Thomas
- Department of Pediatrics, Biostatistics Core, Emory University School of Medicine, Atlanta, GA, USA
| | - Courtney McCracken
- Department of Pediatrics, Biostatistics Core, Emory University School of Medicine, Atlanta, GA, USA
| | - Tamara P Miller
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
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8
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Rotz SJ, Wei W, Thomas SM, Hanna R. Distance to treatment center is associated with survival in children and young adults with acute lymphoblastic leukemia. Cancer 2020; 126:5319-5327. [PMID: 32910494 DOI: 10.1002/cncr.33175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Socioeconomic and demographic categories such as income, race, insurance status, and treatment center type are associated with outcomes in acute leukemia. This study was aimed at determining whether the distance to treatment center affects overall survival for children and young adults with acute leukemia. METHODS The National Cancer Database was queried for patients 39 years old or younger who were diagnosed with acute myeloid leukemia (AML) or acute lymphoblastic leukemia (ALL). A backward elimination procedure was used to select final multivariate Cox models. RESULTS In total, 12,301 patients with AML and 22,683 patients with ALL were analyzed. The ALL model included distance to treatment center, Charlson-Deyo score, age, race, insurance status, and community income level. US census definitions of urban and rural were not statistically significant, and no interaction was significant for included variables. Compared with distances > 50 miles, all other distances were associated with improved survival (hazard ratio [HR] for ≤10 miles, 0.91; P = .04; HR for >10 to ≤20 miles, 0.86; P = .004; HR for >20 to ≤50 miles, 0.87; P = .005). The final model for AML included the same variables as the ALL model except for distance to treatment center, which was not statistically significant. CONCLUSIONS For children and young adults with ALL, distances > 50 miles are associated with inferior overall survival; however, no difference is seen for AML. Although it is unknown whether differences in survival for patients with ALL based on distance are driven by relapse or treatment-related mortality, increased attention to adherence, supportive care, and logistics for patients traveling long distances is warranted. LAY SUMMARY For children and young adults with acute lymphoblastic leukemia, living more than 50 miles from the treatment center is associated with worse outcomes.
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Affiliation(s)
- Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Pediatric Institute, Cleveland Clinic, Cleveland, Ohio
| | - Wei Wei
- Department of Quantitative Health Sciences, Lerner Research Institute Cleveland Clinic, Cleveland, Ohio
| | - Stefanie M Thomas
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Pediatric Institute, Cleveland Clinic, Cleveland, Ohio
| | - Rabi Hanna
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Pediatric Institute, Cleveland Clinic, Cleveland, Ohio
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9
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Regionalization of Isolated Pediatric Femur Fracture Treatment: Recent Trends Observed Using the Kids' Inpatient Database. J Pediatr Orthop 2020; 40:277-282. [PMID: 32501908 DOI: 10.1097/bpo.0000000000001452] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Isolated pediatric femur fractures have historically been treated at local hospitals. Pediatric referral patterns have changed in recent years, diverting patients to high volume centers. The purpose of this investigation was to assess the treatment location of isolated pediatric femur fractures and concomitant trends in length of stay and cost of treatment. METHODS A cross-sectional analysis of surgical admissions for femoral shaft fracture was performed using the 2000 to 2012 Kids' Inpatient Database. The primary outcome was hospital location and teaching status. Secondary outcomes included the length of stay and mean hospital charges. Polytrauma patients were excluded. Data were weighted within each study year to produce national estimates. RESULTS A total of 35,205 pediatric femoral fracture cases met the inclusion criteria. There was a significant shift in the treatment location over time. In 2000, 60.1% of fractures were treated at urban, teaching hospitals increasing to 81.8% in 2012 (P<0.001). Mean length of stay for all hospitals decreased from 2.59 to 1.91 days (P<0.001). Inflation-adjusted total charges increased during the study from $9499 in 2000 to $25,499 in 2012 per episode of treatment (P<0.001). Total charges per hospitalization were ∼$8000 greater at urban, teaching hospitals in 2012. CONCLUSIONS Treatment of isolated pediatric femoral fractures is regionalizing to urban, teaching hospitals. Length of stay has decreased across all institutions. However, the cost of treatment is significantly greater at urban institutions relative to rural hospitals. This trend does not consider patient outcomes but the observed pattern appears to have financial implications. LEVEL OF EVIDENCE Level III-case series, database study.
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Hospital-Level Variability in Broad-Spectrum Antibiotic Use for Children With Acute Leukemia Undergoing Hematopoietic Cell Transplantation. Infect Control Hosp Epidemiol 2018; 39:797-805. [PMID: 29734957 DOI: 10.1017/ice.2018.96] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVETo explore the prevalence and drivers of hospital-level variability in antibiotic utilization among hematopoietic cell transplant (HCT) recipients to inform antimicrobial stewardship initiatives.DESIGNRetrospective cohort study using data merged from the Pediatric Health Information System and the Center for International Blood and Marrow Transplant Research.SETTINGThe study included 27 transplant centers in freestanding children's hospitals.METHODSThe primary outcome was days of broad-spectrum antibiotic use in the interval from day of HCT through neutrophil engraftment. Hospital antibiotic utilization rates were reported as days of therapy (DOTs) per 1,000 neutropenic days. Negative binomial regression was used to estimate hospital utilization rates, adjusting for patient covariates including demographics, transplant characteristics, and severity of illness. To better quantify the magnitude of hospital variation and to explore hospital-level drivers in addition to patient-level drivers of variation, mixed-effects negative binomial models were also constructed.RESULTSAdjusted hospital rates of antipseudomonal antibiotic use varied from 436 to 1121 DOTs per 1,000 neutropenic days, and rates of broad-spectrum, gram-positive antibiotic use varied from 153 to 728 DOTs per 1,000 neutropenic days. We detected variability by hospital in choice of antipseudomonal agent (ie, cephalosporins, penicillins, and carbapenems), but gram-positive coverage was primarily driven by vancomycin use. Considerable center-level variability remained even after controlling for additional hospital-level factors. Antibiotic use was not strongly associated with days of significant illness or mortality.CONCLUSIONAmong a homogenous population of children undergoing HCT for acute leukemia, both the quantity and spectrum of antibiotic exposure in the immediate posttransplant period varied widely. Antimicrobial stewardship initiatives can apply these data to optimize the use of antibiotics in transplant patients.Infect Control Hosp Epidemiol 2018;797-805.
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Maheswaran R, Morley N. Incidence, socioeconomic deprivation, volume-outcome and survival in adult patients with acute lymphoblastic leukaemia in England. BMC Cancer 2018; 18:25. [PMID: 29301507 PMCID: PMC5755332 DOI: 10.1186/s12885-017-3975-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 12/21/2017] [Indexed: 01/29/2023] Open
Abstract
Background We examined incidence and survival in relation to age, gender, socioeconomic deprivation, rurality and trends over time. We also examined the association between volume of patients treated by hospitals and survival. Methods Incident cases (2001–12) were identified using comprehensive National Health Service admissions data for England, with follow-up to March 2013. Socioeconomic deprivation was based on census area of residence. Volume was assessed in a three-year subset of the data with consistent hospital provider codes. Results There were 2921 adults aged 18 or more years diagnosed with acute lymphoblastic leukaemia (ALL) in the 12-year time span, giving a crude annual incidence of 0.61/100,000 population. Five-year survival was 32% (1870 deaths). Compared with patients living in least deprived areas, survival was worse for patients living in intermediate and most deprived areas, with mortality hazard ratios 21% (95% CI 8–35%) and 16% (95% CI 3–30%) higher respectively. Hospitals treating low volumes of adults with ALL were associated with poorer survival. The adjusted mortality hazard ratio in this subset of 465 patients was 33% (95% CI 3–73%) higher in low volume hospitals. There was no evidence of association between socioeconomic deprivation and incidence. Rurality did not appear to be associated with incidence or survival. Incidence was higher in men but there was no evidence of a gender difference in survival. Survival improved over time. Conclusion The associations between socioeconomic deprivation and survival and between volume and outcome for adults with ALL, if confirmed, are likely to have significant implications for the organisation of services for adults with ALL.
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Affiliation(s)
- Ravi Maheswaran
- Public Health GIS Unit, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK.
| | - Nick Morley
- Department of Haematology, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, UK
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