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Pervitsky V, Guglielmo J, Moskoff B, Kneen R, Leija C, Sawicky D, Krackeler ML, Jonas BA, Beechinor R. Characterization of a multidisciplinary team's role in hospital discharge for patients receiving hypomethylating agents with venetoclax as induction therapy for acute myeloid leukemia. Support Care Cancer 2023; 31:224. [PMID: 36941508 DOI: 10.1007/s00520-023-07664-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 03/02/2023] [Indexed: 03/23/2023]
Abstract
PURPOSE Venetoclax combined with a hypomethylating agent (HMA) has become the standard of care for elderly/unfit patients with newly diagnosed acute myeloid leukemia (AML). This study is aimed at characterizing the impact of an interdisciplinary team on the length of stay (LOS) of patients with newly diagnosed AML receiving venetoclax with an HMA. METHODS This retrospective observational study included patients with AML who received HMA with venetoclax as an initial treatment between December 2015 and July 2021. The primary outcome was the median LOS during induction stratified by HMA. Secondary outcomes included barriers to hospital discharge, incidence of tumor lysis syndrome (TLS), response rates, and utilization of the institution's prescription assistance program (PAP). RESULTS Seventy-eight patients were included in our analysis: 51 received azacitidine/venetoclax, and 27 received decitabine/venetoclax. The median LOS from therapy initiation was eight days (range 7-38) for the azacitidine group and six days (range 5-26) for the decitabine group. The most common barriers to discharge were transfusion dependence (33 patients, 42.3%) and insurance coverage (12 patients, 15.4%). Twelve patients (15.3%) had tumor lysis syndrome during hospital admission, and 20 (25.6%) were readmitted during induction. Twenty-three patients (29.5%) required financial assistance for AML care, and a pharmacy-led PAP generated approximately $342,646 in cost savings. CONCLUSION The utilization of an interdisciplinary AML team to target early hospital discharge proved to be safe and effective and led to a reduction in costs for the health system. Future research may identify select patients who may be suitable for earlier discharge or outpatient induction.
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Affiliation(s)
- Vera Pervitsky
- Department of Pharmacy, University of California Davis Medical Center, Sacramento, CA, USA
| | - Julie Guglielmo
- Department of Pharmacy, University of California Davis Medical Center, Sacramento, CA, USA
- University of California, San Francisco School of Pharmacy, San Francisco, CA, 94143, USA
| | - Benjamin Moskoff
- Department of Pharmacy, University of California Davis Medical Center, Sacramento, CA, USA
- University of California, San Francisco School of Pharmacy, San Francisco, CA, 94143, USA
| | - Roxie Kneen
- UC Davis Comprehensive Cancer Center, 2279 45th Street, CA, 95817, Sacramento, USA
- Department of Internal Medicine, Division of Malignant Hematology, Cellular Therapy and Transplantation, University of California Davis School of Medicine, Sacramento, CA, 95817, USA
| | - Carol Leija
- UC Davis Comprehensive Cancer Center, 2279 45th Street, CA, 95817, Sacramento, USA
| | - Deborah Sawicky
- UC Davis Comprehensive Cancer Center, 2279 45th Street, CA, 95817, Sacramento, USA
| | - Margaret Li Krackeler
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Brian A Jonas
- UC Davis Comprehensive Cancer Center, 2279 45th Street, CA, 95817, Sacramento, USA
- Department of Internal Medicine, Division of Malignant Hematology, Cellular Therapy and Transplantation, University of California Davis School of Medicine, Sacramento, CA, 95817, USA
| | - Ryan Beechinor
- University of California, San Francisco School of Pharmacy, San Francisco, CA, 94143, USA.
- UC Davis Comprehensive Cancer Center, 2279 45th Street, CA, 95817, Sacramento, USA.
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2
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Papayannidis C, Nanni J, Cristiano G, Marconi G, Sartor C, Parisi S, Zannoni L, Saed R, Ottaviani E, Bandini L, Testoni N, Baldazzi C, Solli V, Ricci P, Di Giovanni Bezzi C, Abd-Alatif R, Stanzani M, Paolini S, Cavo M, Curti A. Impact of infectious comorbidity and overall time of hospitalization in total outpatient management of acute myeloid leukemia patients following venetoclax and hypomethylating agents. Eur J Haematol Suppl 2022; 108:449-459. [PMID: 35156731 PMCID: PMC9314138 DOI: 10.1111/ejh.13753] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 02/05/2022] [Accepted: 02/07/2022] [Indexed: 12/15/2022]
Abstract
Venetoclax (VEN) and hypomethylating agent (HMAs) regimens are emerging as the standard of care for unfit for chemotherapy acute myeloid leukemia (AML) patients, but the safety and feasibility of a total outpatient management have not been fully investigated. Fifty‐nine AML patients with active disease received VEN and HMAs. Nineteen out of 59 (32.2%) patients received the first cycle as inpatients, whereas 40/59 (67.8%) patients were treated in the outpatient setting. No significant differences were observed with regard to incidence of adverse events (AEs), including tumor lysis syndrome (TLS), and the 30‐day and 60‐day mortality was comparable. Notably, an infectious prophylaxis inspired to that adopted during intensive chemotherapy resulted in a low infection rate with a reduced bacterial infections incidence in out‐ versus hospitalized patients (p < .0001). The overall time of hospitalization was significantly shorter in patients who received a total outpatient treatment as compared to those who received the first cycle as inpatients (5.9 vs. 39.7 days, p < .0001). Despite the adopted differences in treatment management, the efficacy was similar. These data indicate that a total outpatient management of VEN and HMAs is feasible in AML patients without negatively impacting on treatment efficacy and may yield pharmacoeconomic and quality‐of‐life benefits.
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Affiliation(s)
- Cristina Papayannidis
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Jacopo Nanni
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Gianluca Cristiano
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Giovanni Marconi
- IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Chiara Sartor
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Sarah Parisi
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy.,Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Letizia Zannoni
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Rashed Saed
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Emanuela Ottaviani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Lorenza Bandini
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Nicoletta Testoni
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy.,Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Carmen Baldazzi
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Vincenza Solli
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Paolo Ricci
- Assistenza Domiciliare AIL Bologna, Bologna, Italy
| | | | | | - Marta Stanzani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Stefania Paolini
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Michele Cavo
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy.,Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Antonio Curti
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
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3
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Physician and patient perceptions on randomization of treatment intensity for unfit adults with acute myeloid leukemia and other high-grade myeloid neoplasm. Leukemia 2022; 36:1386-1389. [PMID: 35173273 DOI: 10.1038/s41375-022-01524-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/26/2022] [Accepted: 02/03/2022] [Indexed: 11/12/2022]
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4
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Halpern AB, Othus M, Howard NP, Hendrie PC, Percival MEM, Hartley GA, Welch VL, Estey EH, Walter RB. Comparative analysis of infectious complications with outpatient vs. inpatient care for adults with high-risk myeloid neoplasm receiving intensive induction chemotherapy. Leuk Lymphoma 2021; 63:142-151. [PMID: 34608844 DOI: 10.1080/10428194.2021.1984451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
We recently reported an early hospital discharge (EHD) care strategy following intensive acute myeloid leukemia (AML)-like chemotherapy is safe. To evaluate its impact on infectious outcomes, we compared all adults treated from 8/1/2014 to 7/31/2018 discharging within 72 h of completing chemotherapy (EHD) with hospitalized patients (controls) across 354 induction and 259 post-remission cycles. While overall outcomes were similar, gram-positive bacteremias were more common in EHD patients than control (p<.001), although they received fewer days of IV antimicrobials (p< .001). Notably, cumulative infection risks in EHD patients were similar after induction and post-remission therapy. In multivariable analysis, only EHD status was independently associated with risk for gram-positive bacteremia (p= .01), whereas the only independent risk factor for fungal infection was fluconazole (vs. posaconazole) use (p< .001). The observation of increased rates of gram-positive bacteremias with EHD identifies improvements in catheter management as one area to further increase the safety of this care approach.
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Affiliation(s)
- Anna B Halpern
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Megan Othus
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Nicholas P Howard
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Paul C Hendrie
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA
| | - Mary-Elizabeth M Percival
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | | | - Elihu H Estey
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Roland B Walter
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Department of Laboratory Medicine & Pathology, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
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5
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Getz KD, Szymczak JE, Li Y, Madding R, Huang YSV, Aftandilian C, Arnold SD, Bona KO, Caywood E, Collier AB, Gramatges MM, Henry M, Lotterman C, Maloney K, Mian A, Mody R, Morgan E, Raetz EA, Rubnitz J, Verma A, Winick N, Wilkes JJ, Yu JC, Fisher BT, Aplenc R. Medical Outcomes, Quality of Life, and Family Perceptions for Outpatient vs Inpatient Neutropenia Management After Chemotherapy for Pediatric Acute Myeloid Leukemia. JAMA Netw Open 2021; 4:e2128385. [PMID: 34709389 PMCID: PMC8554641 DOI: 10.1001/jamanetworkopen.2021.28385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Pediatric acute myeloid leukemia (AML) requires multiple courses of intensive chemotherapy that result in neutropenia, with significant risk for infectious complications. Supportive care guidelines recommend hospitalization until neutrophil recovery. However, there are little data to support inpatient over outpatient management. OBJECTIVE To evaluate outpatient vs inpatient neutropenia management for pediatric AML. DESIGN, SETTING, AND PARTICIPANTS This cohort study used qualitative and quantitative methods to compare medical outcomes, patient health-related quality of life (HRQOL), and patient and family perceptions between outpatient and inpatient neutropenia management. The study included patients from 17 US pediatric hospitals with frontline chemotherapy start dates ranging from January 2011 to July 2019, although the specific date ranges differed for the individual analyses by design and relative timing. Data were analyzed from August 2019 to February 2020. EXPOSURES Discharge to outpatient vs inpatient neutropenia management. MAIN OUTCOMES AND MEASURES The primary outcomes of interest were course-specific bacteremia incidence, times to next course, and patient HRQOL. Course-specific mortality was a secondary medical outcome. RESULTS Primary quantitative analyses included 554 patients (272 [49.1%] girls and 282 [50.9%] boys; mean [SD] age, 8.2 [6.1] years). Bacteremia incidence was not significantly different during outpatient vs inpatient management (67 courses [23.8%] vs 265 courses [29.0%]; adjusted rate ratio, 0.73; 95% CI, 0.56 to 1.06; P = .08). Outpatient management was not associated with delays to the next course compared with inpatient management (mean [SD] 30.7 [12.2] days vs 32.8 [9.7] days; adjusted mean difference, -2.2; 95% CI, -4.1 to -0.2, P = .03). Mortality during intensification II was higher for patients who received outpatient management compared with those who received inpatient management (3 patients [5.4%] vs 1 patient [0.5%]; P = .03), but comparable with inpatient management at other courses (eg, 0 patients vs 5 patients [1.3%] during induction I; P = .59). Among 97 patients evaluated for HRQOL, outcomes did not differ between outpatient and inpatient management (mean [SD] Pediatric Quality of Life Inventory total score, 70.1 [18.9] vs 68.7 [19.4]; adjusted mean difference, -2.8; 95% CI, -11.2 to 5.6). A total of 86 respondents (20 [23.3%] in outpatient management, 66 [76.7%] in inpatient management) completed qualitative interviews. Independent of management strategy received, 74 respondents (86.0%) expressed satisfaction with their experience. Concerns for hospital-associated infections among caregivers (6 of 7 caregiver respondents [85.7%] who were dissatisfied with inpatient management) and family separation (2 of 2 patient respondents [100%] who were dissatisfied with inpatient management) drove dissatisfaction with inpatient management. Stress of caring for a neutropenic child at home (3 of 3 respondents [100%] who were dissatisfied with outpatient management) drove dissatisfaction with outpatient management. CONCLUSIONS AND RELEVANCE This cohort study found that outpatient neutropenia management was not associated with higher bacteremia incidence, treatment delays, or worse HRQOL compared with inpatient neutropenia management among pediatric patients with AML. While outpatient management may be safe for many patients, course-specific mortality differences suggest that outpatient management in intensification II should be approached with caution. Patient and family experiences varied, suggesting that outpatient management may be preferred by some but may not be feasible for all families. Further studies to refine and standardize safe outpatient management practices are warranted.
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Affiliation(s)
- Kelly D. Getz
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Julia E. Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Yimei Li
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rachel Madding
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Yuan-Shung V. Huang
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Catherine Aftandilian
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Stanford University, Palo Alto, California
| | - Staci D. Arnold
- Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Kira O. Bona
- Pediatric Hematology/Oncology, Children’s Hospital Boston, Boston, Massachusetts
| | - Emi Caywood
- A.I. Dupont Hospital for Children, Nemours, Wilmington, Delaware
| | | | | | | | | | - Kelly Maloney
- Children’s Hospital Colorado and the Department of Pediatrics, University of Colorado School of Medicine, Aurora
| | - Amir Mian
- Arkansas Children’s Hospital, Little Rock
| | | | - Elaine Morgan
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Elizabeth A. Raetz
- Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders, New York, New York
| | - Jeffrey Rubnitz
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Anupam Verma
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of Utah, Salt Lake City
| | - Naomi Winick
- Department of Pediatric Hematology Oncology, University of Texas Southwestern Medical Center, Dallas
| | - Jennifer J. Wilkes
- Department of Pediatrics, University of Washington, Division of Hematology/Oncology, Seattle Children’s Hospital, Seattle
| | - Jennifer C. Yu
- Division of Pediatric Hematology Oncology, Rady Children’s Hospital San Diego, San Diego, California
| | - Brian T. Fisher
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Richard Aplenc
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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6
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Reducing Time to Discharge after Chemotherapy by Standardizing Workflow and Providing Outpatient Intravenous Hydration. Pediatr Qual Saf 2021; 6:e415. [PMID: 34235346 PMCID: PMC8225375 DOI: 10.1097/pq9.0000000000000415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 12/09/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Patients receiving cyclophosphamide or ifosfamide chemotherapy require intravenous fluid hydration to prevent hemorrhagic cystitis. In selected patients without medical contraindications (ie, excess nausea/vomiting), this hydration may be completed after discharge. We aimed to reduce the time to discharge after completing mesna in patients receiving cyclophosphamide or ifosfamide therapy on an inpatient chemotherapy service. Methods The quality improvement team performed a medical record review to capture the time to discharge after mesna therapy and the readmission rate and used quality improvement methods to redesign discharge workflow and increase patient involvement with the discharge process. Results From August 2017 through July 2018, there were 160 admission encounters (73 patients) for cyclophosphamide or ifosfamide on a dedicated chemotherapy service. Of those encounters, 89 (55.6%) were appropriate for outpatient hydration; 48 (53.9%) of these encounters involved a patient who elected to receive outpatient hydration. Although the median time to discharge for the whole cohort did not change, in encounters where patients chose intravenous outpatient hydration, the median time to discharge was reduced from 2.82 to 0.66 hours (76.6% reduction) after implementing the new discharge workflow. No patients experienced readmission within 48 hours. Conclusions Discharge workflow redesign and standardization reduced the time to discharge after chemotherapy in patients who chose outpatient hydration. Outpatient intravenous hydration after cyclophosphamide or ifosfamide appears safe and feasible in selected patient populations.
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Moore NJ, Othus M, Halpern AB, Howard NP, Tang L, Bastys KE, Percival MEM, Hendrie PC, Hartley GA, Welch VL, Estey EH, Walter RB. Financial Implications of Early Hospital Discharge After AML-Like Induction Chemotherapy: A 4-Year Retrospective Analysis. J Natl Compr Canc Netw 2021; 19:1-10. [PMID: 34161925 DOI: 10.6004/jnccn.2020.7683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/03/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Early hospital discharge (EHD) after intensive acute myeloid leukemia (AML) induction chemotherapy has become routine at the University of Washington/Seattle Cancer Care Alliance over the past several years. We assessed the financial implications of EHD over the first 4 years after its broad adoption for patients with AML and other high-grade myeloid neoplasms undergoing AML-like induction chemotherapy. PATIENTS AND METHODS We retrospectively compared charges between 189 patients with EHD who received all postinduction inpatient/outpatient care within our care system between August 2014 and July 2018 and 139 medically matched control patients who remained hospitalized for logistical reasons. Charges from the day of initial discharge (patients with EHD) or end of chemotherapy (control patients) until blood count recovery, additional chemotherapy or care transition, hospital discharge (for control patients only), an elapse of 42 days, or death were extracted from financial databases and separated into categories: facility/provider, emergency department, transfusions, laboratory, imaging, pharmacy, and miscellaneous. RESULTS Combined charges averaged $4,157/day (range, $905-$13,119/day) for patients with EHD versus $9,248/day (range, $4,363-$48,522/day) for control patients (P<.001). The EHD cohort had lower mean facility/provider, transfusion, laboratory, and pharmacy charges but not imaging or miscellaneous charges. During readmissions, there was no statistically significant difference in daily inpatient charges between the EHD and control cohorts. After multivariable adjustment, average charges were $3,837/day lower for patients with EHD (P<.001). CONCLUSIONS Together with previous data from our center showing that EHD is safe and associated with reduced healthcare resource utilization, this study further supports this care approach for AML and other high-grade myeloid neoplasms if infrastructure is available to enable close outpatient follow-up.
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Affiliation(s)
- Nathan J Moore
- 1Department of Medicine, Residency Program, University of Washington
| | - Megan Othus
- 2Public Health Sciences Division, Fred Hutchinson Cancer Research Center
| | - Anna B Halpern
- 3Department of Medicine, Division of Hematology, University of Washington
- 4Clinical Research Division, Fred Hutchinson Cancer Research Center, and
| | - Nicholas P Howard
- 4Clinical Research Division, Fred Hutchinson Cancer Research Center, and
| | - Linyi Tang
- 5Seattle Cancer Care Alliance, Seattle, Washington
| | | | - Mary-Elizabeth M Percival
- 3Department of Medicine, Division of Hematology, University of Washington
- 4Clinical Research Division, Fred Hutchinson Cancer Research Center, and
| | - Paul C Hendrie
- 3Department of Medicine, Division of Hematology, University of Washington
- 5Seattle Cancer Care Alliance, Seattle, Washington
| | | | | | - Elihu H Estey
- 3Department of Medicine, Division of Hematology, University of Washington
- 4Clinical Research Division, Fred Hutchinson Cancer Research Center, and
| | - Roland B Walter
- 3Department of Medicine, Division of Hematology, University of Washington
- 4Clinical Research Division, Fred Hutchinson Cancer Research Center, and
- 7Department of Laboratory Medicine and Pathology, and
- 8Department of Epidemiology, University of Washington, Seattle, Washington
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8
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Outpatient intensive induction chemotherapy for acute myeloid leukemia and high-risk myelodysplastic syndrome. Blood Adv 2021; 4:611-616. [PMID: 32074276 DOI: 10.1182/bloodadvances.2019000707] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 01/07/2020] [Indexed: 02/08/2023] Open
Abstract
To improve patient quality of life and reduce health care costs, many conditions formerly thought to require inpatient care are now treated in the outpatient setting. Outpatient induction chemotherapy for acute myeloid leukemia (AML) may confer similar benefits. This possibility prompted a pilot study to explore the safety and feasibility of intensive outpatient initial or salvage induction chemotherapy administration for adults with AML and high-risk myelodysplastic syndrome (MDS). Patients with no significant organ dysfunction and a treatment-related mortality (TRM) score corresponding to a day 28 mortality rate of <5% to 10% were eligible for study. Patients were treated as outpatients with daily evaluation by providers and only admitted to the hospital if mandated by complications. Twenty patients were consented, and 17 were treated. Eight patients received initial induction chemotherapy and 9 received salvage induction chemotherapy. Fourteen patients completed induction chemotherapy administration in the outpatient setting (82.4%; exact 95% confidence interval [CI], 55.8-95.3). Three patients were admitted during the course of chemotherapy administration, 2 for neutropenic fever and 1 for grade 3 mucositis. No patients died within 14 days of the initiation of induction chemotherapy (exact 95% CI, 0-22.9). Results of this pilot study suggest it is feasible to complete outpatient induction chemotherapy in select patients with AML and high-risk MDS. A team including nurses, social workers, medical providers, and pharmacists was key to the successful implementation of outpatient induction.
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9
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Singh S, Singh J, Paul D, Jain K. Treatment of Acute Leukemia During COVID-19: Focused Review of Evidence. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:289-294. [PMID: 33558204 PMCID: PMC7801183 DOI: 10.1016/j.clml.2021.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/02/2021] [Accepted: 01/06/2021] [Indexed: 01/28/2023]
Abstract
The Coronavirus disease-2019 (COVID-19) pandemic is an unprecedented health care crisis and has led to over 1.5 million deaths worldwide. The risk of severe COVID-19 and mortality is markedly raised in patients with cancer, prompting several collaborative groups to issue guidelines to mitigate the risk of infection by delaying or de-escalating immunosuppressive therapy. However, delayed therapy is often not feasible for patients requiring treatment for acute leukemia or stem cell transplantation. We provide a focused review of the recommendations and evidence for managing this high-risk group of patients while minimizing the risk of COVID-19 infection, and provide a small snapshot of treatment data from our center.
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Affiliation(s)
- Suvir Singh
- Department of Clinical Hematology and Stem Cell Transplantation, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.
| | - Jagdeep Singh
- Department of Medical Oncology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Davinder Paul
- Department of Medical Oncology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Kunal Jain
- Department of Medical Oncology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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10
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Halpern AB, Walter RB. Practice patterns and outcomes for adults with acute myeloid leukemia receiving care in community vs academic settings. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:129-134. [PMID: 33275691 PMCID: PMC7727552 DOI: 10.1182/hematology.2020000097] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Consistent with observations in other disease settings, retrospective studies have indicated that treatment outcomes for adults with acute myeloid leukemia (AML) are better in higher- vs lower-volume hospitals and academic vs nonacademic centers, with greatest benefits noted in acute promyelocytic leukemia. Younger age, more frequent receipt of chemotherapy and hematopoietic cell transplantation, and differences in comorbidities and socioeconomic factors may partially account for these differences. With new therapeutic options including oral small molecule inhibitors and parenteral drugs suitable for outpatient administration, there is increasing interest from patients and physicians in treating AML in the community setting and avoiding referral to academic centers. This may be particularly true for older adults, for whom treatment rates in the community have historically been low, and for those with comorbidities, because treatment benefits are estimated to be low, and thus travel to academic centers is perceived as especially burdensome. How the volume-outcome relationship is affected by the shift of the treatment landscape in AML over the last few years is unknown. Additionally, improvements in supportive care (transfusion support, broad-spectrum oral antimicrobials), resulting in gradually decreasing early death rates over time, and the growing focus on the impact of AML therapy on quality of life and treatment cost concerns further fuel the larger trend toward an increasing proportion of care delivered in the outpatient setting. Here, we examine whether the current shift of administering chemotherapy and supportive care to the outpatient setting can be translated to the community setting without compromising patient outcomes.
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Affiliation(s)
- Anna B. Halpern
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Research Center/University of Washington, Seattle, WA; and
| | - Roland B. Walter
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Research Center/University of Washington, Seattle, WA; and
- Department of Pathology and
- Department of Epidemiology, University of Washington, Seattle, WA
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11
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Wilde L, Isidori A, Keiffer G, Palmisiano N, Kasner M. Caring for AML Patients During the COVID-19 Crisis: An American and Italian Experience. Front Oncol 2020; 10:1689. [PMID: 32984046 PMCID: PMC7492670 DOI: 10.3389/fonc.2020.01689] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/29/2020] [Indexed: 12/19/2022] Open
Abstract
The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the subsequent pandemic have impacted every aspect of oncology care worldwide. Healthcare systems have been forced to rapidly change practices in order to maximize the safety of patients and healthcare providers and preserve scare resources. Patients with acute myeloid leukemia are at increased risk of complications from SARS-CoV-2 not only due to immune compromise related to the malignancy but also due to the acuity of the disease and intensity of treatment. These issues have created unique challenges during this difficult time. In this article, we present the approaches taken by two groups of hematologist/oncologists, one in the United States and one in Italy, who have been caring for acute myeloid leukemia (AML) patients in the face of the pandemic.
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Affiliation(s)
- Lindsay Wilde
- Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
| | - Alessandro Isidori
- Hematology and Stem Cell Transplant Center, AORMN Hospital, Pesaro, Italy
| | - Gina Keiffer
- Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
| | - Neil Palmisiano
- Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
| | - Margaret Kasner
- Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
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12
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Rodrigues ALM, do Nascimento DM, de Lima JM, Reis MLP, Leão LBC, Azevedo MC, Muccini SR, da Silva PC, Carneiro TX. Safety and Feasibility of Outpatient High Dose Cytarabine for Acute Myeloid Leukemia in the Brazilian Amazon. Int J Hematol Oncol Stem Cell Res 2020; 14:151-156. [PMID: 33024520 PMCID: PMC7521396 DOI: 10.18502/ijhoscr.v14i3.3722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: The attempt to manage patients with acute myeloid leukemia as outpatients has become increasingly common due to high hospitalization costs, low availability for beds and patient preference. Publications on the subject are scarce, especially in low-income regions and the safety in this population remains to be determined. The present study aims to assess the safety of consolidation with high-dose cytarabine in the outpatient setting. Materials and Methods: We retrospectively analyzed 39 patients who underwent consolidation with high-dose cytarabine, between 2009 and 2018, at Ophir Loyola Hospital, in Belém, Brazil. Patients treated after 2015 were given high-dose cytarabine as outpatients due to the decision of medical staff. Results: Twenty-seven patients received 76 cycles of cytarabine as outpatients; males were 48.14% of the total population, with a median age of approximately 45 years. The occurrence of delay between cycles was significantly lower among outpatients (48.14% vs. 83.33%, p = 0.04). There was no difference in relapse rates, transfusion requirements and non-relapse mortality between both groups. Hospitalization was required in 40.74% of patients during outpatient cycles and 18.51% of blood cultures were positive for pathogens. Non-relapse mortality was significantly higher among patients above 50 years old and treated on an outpatient basis (44.4% vs. 5.60%, p = 0.03). Conclusion: High-dose cytarabine administration on an outpatient basis appears to be safe and effective in a low-income population at the Brazilian Amazon region, but toxicity seems to be increased for patients older than 50 years.
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Affiliation(s)
| | | | - Josy Marinho de Lima
- Division of Hematology-Oncology and Stem Cell Transplantation, Ophir Loyola Hospital, Belém - PA, Brazil
| | - Marcos Laércio Pontes Reis
- Division of Hematology-Oncology and Stem Cell Transplantation, Ophir Loyola Hospital, Belém - PA, Brazil
| | | | | | | | | | - Thiago Xavier Carneiro
- Division of Hematology-Oncology and Stem Cell Transplantation, Ophir Loyola Hospital, Belém - PA, Brazil
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13
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Abstract
PURPOSE OF REVIEW Patients with acute myeloid leukemia (AML) are almost invariably kept in the hospital until resolution of cytopenias following intensive induction chemotherapy. This care approach is costly and may further contribute to the reduced qualify of life of these patients. This has raised interest in moving at least part of this care to the outpatient setting. Reimbursement challenges for inpatient administration of some of the new drugs approved for AML in the last 2 years adds to this interest. RECENT FINDINGS Retrospective and smaller prospective studies have shown that outpatient management following intensive induction chemotherapy ('Early Hospital Discharge') is feasible and may be well tolerated and cost-effective. Reported experience is more limited regarding administration of intensive chemotherapy in the outpatient setting. SUMMARY Although of interest, barriers to the successful implementation of outpatient care models, such as limited outpatient infrastructure or geographical limitations, will have to be overcome in many cancer centers. Importantly, before wide-spread introduction, the safety and 'efficacy' (e.g. reduction in medical resources and/or cost and improvement in quality of life) of outpatient care strategies will need to be further evaluated in a prospective - and ideally randomized - manner across more heterogeneous types of oncology and geographical settings.
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14
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Talati C, Frantz D, Lubas A, Salamanca C, Tobon K, Kubal T. How I treat newly diagnosed acute myeloid leukemia in an outpatient setting: a multidisciplinary team perspective. Future Oncol 2020; 16:281-291. [PMID: 31985277 DOI: 10.2217/fon-2019-0781] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Historically, patients with acute myeloid leukemia received intensive chemotherapy requiring hospitalization, which can diminish quality of life and increase healthcare costs. The introduction of new therapies facilitated a shift toward outpatient therapy, which requires coordination of a multidisciplinary team, thorough patient evaluation, careful preparation and rigorous patient monitoring. Many patients are candidates for multiple treatment approaches; we generally employ CPX-351 (Vyxeos®) as an intensive outpatient approach and venetoclax (Venclyxto/Venclexta®) plus hypomethylating agents as a lower-intensity approach, with 2-3 visits/week during treatment. Treatment infusions are scheduled in the morning to leave sufficient time for transfusions and other supportive care later the same day, to prevent additional visits. With careful planning and patient monitoring, acute myeloid leukemia treatment can be successfully administered in the outpatient setting.
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Affiliation(s)
- Chetasi Talati
- Moffitt Cancer Center, 12901 Magnolia Drive, Tampa, FL 33612, USA
| | - Diedra Frantz
- Moffitt Cancer Center, 12901 Magnolia Drive, Tampa, FL 33612, USA
| | - Amber Lubas
- Moffitt Cancer Center, 12901 Magnolia Drive, Tampa, FL 33612, USA
| | | | - Katherine Tobon
- Moffitt Cancer Center, 12901 Magnolia Drive, Tampa, FL 33612, USA
| | - Timothy Kubal
- Moffitt Cancer Center, 12901 Magnolia Drive, Tampa, FL 33612, USA
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15
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Halpern AB, Howard NP, Othus M, Hendrie PC, Baclig NV, Buckley SA, Percival MEM, Becker PS, Scott BL, Oehler VG, Gernsheimer TB, Keel SB, Orozco JJ, Cassaday RD, Shustov AR, Hartley GA, Welch VL, Estey EH, Walter RB. Early hospital discharge after intensive induction chemotherapy for adults with acute myeloid leukemia or other high-grade myeloid neoplasm. Leukemia 2019; 34:635-639. [PMID: 31586148 DOI: 10.1038/s41375-019-0586-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 07/12/2019] [Accepted: 07/22/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Anna B Halpern
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Nicholas P Howard
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Megan Othus
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Paul C Hendrie
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA
| | - Nikita V Baclig
- Department of Medicine, Residency Program, University of Washington, Seattle, WA, USA
| | - Sarah A Buckley
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Mary-Elizabeth M Percival
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Pamela S Becker
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Bart L Scott
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA
| | - Vivian G Oehler
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Terry B Gernsheimer
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Siobán B Keel
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA
| | - Johnnie J Orozco
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA
| | - Ryan D Cassaday
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Andrei R Shustov
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | | | - Elihu H Estey
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Roland B Walter
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA. .,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA. .,Department of Pathology, University of Washington, Seattle, WA, USA. .,Department of Epidemiology, University of Washington, Seattle, WA, USA.
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16
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Torres-Acosta MA, Harrison RP, Csaszar E, Rito-Palomares M, Brunck MEG. Ex vivo Manufactured Neutrophils for Treatment of Neutropenia-A Process Economic Evaluation. Front Med (Lausanne) 2019; 6:21. [PMID: 30881955 PMCID: PMC6405517 DOI: 10.3389/fmed.2019.00021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 01/23/2019] [Indexed: 01/11/2023] Open
Abstract
Neutropenia is a common side-effect of acute myeloid leukemia (AML) chemotherapy characterized by a critical drop in neutrophil blood concentration. Neutropenic patients are prone to infections, experience poorer clinical outcomes, and require expensive medical care. Although transfusions of donor neutrophils are a logical solution to neutropenia, this approach has not gained clinical traction, primarily due to challenges associated with obtaining sufficiently large numbers of neutrophils from donors whilst logistically managing their extremely short shelf-life. A protocol has been developed that produces clinical-scale quantities of neutrophils from hematopoietic stem and progenitor cells (HSPC) in 10 L single-use bioreactors (1). This strategy could be used to mass produce neutrophils and generate sufficient cell numbers to allow decisive clinical trials of neutrophil transfusion. We present a bioprocess model for neutrophil production at relevant clinical-scale. We evaluated two production scenarios, and the impact on cost of goods (COG) of multiple model parameters including cell yield, materials costs, and process duration. The most significant contributors to cost were consumables and raw materials, including the cost of procuring HSPC-containing umbilical cord blood. The model indicates that the most cost-efficient culture volume (batch size) is ~100 L in a single bioreactor. This study serves as a framework for decision-making and optimization strategies when contemplating the production of clinical quantities of cells for allogeneic therapy.
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Affiliation(s)
| | - Richard P Harrison
- Centre for Biological Engineering, Holywell Park, Loughborough University, Loughborough, United Kingdom.,Wolfson Centre for Stem Cells, Tissue Engineering and Modelling (STEM), School of Medicine, Nottingham, United Kingdom
| | - Elizabeth Csaszar
- Centre for Commercialization of Regenerative Medicine, Toronto, ON, Canada
| | - Marco Rito-Palomares
- Escuela de Medicina y Ciencias de la Salud, Tecnológico de Monterrey, Monterrey, Mexico
| | - Marion E G Brunck
- Centro de Biotecnología FEMSA, Tecnológico de Monterrey, Monterrey, Mexico
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17
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Infections in Myelodysplastic Syndrome in Relation to Stage and Therapy. Mediterr J Hematol Infect Dis 2018; 10:e2018039. [PMID: 30002795 PMCID: PMC6039080 DOI: 10.4084/mjhid.2018.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 06/12/2018] [Indexed: 11/30/2022] Open
Abstract
Infections remain a significant problem in myelodysplastic syndromes (MDS) in treated as well in non-treated patients and assume a particular complexity. The susceptibility to infections is due, in the absence of intensive chemotherapies, mainly to functional defects in the myeloid lineage with or without neutropenia. Furthermore, MDS includes a heterogeneous group of patients with very different prognosis, therapy and risk factors regarding survival and infections. You should distinguish risk factors related to the disease, like as neutrophils function impairment, neutropenia, unfavorable cytogenetics and bone marrow insufficiency; factors related to the patient, like as age and comorbidities, and factors related to the therapy. When the patients with MDS are submitted to intensive chemotherapy with and without hematopoietic stem cell transplantation (HSCT), they have a risk factor for infection very similar to that of patients with acute myeloid leukemia (AML), and mostly related to neutropenia. Patients with MDS treated with supportive therapy only or with demethylating agent or lenalidomide or immunosuppressive drugs should have a tailored approach. Most of the infections in MDS originate from bacteria, and the main risk factors are represented by neutropenia, thrombocytopenia, and unfavorable cytogenetics. Thus, it is reasonable to give antibacterial prophylaxis to patients who start the therapy with demethylating agents with a number of neutrophils <500 × 109/L, or with thrombocytopenia and unfavorable cytogenetics. The antifungal prophylaxis is not considered cost/benefit adequate and should be taken into consideration only when there is an antecedent fungal infection or presence of filamentous fungi in the surveillance cultures. Subjects submitted to immunosuppression with ATG+CSA have a high rate of infections, and when severely neutropenic should ideally be nursed in isolation, should be given prophylactic antibiotics and antifungals, regular mouth care including an antiseptic mouthwash.
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18
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Associations between cohabitation status, treatment, and outcome in AML patients: a national population-based study. Blood 2018; 131:2730-2733. [DOI: 10.1182/blood-2017-11-814327] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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19
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Stein EM, Bonifacio G, Latremouille-Viau D, Guerin A, Shi S, Gagnon-Sanschagrin P, Briggs O, Joseph GJ. Treatment patterns, healthcare resource utilization, and costs in patients with acute myeloid leukemia in commercially insured and Medicare populations. J Med Econ 2018; 21:556-563. [PMID: 29304724 DOI: 10.1080/13696998.2018.1425209] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To describe the setting, duration, and costs of induction and consolidation chemotherapy for adults with newly-diagnosed acute myeloid leukemia (AML), who are candidates for standard induction chemotherapy, in the US. METHODS Adults newly-diagnosed with AML who received standard induction chemotherapy in an inpatient setting were identified from the Truven Health Analytics MarketScan (2006-2015) and SEER-Medicare (2007-2011) databases. Patients were observed from induction therapy start to the first of hematopoietic stem cell transplant, 180 days after induction discharge, health plan enrollment/data availability end, or death. Induction and consolidation chemotherapy were identified using Diagnosis-Related Group codes (chemotherapy with acute leukemia) or procedure codes for AML chemotherapy administration. AML treatment episode setting (inpatient or outpatient), duration, and costs (2015 USD, payers' perspective) were described for commercially insured patients and Medicare beneficiaries. RESULTS In total, 459 commercially insured patients and 563 Medicare beneficiaries (mean age = 54 and 66 years; 53% and 54% male; respectively) were identified. For induction therapy, mean costs were $145,189 for commercially insured patients and $85,734 for Medicare beneficiaries, and median inpatient duration was 31 days (both). Following induction, 64% of commercially insured patients and 53% of Medicare beneficiaries had ≥1 consolidation cycle; 75% and 65% of consolidation cycles were in an inpatient setting, respectively. For consolidation cycles, in the inpatient setting, mean costs were $28,137 for commercially insured patients and $28,843 for Medicare beneficiaries, median cycle duration was 6 days (both); in the outpatient setting, mean costs were $11,271 for commercially insured patients and $5,803 Medicare beneficiaries, median duration was 5 days (both). LIMITATIONS Granular information on chemotherapy type administered was unavailable. CONCLUSIONS This is the first exploratory study providing a complete picture of recent AML treatment patterns and management costs among commercially insured patients and Medicare beneficiaries. There is substantial heterogeneity in the management and costs of AML.
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Affiliation(s)
- Eytan M Stein
- a Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | | | | | - Annie Guerin
- c Analysis Group, Inc. , Montreal , Quebec , Canada
| | - Sherry Shi
- c Analysis Group, Inc. , Montreal , Quebec , Canada
| | | | - Owanate Briggs
- b Novartis Pharmaceuticals Corporation , East Hanover , NJ , USA
| | - George J Joseph
- b Novartis Pharmaceuticals Corporation , East Hanover , NJ , USA
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20
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Kumar AJ, Henzer T, Rodday AM, Parsons SK. Risk factors for length of stay and charge per day differ between older and younger hospitalized patients with AML. Cancer Med 2018; 7:2744-2752. [PMID: 29663689 PMCID: PMC6010796 DOI: 10.1002/cam4.1492] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 03/15/2018] [Accepted: 03/20/2018] [Indexed: 02/02/2023] Open
Abstract
Acute myeloid leukemia (AML) is associated with frequent hospitalizations. We evaluated factors associated with length of stay (LOS) and charge per day (CPD) for admissions in older (≥60 years) and younger patients (<60 years). We identified patients with ICD‐9‐CM codes for AML or myeloid sarcoma in the 2012 HCUP‐NIS. In separate models based on age, we examined patient (sex, race, income, insurance payer, chronic conditions, chemotherapy administration, death) and hospital (type, geography) characteristics. Multivariable negative binomial regression estimated factor effects on LOS and CPD using rate ratios, with HCUP‐NIS weights. In 43,820 discharges, LOS was longer in patients <60 than ≥60 (6.8 vs. 5.4 days). For patients <60, longer LOS was seen with more chronic conditions (RR = 1.10), Black race (RR = 1.16), chemotherapy (RR = 2.27), and geography; shorter LOS was associated with older age (RR = 0.93), Medicare (RR = 0.83), and hospital type. For patients ≥60, longer LOS associated with chronic conditions (RR = 1.07) and Asian race (RR = 1.33). Shorter LOS associated with older age (RR = 0.86), higher income (RR = 0.93), and hospital type. For patients <60, higher CPD associated with chronic conditions (RR = 1.05), death (RR = 1.93), and geography; lower CPD associated with increasing age (RR = 0.96), Medicaid (RR = 0.93), and rural hospitals (RR = 0.65). For patients ≥60, higher CPD associated with Medicare (RR = 1.05), more chronic conditions (RR = 1.02), younger age (RR = 1.1), west geography (RR = 1.37), death (RR = 1.45), and Hispanic race (RR = 1.15). We identify predictors for increased healthcare utilization in hospitalized patients with AML, which differ within age groups. Future efforts are needed to link utilization outcomes with clinical treatments and response.
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Affiliation(s)
- Anita J Kumar
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts.,Division of Hematology/Oncology, Tufts Medical Center, Boston, Massachusetts
| | - Tobi Henzer
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Angie Mae Rodday
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Susan K Parsons
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts.,Division of Hematology/Oncology, Tufts Medical Center, Boston, Massachusetts
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21
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Vaughn JE, Buckley SA, Walter RB. Outpatient care of patients with acute myeloid leukemia: Benefits, barriers, and future considerations. Leuk Res 2016; 45:53-8. [PMID: 27101148 PMCID: PMC5383350 DOI: 10.1016/j.leukres.2016.03.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 03/14/2016] [Accepted: 03/31/2016] [Indexed: 11/23/2022]
Abstract
Patients with acute myeloid leukemia (AML) who receive intensive induction or re-induction chemotherapy with curative intent typically experience prolonged cytopenias upon completion of treatment. Due to concerns regarding infection and bleeding risk as well as significant transfusion and supportive care requirements, patients have historically remained in the hospital until blood count recovery-a period of approximately 30 days. The rising cost of AML care has prompted physicians to reconsider this practice, and a number of small studies have suggested the safety and feasibility of providing outpatient supportive care to patients following intensive AML (re-) induction therapy. Potential benefits include a significant reduction of healthcare costs, improvement in quality of life, and decreased risk of hospital-acquired infections. In this article, we will review the currently available literature regarding this practice and discuss questions to be addressed in future studies. In addition, we will consider some of the barriers that must be overcome by institutions interested in implementing an "early discharge" policy. While outpatient management of selected AML patients appears safe, careful planning is required in order to provide the necessary support, education and rapid management of serious complications that occur among this very vulnerable patient population.
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Affiliation(s)
- Jennifer E Vaughn
- Department of Internal Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA; Virginia Tech Carilion Research Institute, Roanoke, VA, USA; Blue Ridge Cancer Care, Roanoke, VA, USA.
| | - Sarah A Buckley
- Hematology/Oncology Fellowship Program, University of Washington, Seattle, WA, USA
| | - Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA
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22
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Vaughn JE, Othus M, Powell MA, Gardner KM, Rizzuto DL, Hendrie PC, Becker PS, Pottinger PS, Estey EH, Walter RB. Resource Utilization and Safety of Outpatient Management Following Intensive Induction or Salvage Chemotherapy for Acute Myeloid Leukemia or Myelodysplastic Syndrome: A Nonrandomized Clinical Comparative Analysis. JAMA Oncol 2016; 1:1120-7. [PMID: 26355382 DOI: 10.1001/jamaoncol.2015.2969] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Adults with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) typically remain hospitalized after induction or salvage chemotherapy until blood cell count recovery, with resulting prolonged inpatient stays being a primary driver of health care costs. Pilot studies suggest that outpatient management following chemotherapy might be safe and could reduce costs for these patients. OBJECTIVE To compare safety, resource utilization, infections, and costs between adults discharged early following AML or MDS induction or salvage chemotherapy and inpatient controls. DESIGN Nonrandomized, phase 2, single-center study conducted at the University of Washington Medical Center. Over a 43-month period (January 1, 2011, through July 31, 2014), 178 adults receiving intensive AML or MDS chemotherapy were enrolled. After completion of chemotherapy, 107 patients met predesignated medical and logistical criteria for early discharge, while 29 met medical criteria only and served as inpatient controls. INTERVENTIONS Early-discharge patients were released from the hospital at the completion of chemotherapy, and supportive care was provided in the outpatient setting until blood cell count recovery (median, 21 days; range, 2-45 days). Controls received inpatient supportive care (median, 16 days; range, 3-42 days). MAIN OUTCOMES AND MEASURES We analyzed differences in early mortality, resource utilization including intensive care unit (ICU) days, transfusions per study day, and use of intravenous (IV) antibiotics per study day), numbers of infections, and total and inpatient charges per study day among early-discharge patients vs controls. RESULTS Four of the 107 early-discharge patients and none of the 29 control patients died within 30 days of enrollment (P=.58). Nine early-discharge patients (8%) but no controls required ICU-level care (P=.20). No differences were noted in the median daily number of transfused red blood cell units (0.27 vs 0.29; P=.55) or number of transfused platelet units (0.26 vs 0.29; P=.31). Early-discharge patients had more positive blood cultures (37 [35%] vs 4 [14%]; P=.04) but required fewer IV antibiotic days per study day (0.48 vs 0.71; P=.01). Overall, daily charges among early-discharge patients were significantly lower than for inpatients (median, $3840 vs $5852; P<.001) despite increased charges per inpatient day when readmitted (median, $7405 vs $5852; P<.001). CONCLUSIONS AND RELEVANCE Early discharge following intensive AML or MDS chemotherapy can reduce costs and use of IV antibiotics, but attention should be paid to complications that may occur in the outpatient setting.
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Affiliation(s)
- Jennifer E Vaughn
- Hematology/Oncology Fellowship Program, University of Washington, Seattle2Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington3now with Blue Ridge Cancer Care, Department of Medicine, Virginia Tech Carilion School of Med
| | - Megan Othus
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Morgan A Powell
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | | | - Paul C Hendrie
- Division of Hematology, Department of Medicine, University of Washington, Seattle
| | - Pamela S Becker
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington6Division of Hematology, Department of Medicine, University of Washington, Seattle
| | - Paul S Pottinger
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle
| | - Elihu H Estey
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington6Division of Hematology, Department of Medicine, University of Washington, Seattle
| | - Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington6Division of Hematology, Department of Medicine, University of Washington, Seattle8Department of Epidemiology, University of Washington, Seattle
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23
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Møller T, Moser C, Adamsen L, Rugaard G, Jarden M, Bøtcher TS, Wiedenbein L, Kjeldsen L. Early warning and prevention of pneumonia in acute leukemia by patient education, spirometry, and positive expiratory pressure: A randomized controlled trial. Am J Hematol 2016; 91:271-6. [PMID: 26661344 PMCID: PMC5067626 DOI: 10.1002/ajh.24262] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 11/19/2015] [Accepted: 11/28/2015] [Indexed: 11/13/2022]
Abstract
Long‐lasting neutropenia associated with acute myeloid leukemia (AML) and its treatment gives rise to a high risk of pneumonia. The use of broad‐spectrum antibiotic prophylaxis during outpatient management has not completely protected patients against admission due to infections and neutropenic fever, emphasizing the need to approach infection protection with complementary efforts. In a randomized controlled design, we examined the applicability of patient‐performed daily spirometry [forced expiratory volume in one second (FEV1)] as an early warning tool and explored the effectiveness of positive expiratory pressure (PEP) in preventing pneumonia among 80 AML patients. Twenty‐five incidences of pneumonia were detected among 23 patients (6 interventions, 17 controls), giving a prevalence of 28.75% during 5420 days of observation. We found a significant difference in incidence between intervention versus control group (2.17 per 1000 days vs. 6.52 per 1000 days, P = 0.021, respectively). A cross point at 80‐76% of the personal FEV1 reference value showed high sensitivity and specificity on pneumonia development. Our data demonstrate the feasibility of educating AML patients in their continuous daily measurement of FEV1 and use of PEP. Daily measures of FEV1 may be an important early warning tool for assessment of pulmonary deterioration during critical phases of neutropenia. We suggest that strategic patient education in the use of spirometry and PEP should be part of standard of care for AML patients undergoing induction chemotherapy. Am. J. Hematol. 91:271–276, 2016. © 2015 The Authors. American Journal of Hematology Published by Wiley Periodicals, Inc.
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Affiliation(s)
- Tom Møller
- University Hospitals Centre for Health Research (UCSF)Copenhagen Denmark
| | - Claus Moser
- Department of Clinical MicrobiologyCopenhagen University HospitalRigshospitalet Denmark
| | - Lis Adamsen
- University Hospitals Centre for Health Research (UCSF)Copenhagen Denmark
| | - Grith Rugaard
- University Hospitals Centre for Health Research (UCSF)Copenhagen Denmark
| | - Mary Jarden
- University Hospitals Centre for Health Research (UCSF)Copenhagen Denmark
| | - Tina S. Bøtcher
- Department of HaematologyCopenhagen University Hospital Herlev, Copenhagen Denmark
| | - Liza Wiedenbein
- University Hospitals Centre for Health Research (UCSF)Copenhagen Denmark
| | - Lars Kjeldsen
- Department of HaematologyCopenhagen University HospitalRigshospitalet Denmark
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Luo Y, Liu T, Xie S, Wang S, Fang Z, Su R, Li Z, Huang Y, Lin Z, Han M. [Clinical features and risk factors for infections in adult acute leukemia after chemotherapy]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2015; 36:1020-4. [PMID: 26759105 PMCID: PMC7342312 DOI: 10.3760/cma.j.issn.0253-2727.2015.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To observe the clinical characteristics of infections in adult acute leukemia (AL)patients during chemotherapy in hospital, and identify the risk factors for infections. METHODS A retrospective study of patients with AL who underwent chemotherapy between July 2010 and Dec 2014 in the First Affiliated Hospital of Xiamen University was conducted. Clinical features and risk factors for infections were analyzed. RESULTS 191 patients with AL received a total of 728 courses of chemotherapies. During these admissions, 385(52.9%) infections episodes occurred. The common infections sites were lower respiratory tract infection(36.3%,153/374), bloodstream infection(17.1%, 64/374), oral infection(13.6%,51/374), and perianal infection(13.4%, 50/374). 164 strains of pathogenic bacteria were detected. Gram- negative bacteria were recorded in 59.1% of documented pathogens, and Gram- positive bacteria were responsible for 32.9% of infections. Multivariate unconditioned logistic analysis of factors identified consistent independent risk factors for no completely remission(OR=0.142, P< 0.001), duration of neutropenia longer than 7 days(OR=12.764, P<0.001), general wards(OR=1.821, P< 0.001), and hospitalization interval longer than 10 days(OR=0.720, P=0.039). CONCLUSION Infections after chemotherapy for AL continues to be common. AL patients with induction chemotherapy or severe neutropenia faced an increased risk of infections by multivariate analysis. And patients with short-term stay or laminar flow wards seem to be less susceptible to infections.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Mingzhe Han
- Institute of Hematology and Blood Disease Hospital, CAMS & PUMC, Tianjin 300020, China
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25
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Getz KD, Li Y, Alonzo TA, Hall M, Gerbing RB, Sung L, Huang YS, Arnold S, Seif AE, Miller TP, Bagatell R, Fisher BT, Adamson PC, Gamis A, Keren R, Aplenc R. Comparison of in-patient costs for children treated on the AAML0531 clinical trial: A report from the Children's Oncology Group. Pediatr Blood Cancer 2015; 62:1775-81. [PMID: 25946708 PMCID: PMC4546551 DOI: 10.1002/pbc.25569] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 03/26/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND A better understanding of drivers of treatment costs may help identify effective cost containment strategies and prioritize resources. We aimed to develop a method for estimating inpatient costs for pediatric patients with acute myeloid leukemia (AML) enrolled on NCI-funded Phase III trials, compare costs between AAML0531 treatment arms (standard chemotherapy ± gemtuzumab ozogamicin (GMTZ)), and evaluate primary drivers of costs for newly diagnosed pediatric AML. PROCEDURE Patients from the AAML0531 trial were matched on hospital, sex, and dates of birth and diagnosis to the Pediatric Health Information Systems (PHIS) database to obtain daily billing data. Inpatient treatment costs were calculated as adjusted charges multiplied by hospital-specific cost-to-charge ratios. Generalized linear models were used to compare costs between treatment arms and courses, and by patient characteristics. RESULTS Inpatient costs did not differ by randomized treatment arm. Costs varied by course with stem cell transplant being most expensive, followed by Intensification II (cytarabine/mitoxantrone) and Induction I (cytarabine/daunorubicin/etoposide). Room/board and pharmacy were the largest contributors to inpatient treatment cost, representing 74% of the total cost. Higher AML risk group (P = 0.0003) and older age (P < 0.0001) were associated with significantly higher daily inpatient cost. CONCLUSIONS Costs from external data sources can be successfully integrated into NCI-funded Phase III clinical trials. Inpatient treatment costs did not differ by GMTZ exposure but varied by chemotherapy course. Variation in cost by course was driven by differences in duration of hospitalization through room/board charges as well as increased clinical and pharmacy charges in specific courses.
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Affiliation(s)
- Kelly D. Getz
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Correspondence to: Kelly Getz, Division of Oncology, The Children’s Hospital of Philadelphia, 3535 Market Street, Room 1507, Philadelphia, PA 19104.
| | - Yimei Li
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Todd A. Alonzo
- University of Southern California, Los Angeles, California
| | - Matthew Hall
- Children’s Hospital Association, Overland Park, Kansas
| | | | | | - Yuan-Shung Huang
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Staci Arnold
- Columbia University Medical Center, New York, New York
| | - Alix E. Seif
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Tamara P. Miller
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Brian T. Fisher
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Peter C. Adamson
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alan Gamis
- Children’s Mercy Hospitals and Clinics, Kansas City, Missouri
| | - Ron Keren
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Richard Aplenc
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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26
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Watkins T, Surowiecka MK, McCullough J. Transfusion indications for patients with cancer. Cancer Control 2015; 22:38-46. [PMID: 25504277 DOI: 10.1177/107327481502200106] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND During the last few years, considerable focus has been given to the management of anemia and coagulopathies. This article provides current concepts of red blood cell (RBC) and plasma coagulation factor replacements. METHODS The literature was reviewed for clinical studies relevant to RBC transfusion indications and outcomes as well as for the uses of coagulation factor replacement products for coagulopathies most likely encountered in patients with cancer. RESULTS Most patients without complications can be treated with a hemoglobin level of 7 g/dL as an indication for RBC transfusion. However, the effects of disease among patients with cancer may cause fatigue, so transfusions at higher hemoglobin levels may be clinically helpful. Leukoreduced RBCs are recommended as standard therapy for all patients with cancer, most of whom do not develop coagulopathy. Transfusions to correct mild abnormalities are not indicated in this patient population. Data are inconclusive regarding the value of coagulation factor replacement for invasive procedures when the international normalized ratio is below 2. CONCLUSIONS Indications for RBC transfusion have become more conservative as data and experience have shown that patients can be safely and effectively maintained at lower hemoglobin levels. Coagulation factor replacement is unnecessary for most modest coagulopathies.
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Affiliation(s)
- Thomas Watkins
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, 55455, USA.
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27
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He H, Liu ZQ, Li X, Yin JY, Zhai M, Zhou HH. The influence of cytidine deaminase -33delC polymorphism on treatment outcome with high-dose cytarabine in Chinese patients with relapsed acute myeloid leukaemia. J Clin Pharm Ther 2015; 40:555-560. [PMID: 26174689 DOI: 10.1111/jcpt.12309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Accepted: 06/23/2015] [Indexed: 11/26/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Identification of biomarkers that could predict high-dose cytarabine (Ara-C) efficacy and toxicity is a key issue in individualized therapy. The aim of our study was to evaluate the influence of cytidine deaminase (CDA) single nucleotide polymorphisms (SNPs) -451G>A (rs532545), 435C>T (rs1048977) and -33delC (rs3215400) on treatment outcome in patients with relapsed acute myeloid leukaemia (AML) after high-dose Ara-C chemotherapy. METHODS In total, 173 patients with relapsed AML, treated with high-dose Ara-C chemotherapy, were genotyped for three polymorphisms in CDA gene using the allele-specific matrix-assisted laser desorption/ionization time-of-flight mass spectrometry assays. Binary logistic regression was used to evaluate the influence of selected polymorphisms on tumour response and occurrence of treatment-related toxicity. RESULTS AND DISCUSSION The CC genotype at -33delC, a promoter polymorphism, increased the odds of overall response rate (odds ratio [OR] = 5·125; 95% confidence intervals (CI) = 2·446-10·74; P = 0·0008) and grade ≥3 infection toxicity incidence rate (OR = 3·572; 95% CI = 1·68-7·594; P = 0·003). In multivariable analysis, this polymorphism was a potential independent prognostic marker for the risk of overall response (P = 0·011), but not grade ≥3 infection toxicity incidence rate (P = 0·49). Two other polymorphisms, -451G>A and 435C>T, did not influence treatment outcome, including overall response rate, infection toxicity and nausea/vomiting, in patients with relapsed AML (P > 0·05). WHAT IS NEW AND CONCLUSION The findings suggest that CDA -33delC variant might be a potential marker for predicting treatment outcome in Chinese patients with relapsed AML given high-dose cytarabine chemotherapy.
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Affiliation(s)
- H He
- Research laboratory, Liaoning province Benxi Central Hospital, Liaoning Benxi, China.,Department of Hematology, Liaoning Province Benxi Central Hospital, Liaoning Benxi, China.,Institute of Clinical Pharmacology, Hunan Key Laboratory of Pharmacogenetics, Central South University, Changsha, China
| | - Z Q Liu
- Institute of Clinical Pharmacology, Hunan Key Laboratory of Pharmacogenetics, Central South University, Changsha, China
| | - X Li
- Institute of Clinical Pharmacology, Hunan Key Laboratory of Pharmacogenetics, Central South University, Changsha, China
| | - J Y Yin
- Institute of Clinical Pharmacology, Hunan Key Laboratory of Pharmacogenetics, Central South University, Changsha, China
| | - M Zhai
- Department of Hematology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - H H Zhou
- Institute of Clinical Pharmacology, Hunan Key Laboratory of Pharmacogenetics, Central South University, Changsha, China
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28
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Getz KD, Miller TP, Seif AE, Li Y, Huang YS, Bagatell R, Fisher BT, Aplenc R. A comparison of resource utilization following chemotherapy for acute myeloid leukemia in children discharged versus children that remain hospitalized during neutropenia. Cancer Med 2015; 4:1356-64. [PMID: 26105201 PMCID: PMC4567020 DOI: 10.1002/cam4.481] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 04/23/2015] [Accepted: 04/27/2015] [Indexed: 12/04/2022] Open
Abstract
Comparisons of early discharge and outpatient postchemotherapy supportive care in pediatric acute myeloid leukemia (AML) patients are limited. We used data from the Pediatric Health Information System on a cohort of children treated for newly diagnosed AML to compare course-specific mortality and resource utilization in patients who were discharged after chemotherapy to outpatient management during neutropenia relative to patients who remained hospitalized. Patients were categorized at each course as early or standard discharge. Discharges within 3 days after chemotherapy completion were considered “early”. Resource utilization was determined based on daily billing data and reported as days of use per 1000 hospital days. Inpatient mortality, occurrence of intensive care unit (ICU)-level care, and duration of hospitalization were compared using logistic, log-binomial and linear regression methods, respectively. Poisson regression with inpatient days as offset was used to compare resource use by discharge status. The study population included 996 patients contributing 2358 treatment courses. Fewer patients were discharged early following Induction I (7%) than subsequent courses (22–24%). Across courses, patients discharged early experienced high readmission rates (69–84%), yet 9–12 fewer inpatient days (all P < 0.001). Inpatient mortality was low across courses and did not differ significantly by discharge status. The overall risk for ICU-level care was 116% higher for early compared to standard discharge patients (adjusted risk ratio: 2.16, 95% confidence interval: 1.50, 3.11). Rates of antibiotic, vasopressor, and supplemental oxygen use were consistently elevated for early discharge patients. Despite similar inpatient mortality to standard discharge patients, early discharge patients may be at greater risk for life-threatening chemotherapy-related complications, including infections.
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Affiliation(s)
- Kelly D Getz
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Tamara P Miller
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alix E Seif
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Yimei Li
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Yuan-Shung Huang
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rochelle Bagatell
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Brian T Fisher
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.,Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Richard Aplenc
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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29
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Fedele PL, Avery S, Patil S, Spencer A, Haas M, Wei A. Health economic impact of high-dose versus standard-dose cytarabine induction chemotherapy for acute myeloid leukaemia. Intern Med J 2014; 44:757-63. [DOI: 10.1111/imj.12478] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 05/12/2014] [Indexed: 11/29/2022]
Affiliation(s)
- P. L. Fedele
- Department of Clinical Haematology; The Alfred Hospital; Melbourne Victoria Australia
| | - S. Avery
- Department of Clinical Haematology; The Alfred Hospital; Melbourne Victoria Australia
| | - S. Patil
- Department of Clinical Haematology; The Alfred Hospital; Melbourne Victoria Australia
| | - A. Spencer
- Department of Clinical Haematology; The Alfred Hospital; Melbourne Victoria Australia
| | - M. Haas
- Centre for Health Economics Research and Evaluation; University of Technology; Sydney New South Wales Australia
| | - A. Wei
- Department of Clinical Haematology; The Alfred Hospital; Melbourne Victoria Australia
- Australian Centre for Blood Diseases; Monash University; Melbourne Victoria Australia
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30
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Walter RB, Taylor LR, Gardner KM, Dorcy KS, Vaughn JE, Estey EH. Outpatient management following intensive induction or salvage chemotherapy for acute myeloid leukemia. CLINICAL ADVANCES IN HEMATOLOGY & ONCOLOGY : H&O 2013; 11:571-577. [PMID: 24518520 PMCID: PMC4212516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Adults with newly diagnosed or relapsed acute myeloid leukemia (AML) commonly receive intensive chemotherapy to achieve disease remission. In the United States and many other countries, it is standard practice that these patients remain hospitalized "preemptively" until blood count recovery, owing to the risk for overwhelming infections and bleeding during pancytopenia. This care policy requires hospitalization for an average of 3 to 4 weeks after completion of chemotherapy. However, highly effective oral prophylactic antimicrobials are now available, and transfusion support of outpatients has become routine in recent years. As a result, the care of patients with hematologic malignancies treated with intensive modalities is increasingly shifting from inpatient to outpatient settings. Benefits of this shift could include the reduced need for medical resources (eg, transfusions or intravenous antimicrobial therapy), improved quality of life (QOL), decreased rates of nosocomial infections, and lower costs. Increasing evidence indicates that select AML patients undergoing intensive remission induction or salvage chemotherapy can be discharged early after completion of chemotherapy and followed closely in a well-equipped outpatient facility in a safe and costeffective manner. Further demonstration that the current approach of preemptive hospitalization is medically unjustified, economically more burdensome, and adversely affects health-related QOL would very likely change the management of these patients throughout this country and elsewhere, resulting in the establishment of a new standard practice that improves cancer care.
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Affiliation(s)
- Roland B. Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | | | | | | | - Jennifer E. Vaughn
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Elihu H. Estey
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA
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31
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Leunis A, Blommestein HM, Huijgens PC, Blijlevens NMA, Jongen-Lavrencic M, Uyl-de Groot CA. The costs of initial treatment for patients with acute myeloid leukemia in the Netherlands. Leuk Res 2012; 37:245-50. [PMID: 23069745 DOI: 10.1016/j.leukres.2012.09.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 09/17/2012] [Accepted: 09/23/2012] [Indexed: 01/08/2023]
Abstract
The aim of this study was to calculate the costs of the current initial treatment of acute myeloid leukemia. Resource use was collected for 202 patients who started with intensive chemotherapy in 2008 or 2009. The costs of the first induction course were significantly higher than the costs of the second induction course. Allogeneic transplantation from a matched unrelated donor was significantly more expensive than the other consolidation treatments. In-hospital stay was the major cost driver in the treatment of AML. Research regarding possibilities of achieving the same or better health outcome with lower costs is warranted.
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Affiliation(s)
- Annemieke Leunis
- Institute for Medical Technology Assessment/Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
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