How essential are in‐person clinic visits during maintenance treatment of children with acute lymphoblastic leukemia?

Abstract

Background: Acute lymphoblastic leukemia (ALL) is the most common cancer in children. Treatment consists of an initial intensive phase of chemotherapy, followed by a prolonged period of maintenance chemotherapy intended to reduce the risk of relapse.During the COVID-19 pandemic, the need arose to identify and reduce non-essential hospital visits.Objective: We aimed to determine which proportion of in-person clinic visits during ALL maintenance therapy was associated with a change of management based on the results of the physical examination.Patients and methods: Medical records of children receiving maintenance chemotherapy for B-precursor ALL between September 2019 and February 2020 were reviewed.Visits with a new finding on physical examination were divided into those where an inperson assessment was deemed essential versus not essential. Finally, we determined the proportion of essential in-person visits that resulted in a change of management.Results: A total of 240 maintenance visits by 75 children were analyzed. An abnormal finding on physical examination was noted during 20 visits (8.3%). Of those, 14 (5.8%) uncovered a new finding, six (2.5%) were classified as "in-person visit essential," and among those six visits, three (1.2%) resulted in a change of patient management (one for acute otitis media, one for wheezing, and one for limp). Conclusion:Our findings support the evaluation of care delivery models other than in-person visits during ALL maintenance therapy. A prospective study is required to delineate criteria, benefits/risks, and families' perspectives associated with virtual care delivery and the optimal frequency of in-person visits.

Can virtual care reduce treatment burden in pediatric leukemia? A retrospective cost analysis

“…Recent research at the Hospital for Sick Children in Toronto indicates the safety of video consultations during maintenance therapy. Of 240 regular visits, only 2.5% resulted in new abnormal findings that could only be detected during in‐person visits, and only half of these findings resulted in a change in patient treatment 11 . Although further studies are needed, these results underscore the large potential for the use of modern technologies as part of care delivery in ALL maintenance therapy.…”

Hybrid Email and Outpatient Clinics to Optimize Maintenance Therapy in Acute Lymphoblastic Leukemia

“…As shown in Table 2, of the expected 48 clinic visits in era 4, "virtual" patients recorded a median 56 visits (e-clinics: 38 [35 to 42]; in-person visits: 18 [13 to 22]), with the additional visits: required for weekly supervision during neutropenia episodes. "Direct" patients recorded a 4:2 ratio of e-clinic to OP visits (median e-clinics: 30 [28 to 32]; median in-patient visits: 18 [13][14][15][16][17][18][19][20][21][22][23][24]) highlighting that these patients too were using the e-clinic more often than OP reviews. With the frequency of OP visits halved, the number of patients in each OP clinic reduced considerably.…”

“…A telephone survey was carried out with a pre-tested questionnaire to assess the acceptance of the hybrid clinic [11][12][13][14][15][16][17] 15 [12][13][14][15][16][17][18][19] 18 [13][14][15][16][17][18][19][20][21][22] 14 [12][13][14][15][16][17][18] Values represent median [interquartile range] unless stated otherwise. "Direct" refers to patients whose e-clinic consultations were ≤ the median e-clinic consultations per patient † for the respective era.…”

The new reality is virtual

“…In this issue of Pediatric Blood and Cancer, Rabinowicz et al raise the question of how essential are in-person visits during maintenance therapy for B-cell acute lymphoblastic leukemia (ALL), the most common childhood cancer. 5 The authors conducted a retrospective study to determine if an in-person visit was essential to detect an abnormal finding on physical examination, especially if it resulted in a change in medical management. They excluded patients during the first 3 months of maintenance when more frequent laboratory evaluations are needed to titrate medication dosages, when children required intrathecal or intravenous therapy, or when other specialists saw patients.…”

“…In this issue of Pediatric Blood and Cancer , Rabinowicz et al. raise the question of how essential are in‐person visits during maintenance therapy for B‐cell acute lymphoblastic leukemia (ALL), the most common childhood cancer 5 . The authors conducted a retrospective study to determine if an in‐person visit was essential to detect an abnormal finding on physical examination, especially if it resulted in a change in medical management.…”