Medical Outcomes, Quality of Life, and Family Perceptions for Outpatient vs Inpatient Neutropenia Management After Chemotherapy for Pediatric Acute Myeloid Leukemia

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. OBJECTIVETo evaluate outpatient vs inpatient neutropenia management for pediatric AML. DESIGN, SETTING, AND PARTICIPANTSThis 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 MEASURESThe primary outcomes of interest were course-specific bacteremia incidence, times to next course, and patient HRQOL. Course-specific mortality was a secondary medical outcome. RESULTSPrimary 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

Leveraging machine learning to identify acute myeloid leukemia patients and their chemotherapy regimens in an administrative database

“…The external validation used a separate cohort assembled in the Home or Away From Home study (HAFH) (ClinicalTrials.gov identifier: NCT02774850). This study included patients aged 0–18 years with newly diagnosed AML who received treatment at 17 US pediatric centers between 2011 and 2019, and data were collected using standardized manual chart abstractions 40,41 . Case status and chemotherapy regimens data from 11 HAFH study centers contributing data to PHIS served as the GS (Figure 1C).…”

Risk of bacterial bloodstream infection does not vary by central-line type during neutropenic periods in pediatric acute myeloid leukemia

“…We performed a secondary analysis of data captured for a bidirectional observational cohort that included children diagnosed with de novo AML (excluding acute promyelocytic leukemia) who received frontline chemotherapy between January 2011 and July 2019 at 18 pediatric institutions across the United States. 12 The objective of the primary study was to understand the impact of outpatient versus inpatient post-chemotherapy neutropenia management. The cohort included patients aged <19 years at AML diagnosis.…”

Child and family perceptions of satisfaction with neutropenia management in pediatric acute myeloid leukemia

“…[11][12][13] We recently reported results from a large, multicenter cohort study focused on clinical and patient-centered outcomes and family experiences with inpatient versus outpatient management after pediatric AML chemotherapy. 14 In that study, we found that there were no differences in important clinical outcomes between inpatient and outpatient management. While these comparative effectiveness data are foundational to inform future decision-making, they cannot be implemented without considering the life context, circumstances, and preferences of patients and their families.…”

“…The development of such strategies must be complex and nuanced, given the previously reported outcome data indicating greater potential risk for bloodstream infection with inpatient management, but greater potential risk for critical illness with outpatient management. 14 The minority who expressed dissatisfaction endorsed life circumstances, resources, and abilities that supported their preference for the alternative neutropenia management strategy to the one they experienced. In general, respondents considered the risks and benefits of each neutropenia management strategy as a tradeoff between patient safety and psychosocial concerns.…”