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Palmieri R, Billio A, Ferrara F, Galimberti S, Lemoli RM, Todisco E, Moretti F, Venditti A. Literature review and expert opinion on the treatment of high-risk acute myeloid leukemia in patients who are eligible for intensive chemotherapy. Front Oncol 2024; 14:1367393. [PMID: 38444680 PMCID: PMC10912626 DOI: 10.3389/fonc.2024.1367393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 02/06/2024] [Indexed: 03/07/2024] Open
Abstract
In patients with Acute Myeloid Leukemia (AML), the assessment of disease risk plays a central role in the era of personalized medicine. Indeed, integrating baseline clinical and biological features on a case-by-case basis is not only essential to select which treatment would likely result in a higher probability of achieving complete remission, but also to dynamically customize any subsequent therapeutic intervention. For young high-risk patients with low comorbidities burden and in good general conditions (also called "fit" patients), intensive chemotherapy followed by allogeneic stem cell transplantation still represents the backbone of any therapeutic program. However, with the approval of novel promising agents in both the induction/consolidation and the maintenance setting, the algorithms for the management of AML patients considered eligible for intensive chemotherapy are in constant evolution. In this view, we selected burning issues regarding the identification and management of high-risk AML, aiming to provide practical advice to facilitate their daily clinical management in patients considered eligible for intensive chemotherapy.
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Affiliation(s)
- Raffaele Palmieri
- Hematology, Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy
| | - Atto Billio
- Division of Hematology and Bone Marrow Transplant (BMT), Hospital S. Maurizio, Bolzano, Italy
| | | | - Sara Galimberti
- Hematology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Roberto M. Lemoli
- Cattedra di Ematologia, Dipartimento di Medicina Interna (DiMI), Università di Genova, Genova, Italy
- Clinica Ematologica, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Martino, Genova, Italy
| | - Elisabetta Todisco
- Struttura Complessa (SC) Ematologia, Ospedale Busto Arsizio, Azienda Socio Sanitaria Territoriale (ASST) Valle Olona, Varese, Italy
| | - Federico Moretti
- Hematology, Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy
| | - Adriano Venditti
- Hematology, Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy
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2
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Li W, Richter K, Lee J, McCarthy K, Kubal T. Safety and feasibility of outpatient high-dose cytarabine and intermediate-dose cytarabine for consolidation therapy in acute myeloid leukemia. J Oncol Pharm Pract 2021; 28:1812-1818. [PMID: 34609924 DOI: 10.1177/10781552211046574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The standard of care consolidation therapy for acute myeloid leukemia is high-dose cytarabine or intermediate-dose cytarabine, which are traditionally given inpatient. At Moffitt Cancer Center, we have moved the administration of high-dose cytarabine and intermediate-dose cytarabine to the outpatient setting through the inpatient/outpatient program. To facilitate outpatient administration, high-dose cytarabine and intermediate-dose cytarabine are given in a shorter interval of every 10 h instead of 12 h. The safety of a shorter duration interval of high-dose cytarabine and intermediate-dose cytarabine is unknown. This study aims to assess the safety and feasibility of administering high-dose cytarabine and intermediate-dose cytarabine consolidation therapy in the inpatient/outpatient setting. METHODS This is a retrospective chart review to analyze acute myeloid leukemia patients treated with inpatient/outpatient high-dose cytarabine or intermediate-dose cytarabine consolidation therapy at Moffitt Cancer Center from January 1, 2015, through November 1, 2018. The primary objective was to determine the incidence of hospitalization during the inpatient/outpatient administration of high-dose cytarabine or intermediate-dose cytarabine. RESULTS Two hundred fifty-three of 255 cycles of high-dose cytarabine/intermediate-dose cytarabine were delivered outpatient over the reviewed time period to 118 patients. No patients receiving outpatient high-dose cytarabine/intermediate-dose cytarabine consolidation required hospitalization during chemotherapy. Our incidence of hospitalization (24%) after chemotherapy is consistent with the reported literature. Through the inpatient/outpatient administration of high-dose cytarabine and intermediate-dose cytarabine, 1265 inpatient days were saved with an approximate revenue of $3,135,176 generated in our study period. CONCLUSION Inpatient/outpatient administration of high-dose cytarabine and intermediate-dose cytarabine is both safe and feasible. Moving high-dose cytarabine/intermediate-dose cytarabine administration to the outpatient setting resulted in significant additional revenue vs. inpatient administration.
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Affiliation(s)
- Wenhui Li
- 158424University of Miami Hospital and Clinics, Miami, FL, USA
| | | | - Jamie Lee
- 25301H. Lee Moffitt Cancer Center, Tampa, FL, USA
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3
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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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4
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Ning L, Li D, Lu P, Que Y. Exploring the determinants that influence hospital costs of induction therapy for acute myeloid leukemia. Leuk Lymphoma 2020; 62:1211-1218. [PMID: 33300383 DOI: 10.1080/10428194.2020.1855339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The financial burden of acute myeloid leukemia (AML) patients is substantial. We retrospectively analyzed the hospital costs of the first induction therapy for 353 newly diagnosed AML patients who were admitted to our hospital from January 2013 to December 2018. We found the median hospital costs were estimated at 110,291.8 RMB. Multivariate analysis showed that length of hospital stay was the leading determinant affecting hospital costs (p < 0.0001), followed by length of agranulocytosis days (p < 0.01), but for the patients who failed to achieve complete remission (CR), length of hospital stay was the independent factor contributing to hospital costs. Besides, patients achieving CR had similar hospital costs to the patients failing to achieve CR. The hospital costs of low-intensity chemotherapy might not be lower than that of intensive chemotherapy.
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Affiliation(s)
- Liqing Ning
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dengju Li
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Pingfan Lu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yimei Que
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Halpern AB, Othus M, Howard NP, Hendrie PC, Percival MEM, Scott BL, Gernsheimer TB, Baclig NV, Buckley SA, Cassaday RD, Hartley GA, Welch VL, Estey EH, Walter RB. Comparison of outpatient care following intensive induction versus post-remission chemotherapy for adults with acute myeloid leukemia and other high-grade myeloid neoplasms. Leuk Lymphoma 2020; 62:234-238. [PMID: 32921204 DOI: 10.1080/10428194.2020.1821008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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/University of Washington, 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/University of Washington, 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/University of Washington, Seattle, WA, USA
| | - Bart L Scott
- Clinical Research Division, Fred Hutchinson Cancer Research Center/University of Washington, Seattle, WA, USA.,Department of Medicine, Division of Medical Oncology, University of Washington, 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/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/University of Washington, Seattle, WA, USA.,Department of Medicine, Residency Program, 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/University of Washington, 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/University of Washington, 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/University of Washington, 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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6
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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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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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8
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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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9
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McBride A, Campen CJ, Camamo J, Maloney M, Persky D, Kurtin SE, Barket NL, Krishnadasan R, Elquza E, Anwer F, Weibel K. Implementation of a pharmacy-managed program for the transition of chemotherapy to the outpatient setting. Am J Health Syst Pharm 2019; 75:e246-e258. [PMID: 29691269 DOI: 10.2146/ajhp170138] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Implementation of a pharmacy-managed program for the transition of chemotherapy to the outpatient setting is described. SUMMARY The University of Arizona Cancer Center and Banner-University Medical Center Tucson are affiliated not-for-profit academic medical centers in Tucson, Arizona, whose facilities include a hospital and ambulatory care clinics that maintain 3 outpatient infusion centers. The cancer center pharmacy currently employs 25 pharmacists, with 4 clinical pharmacists serving both the inpatient and outpatient treatment sites. A multidisciplinary team of staff members was assembled to address the transition of chemotherapy from inpatient to outpatient that included physicians, ambulatory clinical oncology pharmacists, finance, social workers, pharmacy staff, nursing staff, and information technology. The program was initiated in May 2014, with a 2-year postimplementation evaluation of our transition of chemotherapy to the outpatient setting. Chemotherapy order sets were developed in our electronic medical record for transitioning rituximab to the outpatient setting for inpatient chemotherapy orders as well as transitioning leukemia, lymphoma, and solid tumor chemotherapy regimens to be administered in the outpatient setting. Eighteen rituximab-containing regimens and 14 chemotherapy protocols were switched to the outpatient setting, with numerous variants of these regimens also created for outpatient only administration. The realized savings for high-cost chemotherapy transitioned to the outpatient setting with rituximab and clofarabine was $1,902,890. Over 747 inpatient bed days were saved, with an approximated cost savings to the health system of $1,402,866, with a cumulative cost savings to our health system of $3,305,756. CONCLUSION This model for transitioning chemotherapy from the hospital to the outpatient setting enhanced access to care, decreased bed utilization in the hospital, and improved clinical and financial metrics.
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Affiliation(s)
- Ali McBride
- University of Arizona Cancer Center, Tucson, AZ
| | | | - James Camamo
- Banner-University Medical Center Tucson, Tucson, AZ
| | | | | | - Sandra E Kurtin
- Clinical Assistant Professor of Medicine Adjunct Clinical Assistant Professor of Nursing, University of Arizona Cancer Center, Tucson, Arizona
| | | | | | - Emad Elquza
- Department of Medicine, University of Arizona Cancer Center, Tucson, AZ
| | - Faiz Anwer
- Department of Medicine, University of Arizona Cancer Center, Tucson, AZ
| | - Kurt Weibel
- Banner-University Medical Center Tucson, Tucson, AZ
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Fridthjof KS, Kampmann P, Dünweber A, Gørløv JS, Nexø C, Friis LS, Nørskov KH, Welinder PC, Moser C, Kjeldsen L, Møller T. Systematic patient involvement for homebased outpatient administration of complex chemotherapy in acute leukemia and lymphoma. Br J Haematol 2018; 181:637-641. [PMID: 29676445 DOI: 10.1111/bjh.15249] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/01/2018] [Indexed: 11/27/2022]
Abstract
Based on experience with comprehensive patient involvement, we present data from implementation of portable, programmable infusion pumps (PPP) for home-based chemotherapy administration in patients with acute leukaemia and in lymphoma patients receiving (carmustine, etoposide, cytarabine, melphalan) BEAM regimen. Data from 84 patients, receiving 177 cycles of PPP administered chemotherapy, showed convincing safety with minor equipment errors encountered and with high patient satisfaction. In-hospital days could be reduced with 52% out of a total of 1197 treatment days. Homebased PPP has several advantages from a patient perspective and furthermore frees up in-hospital beds for patients in need of them.
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Affiliation(s)
- Katrine S Fridthjof
- Department of Haematology, University Hospital of Copenhagen Rigshospitalet Denmark, Copenhagen, Denmark
| | - Peter Kampmann
- Department of Haematology, University Hospital of Copenhagen Rigshospitalet Denmark, Copenhagen, Denmark
| | - Anne Dünweber
- Department of Haematology, University Hospital of Copenhagen Rigshospitalet Denmark, Copenhagen, Denmark
| | - Jette S Gørløv
- Department of Haematology, University Hospital of Copenhagen Rigshospitalet Denmark, Copenhagen, Denmark
| | - Connie Nexø
- Department of Haematology, University Hospital of Copenhagen Rigshospitalet Denmark, Copenhagen, Denmark
| | - Lone S Friis
- Department of Haematology, University Hospital of Copenhagen Rigshospitalet Denmark, Copenhagen, Denmark
| | - Kristina H Nørskov
- Department of Haematology, University Hospital of Copenhagen Rigshospitalet Denmark, Copenhagen, Denmark
| | - Pernille C Welinder
- Department of Haematology, University Hospital of Copenhagen Rigshospitalet Denmark, Copenhagen, Denmark
| | - Claus Moser
- Department of Clinical Microbiology, University Hospital of Copenhagen Rigshospitalet Denmark, Copenhagen, Denmark
| | - Lars Kjeldsen
- Department of Haematology, University Hospital of Copenhagen Rigshospitalet Denmark, Copenhagen, Denmark
| | - Tom Møller
- The University Hospitals Centre for Health Research, UCSF, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
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11
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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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12
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Hershenfeld SA, Maki K, Rothfels L, Murray CS, Nixon S, Schimmer AD, Doherty MC. Sharing post-AML consolidation supportive therapy with local centers reduces patient travel burden without compromising outcomes. Leuk Res 2017; 59:93-96. [PMID: 28599190 DOI: 10.1016/j.leukres.2017.05.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 05/12/2017] [Accepted: 05/29/2017] [Indexed: 11/26/2022]
Abstract
Acute myeloid leukemia (AML) is frequently treated with induction and consolidation chemotherapy. Consolidation chemotherapy can be delivered on an ambulatory basis, requiring some patients to travel long distances for treatment at specialized centers. We developed a shared care model where patients receive consolidation chemotherapy at a quaternary center, but post-consolidation supportive care at local hospitals. To evaluate the impact of our model on patient travel and outcomes we conducted a retrospective analysis of AML and acute promyelocytic leukemia patients receiving consolidation over four years at our quaternary center. 73 patients received post-consolidation care locally, and 344 at the quaternary center. Gender, age and cytogenetic risk did not significantly differ between groups. Shared care patients saved mean round trip distance of 146.5km±99.6 and time of 96.7min±63.4 compared to travelling to quaternary center. There was no significant difference in overall survival between groups, and no increased hazard of death for shared care patients. 30, 60, and 90day survival from start of consolidation was 98.6%, 97.2%, and 95.9% for shared care and 98.8%, 97.1%, and 95.3% for quaternary center patients. Thus, a model utilizing regional partnerships for AML post-consolidation care reduces travel burden while maintaining safety.
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Affiliation(s)
- Samantha A Hershenfeld
- Princess Margaret Cancer Center, University Health Network, 610 University Ave, Toronto, Ontario, Canada M5G 2M9
| | - Kimberly Maki
- Princess Margaret Cancer Center, University Health Network, 610 University Ave, Toronto, Ontario, Canada M5G 2M9
| | - Lana Rothfels
- Princess Margaret Cancer Center, University Health Network, 610 University Ave, Toronto, Ontario, Canada M5G 2M9
| | - Cindy S Murray
- Princess Margaret Cancer Center, University Health Network, 610 University Ave, Toronto, Ontario, Canada M5G 2M9
| | - Shannon Nixon
- Princess Margaret Cancer Center, University Health Network, 610 University Ave, Toronto, Ontario, Canada M5G 2M9
| | - Aaron D Schimmer
- Princess Margaret Cancer Center, University Health Network, 610 University Ave, Toronto, Ontario, Canada M5G 2M9
| | - Mary C Doherty
- Princess Margaret Cancer Center, University Health Network, 610 University Ave, Toronto, Ontario, Canada M5G 2M9.
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13
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Park JY. Implementing a central venous catheter self-management education program for patients with cancer. Eur J Oncol Nurs 2016; 25:1-8. [PMID: 27865247 DOI: 10.1016/j.ejon.2016.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 08/29/2016] [Accepted: 08/31/2016] [Indexed: 12/25/2022]
Abstract
PURPOSE To evaluate the effects of the central venous catheter self-management education program (CVC S-MEP) in improving knowledge, attitude, and behavior regarding CVC and in decreasing CVC-related complications in patients with cancer during homecare service. METHODS A quasi-experimental, sequential cohort design study of patients with cancer and who have CVCs was performed to compare the effect of CVC S-MEP with usual care. RESULTS The study group consisted of 45 participants (26 male and 19 female), and the mean age was 46.1 (SD, 10.5) years. The subjects of the CVC S-MEP had significantly high mean levels of self-management knowledge (p = 0.007), attitude (p < 0.001), and behavior (p = 0.002). Also, the participants in the CVC S-MEP had significantly lower frequency of catheter-related complications (p = 0.030). CONCLUSIONS The CVC S-MEP helped improve patients' ability to resolve problems and adequately respond to CVC-related emergency situations by fostering greater self-care ability. Additionally, providing practical information for CVC self-management in a gradual and repetitive manner had a notable positive effect on patients.
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14
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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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15
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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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16
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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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17
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Miller TP, Getz KD, Kavcic M, Li Y, Huang YSV, Sung L, Alonzo TA, Gerbing R, Daves M, Horton TM, Pulsipher MA, Pollard J, Bagatell R, Seif AE, Fisher BT, Gamis AS, Aplenc R. A comparison of discharge strategies after chemotherapy completion in pediatric patients with acute myeloid leukemia: a report from the Children's Oncology Group. Leuk Lymphoma 2016; 57:1567-74. [PMID: 26727639 DOI: 10.3109/10428194.2015.1088652] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
While most children receive acute myeloid leukemia (AML) chemotherapy as inpatients, there is variability in timing of discharge after chemotherapy completion. This study compared treatment-related morbidity, mortality and cumulative hospitalization in children with AML who were discharged after chemotherapy completion (early discharge) and those who remained hospitalized. Chart abstraction data for 153 early discharge-eligible patients enrolled on a Children's Oncology Group trial were compared by discharge strategy. Targeted toxicities included viridans group streptococcal (VGS) bacteremia, hypoxia and hypotension. Early discharge occurred in 11% of courses post-Induction I. Re-admission occurred in 80-100%, but median hospital stay was 7 days shorter. Patients discharged early had higher rates of VGS (adjusted risk ratio (aRR) = 1.67, 95% CI = 1.11-2.51), hypoxia (aRR = 1.92, 95% CI = 1.06-3.48) and hypotension (aRR = 4.36, 95% CI = 2.01-9.46), but there was no difference in mortality. As pressure increases to shorten hospitalizations, these results have important implications for determining discharge practices in pediatric AML.
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Affiliation(s)
| | - Kelly D Getz
- a Division of Oncology ;,b Center for Pediatric Clinical Effectiveness , The Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | | | - Yimei Li
- a Division of Oncology ;,c Center for Clinical Epidemiology and Biostatistics , University of Pennsylvania School of Medicine , Philadelphia , PA , USA
| | - Yuan-Shun V Huang
- b Center for Pediatric Clinical Effectiveness , The Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - Lillian Sung
- d Department of Haematology/Oncology , The Hospital for Sick Children , Toronto , Canada
| | - Todd A Alonzo
- e Department of Preventative Medicine , University of Southern California , Arcadia , CA , USA ;,f Children's Oncology Group , Monrovia , CA , USA
| | | | - Marla Daves
- g Department of Pediatrics , Children's Healthcare of Atlanta , Atlanta , GA , USA
| | - Terzah M Horton
- h Department of Pediatrics , Section of Hematology-Oncology, Texas Children's Hospital , Houston , TX , USA
| | - Michael A Pulsipher
- i Hematology Division , University of Utah School of Medicine , Salt Lake City , UT , USA
| | - Jessica Pollard
- j Cancer and Blood Disorders Center , Seattle Children's Hospital , Seattle , WA , USA
| | - Rochelle Bagatell
- a Division of Oncology ;,k Departments of Pediatrics , University of Pennsylvania School of Medicine , Philadelphia , PA , USA
| | - Alix E Seif
- a Division of Oncology ;,k Departments of Pediatrics , University of Pennsylvania School of Medicine , Philadelphia , PA , USA
| | - Brian T Fisher
- b Center for Pediatric Clinical Effectiveness , The Children's Hospital of Philadelphia , Philadelphia , PA , USA ;,c Center for Clinical Epidemiology and Biostatistics , University of Pennsylvania School of Medicine , Philadelphia , PA , USA ;,k Departments of Pediatrics , University of Pennsylvania School of Medicine , Philadelphia , PA , USA ;,l Infectious Diseases , The Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - Alan S Gamis
- m Pediatric Hematology/Oncology , Children's Mercy Hospital , Kansas City , MO , USA
| | - Richard Aplenc
- a Division of Oncology ;,c Center for Clinical Epidemiology and Biostatistics , University of Pennsylvania School of Medicine , Philadelphia , PA , USA ;,k Departments of Pediatrics , University of Pennsylvania School of Medicine , Philadelphia , PA , USA ;,l Infectious Diseases , The Children's Hospital of Philadelphia , Philadelphia , PA , USA
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18
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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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19
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Postinduction Supportive Care of Pediatric Acute Myelocytic Leukemia: Should Patients be Kept in the Hospital? LEUKEMIA RESEARCH AND TREATMENT 2014; 2014:592379. [PMID: 25349742 PMCID: PMC4198778 DOI: 10.1155/2014/592379] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 09/14/2014] [Accepted: 09/15/2014] [Indexed: 11/17/2022]
Abstract
Children with AML become profoundly neutropenic while they undergo remission induction chemotherapy. It is unknown whether these children should be kept in the hospital while they are severely neutropenic to prevent life-threatening complications associated with neutropenia and reduce fatality. We at our institution routinely discharge patients after completing remission induction chemotherapy in the presence of profound neutropenia, unless it is clinically contraindicated. We reviewed all AML patients who were consecutively treated at our hospital from 1989 to 2011. Thirteen patients were electively discharged after completion of induction I chemotherapy. Of the 13, 4 died due to relapse or complications of stem cell transplants (not due to neutropenia related complications). Another eight are long term survivors. In this very small series, discharge from the hospital even though patients were severely neutropenic did not adversely affect the survival.
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20
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Saini L, Rostein C, Atenafu EG, Brandwein JM. Ambulatory consolidation chemotherapy for acute myeloid leukemia with antibacterial prophylaxis is associated with frequent bacteremia and the emergence of fluoroquinolone resistant E. Coli. BMC Infect Dis 2013; 13:284. [PMID: 23800256 PMCID: PMC3694510 DOI: 10.1186/1471-2334-13-284] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Accepted: 06/19/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ambulatory consolidation chemotherapy for acute myeloid leukemia (AML) is frequently associated with bloodstream infections but the spectrum of bacterial pathogens in this setting has not been well-described. METHODS We evaluated the emergence of bacteremias and their respective antibiotic susceptibility patterns in AML patients receiving ambulatory-based consolidation therapy. Following achievement of complete remission, 207 patients received the first cycle (C1), and 195 the second cycle (C2), of consolidation on an ambulatory basis. Antimicrobial prophylaxis consisted of ciprofloxacin, amoxicillin and fluconazole. RESULTS There were significantly more positive blood cultures for E. coli in C2 as compared to C1 (10 vs. 1, p=0.0045); all E. coli strains for which susceptibility testing was performed demonstrated resistance to ciprofloxacin. In patients under age 60 there was a significantly higher rate of Streptococccus spp. bacteremia in C2 vs. C1; despite amoxicillin prophylaxis all Streptococcus isolates in C2 were sensitive to penicillin. Patients with Staphylococcus bacteremia in C1 had significantly higher rates of Staphylococcus bacteremia in C2 (p=0.009, OR=8.6). CONCLUSIONS For AML patients undergoing outpatient-based intensive consolidation chemotherapy with antibiotic prophylaxis, the second cycle is associated with higher rates of ciprofloxacin resistant E. coli, penicillin-sensitive Streptococcus bacteremias and recurrent Staphylococcus infections.
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Affiliation(s)
- Lalit Saini
- Department of Medical Oncology and Hematology, Princess Margaret Hospital, University of Toronto, 610 University Avenue, Rm. 5-109, Toronto, ON M5G 2M9, Canada
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21
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Møller T, Adamsen L, Appel C, Welinder P, Stage M, Jarden M, Hjerming M, Kjeldsen L. Health related quality of life and impact of infectious comorbidity in outpatient management of patients with acute leukemia. Leuk Lymphoma 2012; 53:1896-904. [PMID: 22420948 DOI: 10.3109/10428194.2012.676169] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Although survival has improved among patients with acute leukemia, there is still a considerable risk of severe complications throughout the course of treatment. This contrast increases the interest in monitoring health related quality of life (HRQOL) in these patients. This study presents a longitudinal HRQOL evaluation (European Organisation for Research and Treatment of Cancer core 30-item questionnaire; EORTC-QLQ C-30) and the impact of infectious comorbidity among 60 patients with leukemia (median age 47) treated in an outpatient management program at Copenhagen University Hospital. Significant improvement was seen on several HRQOL scores during follow-up. Explorative general linear models (GLMs) suggest that high cumulative severity of infectious comorbidity significantly reduces physical functioning and overall quality of life at treatment completion.
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Affiliation(s)
- Tom Møller
- UCSF, The University Hospital's Center for Nursing and Care Research, Copenhagen, Denmark.
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22
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Walter RB, Lee SJ, Gardner KM, Chai X, Shannon-Dorcy K, Appelbaum FR, Estey EH. Outpatient management following intensive induction chemotherapy for myelodysplastic syndromes and acute myeloid leukemia: a pilot study. Haematologica 2011; 96:914-7. [PMID: 21393334 DOI: 10.3324/haematol.2011.040220] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Due to infectious and bleeding risks, adults with acute myeloid leukemia or high-risk myelodysplastic syndromes typically remain hospitalized after remission induction chemotherapy until blood count recovery. Here, we explored the medical and financial effects of discharge immediately after chemotherapy completion with close outpatient follow up. Within 12 months, 15 patients fulfilling both medical and logistical criteria were discharged early, whereas 5 patients meeting medical criteria only served as inpatient controls. No patient died. Patients discharged early spent a median of 8 days (range 3-36 days), or 54% of their study time, as outpatients. These patients required less time on intravenous antibiotics (6 vs. 16 days; P=0.11), received fewer red blood cell transfusions (0.25 vs. 0.48 units/day; P=0.08), and incurred lower median daily charges ($3,270 vs. $5,467; P=0.01) than controls. Thus, early discharge of selected patients appears, safe and may reduce cost and resource utilization. (ClinicalTrials.gov Identifier: NCT00844441).
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Affiliation(s)
- Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, D2-190; Seattle, WA 98109-1024, USA.
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23
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Hematologic patients' clinical and psychosocial experiences with implanted long-term central venous catheter: self-management versus professionally controlled care. Cancer Nurs 2011; 33:426-35. [PMID: 20562617 DOI: 10.1097/ncc.0b013e3181dc1908] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A significant decrease in catheter-related infections was demonstrated in our earlier randomized controlled trial of central venous catheter (CVC) care in hematologic patients. OBJECTIVE This article focuses on patients' clinical and psychosocial experiences with CVC self-care compared with professionally controlled CVC care. METHODS Eighty-two patients with tunneled CVCs were enrolled in the randomized controlled trial. The intervention group (n = 42) was trained to perform CVC self-care. The control group (n = 40) followed standard CVC procedure provided by nurses. Eighteen patients were selected for semistructured interviews focusing on patients' clinical and psychosocial experiences with CVCs. RESULTS Methods of CVC care have different influences on the patients' clinical and psychosocial outcomes, depending on whether they were hospitalized or outpatients. Central venous catheter was viewed as important because it was the main port of treatment toward a cure, although patients constantly fear complications. Central venous catheter self-care increased patients' independence from health professionals and supported perceived self-efficacy and control. Central venous catheters cause psychosocial problems including altered body perception, sexual activity avoidance, and feeling stigmatized. CONCLUSIONS Patients experience increased perceived self-control and independence when individually supervised and trained in CVC self-management. Assuming ownership of CVC care can encourage patients to feel less inhibited about sexual activity and socialization. IMPLICATIONS FOR PRACTICE Placement of a tunneled CVC should engage nurses to organize individualized structured and supervised patient education. Stigma originating from CVCs should be carefully considered by health professionals when maintaining CVC insertion for longer periods. Central venous catheters should be removed whenever the potential risks exceed the catheter's functional necessity.
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24
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The duration of functioning of a subcutaneous implantable port for the treatment of hematological tumors: a single institution-based study. Int J Clin Oncol 2010; 15:172-8. [DOI: 10.1007/s10147-010-0039-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2009] [Accepted: 10/21/2009] [Indexed: 10/19/2022]
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25
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Bakhshi S, Singh P, Swaroop C. Outpatient consolidation chemotherapy in pediatric acute myeloid leukemia: a retrospective analysis. ACTA ACUST UNITED AC 2010; 14:255-60. [PMID: 19843379 DOI: 10.1179/102453309x446144] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND To assess the outcomes of outpatient high dose cytosine arabinoside consolidation cycles in pediatric acute myeloid leukemia (AML) patients in comparison to inpatient treatment. METHODS We retrospectively analyzed 90 cycles of AML consolidation given to 30 patients between July 2003 and July 2007. RESULTS Median age was 8 years (range 1.5-15) and 22/30 (73.3%) were males. Sixty-nine of 90 (76.7%) cycles were given on an ambulatory basis; readmission occurred in 25/69 (36.2%) and there was one death. The outpatient cycles in comparison to the inpatient cycles required significantly fewer invasive blood investigations (p<0.001) but had comparable number of blood products administered as supportive therapy. There was no significant difference in the frequency of granulocyte colony stimulating factor usage and recovery time of absolute neutrophil count and platelet count. The incidence of febrile neutropenia though was comparable in the groups (72.5% outpatient versus 76.2% inpatient), but the duration (p=0.003) and subsequent therapeutic antifungal usage (p=0.001) was significantly more in inpatient administered cycles. Second line antibiotics were needed in 16/50 (32%) outpatient episodes of febrile neutropenia in contrast to 10/16 (72.5%) episodes of febrile neutropenia in inpatient courses (p=0.030). CONCLUSIONS Outpatient AML consolidation therapy is safe and feasible in children. It appears to result in less frequent invasive blood studies; shorter duration of febrile neutropenia and consequently less antimicrobial and antifungal usage as compared to inpatient consolidation cycles. To our knowledge, this report is the first of its kind looking specifically at outpatient consolidation chemotherapy in AML.
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Affiliation(s)
- Sameer Bakhshi
- Department of Medical Oncology, Dr B R A Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India.
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26
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Møller T, Nielsen OJ, Welinder P, Dünweber A, Hjerming M, Moser C, Kjeldsen L. Safe and feasible outpatient treatment following induction and consolidation chemotherapy for patients with acute leukaemia. Eur J Haematol 2009; 84:316-22. [PMID: 20002732 DOI: 10.1111/j.1600-0609.2009.01397.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Traditionally, patients with acute leukaemia are admitted to hospital during chemotherapy-induced pancytopenia, although a few recent reports have reported the feasibility and safety of outpatient treatment. We have developed an outpatient treatment programme for patients with acute leukaemia incorporating comprehensive patient education for self-care management at home during pancytopenia and involvement of patients in care of their tunnelled central venous catheter (CVC). During neutropenia, patients are treated with prophylactic ciprofloxacine, amoxicillin/clavulanic acid and fluconazole. Herein, we report the results of outpatient treatment of 60 patients with acute leukaemia (54 with acute myeloid leukaemia) followed prospectively in the period from March 2004 to 2007. After induction chemotherapy, outpatient treatment was possible after 48 of 73 induction courses, with no readmission in 19 of these (40%). A total of 129 consolidation courses were administered with outpatient treatment following 116 of these, with no readmission in 69 (59%). The median number of days spent at home with neutrophils below 0.5 x 10(9)/L was 8 d per course following induction and 12 d following consolidation chemotherapy. The predominant cause of readmission was neutropenic fever, in most instances of unknown origin. Coagulase-negative staphylococci and Enterococcus faecium were the most frequently identified bacteria in blood cultures, whereas only four positive blood cultures with multiresistant Escherichia coli were identified in the entire patient cohort, the latter exclusively observed in patients receiving antibiotic prophylaxis. The majority of the patients were able to take care of their CVC including change in dressing and heparin flushing. There were 12 CVC-related infections. There were no treatment-related deaths. We conclude that outpatient treatment of patients with acute leukaemia is feasible and safe.
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Affiliation(s)
- Tom Møller
- Department of Haematology, National University Hospital, Copenhagen, Denmark
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27
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Halim TY, Song KW, Barnett MJ, Forrest DL, Hogge DE, Nantel SH, Nevill TJ, Shepherd JD, Smith CA, Sutherland HJ, Toze CL, Lavoie JC. Positive impact of selective outpatient management of high-risk acute myelogenous leukemia on the incidence of septicemia. Ann Oncol 2007; 18:1246-52. [PMID: 17442662 DOI: 10.1093/annonc/mdm112] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Curative intent chemotherapy for acute myelogenous leukemia (AML) leads to prolonged severe neutropenia, during which patients are highly susceptible to infection. Traditionally these high-risk patients were treated as inpatients. Our center recently implemented a selective ambulatory management policy for AML patients undergoing chemotherapy. MATERIALS AND METHODS A retrospective analysis was conducted to assess the occurrence of septicemia in AML patients treated over a 5 years period with curative intent chemotherapy. This review encompasses a change in policy from primarily inpatient care to selective outpatient management coupled with prophylactic antibiotic therapy. RESULTS A total of 294 patients, receiving 623 cycles of chemotherapy were identified. A significant decrease in septicemia was observed from the inpatient to outpatient cohort (22% to 13% P < 0.05), which correlated with the shift towards outpatient treatment of consolidation cycles. A shift from Gram-negative to Gram-positive organisms as the cause of septicemia was also detected in the outpatient cohort, likely due to the introduction of ciprofloxacin prophylaxis. No significant emerging resistance and no septicemia-related mortality were noted in the outpatient cohort. CONCLUSION The observed decrease in the incidence of septicemia in the ambulatory cohort adds supportive evidence to the feasibility of selective outpatient management of AML patients with respect to infectious complications.
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Affiliation(s)
- T Y Halim
- Department of Immunology and Microbiology, University of British Columbia, Vancouver, Canada
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28
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Savoie ML, Nevil TJ, Song KW, Forrest DL, Hogge DE, Nantel SH, Shepherd JD, Smith CA, Sutherland HJ, Toze CL, Lavoie JC. Shifting to outpatient management of acute myeloid leukemia: a prospective experience. Ann Oncol 2006; 17:763-8. [PMID: 16497826 DOI: 10.1093/annonc/mdl011] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We assessed the feasibility of outpatient chemotherapy and supportive care in patients with acute myeloid leukemia (AML). PATIENTS AND METHODS All patients receiving curative intent chemotherapy between 09/01 and 10/02 and meeting our criteria received supportive care post induction chemotherapy as well as their entire consolidation chemotherapy cycles as outpatients. Patients received antimicrobial prophylaxis; those developing episodes of fever and not meeting the criteria for admission were treated with outpatient intravenous antibiotics. RESULTS Seventy-one cycles of induction chemotherapy were administered for newly diagnosed or relapsed AML. In 25 cycles the patient was discharged post chemotherapy prior to count recovery. Of these, 14 patients developed one or more febrile episodes as an outpatient and nine (36%) required readmission to hospital. Sixty-seven consolidation cycles were given on an outpatient basis. In 39 cycles there was one or more febrile episodes and in 14 (21%) admission was required. Infections were documented in four cases during induction and in 27 during consolidation. There were no treatment-related deaths. CONCLUSIONS Outpatient management of AML is safe and feasible using the strategies outlined in this report.
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Affiliation(s)
- M L Savoie
- The Leukemia/Bone Marrow Transplant Program of British Columbia, Division of Hematology, Vancouver Hospital Health Sciences Centre, BC Cancer Agency and the University of British Columbia, Vancouver, Canada.
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29
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McGrath P, Paton MA, Huff N. Beginning treatment for paediatric acute myeloid leukaemia: diagnosis and the early hospital experience. Scand J Caring Sci 2004; 18:358-67. [PMID: 15598243 DOI: 10.1111/j.1471-6712.2004.00293.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Despite the plethora of clinical literature on the medical treatment for paediatric acute myeloid leukaemia (AML), there is a dearth of psycho-social literature on how families cope with either the disease or its treatments. The present article seeks to make a contribution by placing psychosocial aspects of childhood AML on the agenda. The findings are from a 5-year longitudinal, qualitative study on the psychosocial aspects of paediatric leukaemia. Qualitative data is gathered from open-ended interviews at three points in time on the experience of illness. The holistic findings from T1 present the impact of diagnosis and early treatment for childhood AML from the perspective of mothers, father, sibling and child patients. The study is also following up families with related disorders, thus it is possible to assess difference to other haematological groups. The findings indicate that the families bring scant prior understanding of the illness, and experience the diagnosis with fear and seriousness as a confrontation with death. At the point of entering treatment they are in a profound sense of shock and grief, which is exacerbated by a distressing, all pervading, sense of uncertainty. Families can be overwhelmed by the exhaustion of attending to the escalating practical demands of the situation combined with fatigue, worry and poor nutrition. All families find dealing with the invasive procedures and aggressive drug protocols emotionally challenging. However, in spite of the difficulties, parents have a strong desire to be with their child and find any separation painful. Families come to view the ward as a comfort zone where they have the support of the health and allied health team and the camaraderie of others experiencing a similar situation. However, even this support has to be qualified by the need for personal space, the difficulty of handling complex emotions, and the fear of being overwhelmed by difficulties other families face. The insights argue strongly for sensitive support for all individuals coping with childhood AML.
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Affiliation(s)
- Pam McGrath
- Centre for Social Science Research, School of Nursing and Health, Central Queensland University, Rockhampton, Queensland, Australia.
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Redaelli A, Botteman MF, Stephens JM, Brandt S, Pashos CL. Economic burden of acute myeloid leukemia: a literature review. Cancer Treat Rev 2004; 30:237-47. [PMID: 15059647 DOI: 10.1016/j.ctrv.2003.11.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The primary objective was to examine the economic burden associated with acute myeloid leukemia (AML), a deadly hematological malignancy. AML is the most common form of acute leukemia in adults, particularly in individuals over 60 years of age; AML also accounts for 15-20% of childhood leukemia. MATERIALS AND METHODS A systematic review was conducted of relevant studies published in the English language. Economic analyses of AML published between 1990 and 2002 were identified from electronic data sources using broad search criteria. Additional studies were obtained by manual searches of bibliographies of articles identified in the electronic searches. Articles were screened for relevance and included if the main theme included some element of AML cost of treatment, cost drivers, or cost-effectiveness. Studies reporting only drug prices without a formal comparison or analysis were not included. RESULTS Twenty-nine studies were included in the review. Although information was limited on the comprehensive economic burden of AML from a societal perspective, the costs appear to be split equally between direct and indirect costs. Direct costs of AML from a public payer perspective were available for a few countries such as the Netherlands, Sweden, US (Medicare), and Italy. These studies found that the key cost drivers appear to be hospitalization length of stay related to initial chemotherapy, relapse of disease, and bone marrow transplant (BMT) and peripheral blood stem cell transplant (PBSCT). Several cost analyses have been published comparing the different treatment strategies; however, most of them were published in the early 1990s, and their analysis revolved around cost-comparison rather than comprehensive cost-effectiveness. The published studies investigated pharmacological agents (e.g., idarubicin, daunorubicin, mitoxantrone, fludarabine and combination therapies), as well as BMT, PBSCT, and the treatment of complications. CONCLUSION Studies addressing the economic costs and burden of AML are relatively sparse in the international literature. Possible reasons for such a lack of information appear to include the low incidence rate of AML (e.g., about 260,000 new cases were reported in 2002 in the world) and the fact that it primarily afflicts older adults >60 years of age, making broad, well-designed economic analyses a challenge for most researchers. However, due to the high cost associated with the medical procedures (e.g., BMT, PBSCT) and the aging of the world population, further research is warranted.
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Affiliation(s)
- Alberto Redaelli
- Global Outcomes Research-Oncology, Pharmacia Corporation, Via Robert Koch 1.2, 20152 Milan, Italy.
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