Quality Improvement Initiative of Patients with Acute Myeloid Leukemia Receiving Non-Intensive Therapy in Academic-Community Medicine Partnerships in Rural Appalachia
Authors: Pham Natalie , Lantz Jeffrey , Jones Caroline , Kundu Debamita , McCann Nicholas , El Chaer Firas , Reed Daniel , Keng Michael 
Published: December 2024

Introduction: Studies have previously reported improved outcomes for patients with acute myeloid leukemia (AML) in academic over nonacademic settings potentially due to the availability of multidisciplinary teams, clinical trials and increased resources (median overall survival12.6 months vs. 7 months, p&lt;0.001; Giri et. al.). Southwest Virginia has a large population of individuals of lower socioeconomic status as demonstrated by a poverty rate of 15.8% [Rural Health Community Hub, HRSA] and decreased access to cancer providers. UVA Health formed a quality improvement initiative that partnered with community hematology-oncology practices in rural Appalachia to overcome this treatment disparity. Prior to this, patients with AML were only treated at UVA Health and were not co-treated with community providers. In this prospective quality improvement study, we analyzed treatment outcomes when nonacademic centers partnered with academic centers to treat patients with AML using a regimen of venetoclax and a hypomethylating agent (HMA).

Methods: We identified 129 patients with AML treated between 2020-2024 with venetoclax and either decitabine or azacitidine solely at an academic center (n=77, 60%) or community practice with academic center support (n=52, 40%). The project was developed by a multidisciplinary team of physicians, nurses, pharmacists, social workers, and case managers. The team met to develop a cause/effect diagram and pareto chart for obstacles to AML treatment in the community and created an ideal state process map and communication tools after diagnosis of AML at our center. For our test of change, patients received their first cycle of therapy at our academic center in the collaborative community/academic center treatment setting. Before discharging to a community practice, our team worked to ensure completion of financial screening, community referral to establish appointments for treatment and supportive care, provided prescriptions/drugs in hand and chemotherapy teaching, and provided contact information to our center. The primary objective was to evaluate the overall response rate (ORR), with a secondary evaluation of differences in chemotherapy management and complications. P-values were calculated using Fisher's exact test.

Results: The ORR was similar in the academic setting versus the community setting with academic center support (35.1% vs. 38.5%, p=0.324) and there was no significant difference in OS with a median survival of 9.67 months in all patients (95% CI 8.33-12.70). Of note, patients treated at the academic center did have a 33% higher relative risk in regards to their survival probabilities when accounting for performance status, European LeukemiaNet (ELN) risk, poverty status and exposure to prior chemotherapy; however, this difference was not statistically significant (HR=1.33, 95% CI 0.78-2.26, p=0.285). In the decitabine-based regimen, there was an increased rate of dose reduction in the community at 68.6% versus only 33.3% in the academic setting (p=0.012). There was an increased report of fatigue in the academic center at 76.6% versus 55.6% in the community (p=0.021), but other adverse events were without significant difference including febrile neutropenia, cytopenias, mucositis, nausea, emesis, diarrhea, infection and adverse bleeding.

Conclusions: Contrary to prior studies, this quality improvement initiative demonstrated that partnerships between academic and community oncology centers in rural Appalachia can successfully have similar treatment options when compared to treatment solely in an academic setting. This demonstrates that our novel academic/community collaboration can overcome previously studied socioeconomic differences of leukemia treatment settings. Although there were some differences in management, such as increased dose reduction in the community, the OS and ORR were similar. Furthermore, this study did not identify any significant safety concerns that could prevent patients from receiving this regimen in either setting. Our goal is to continue evaluating this partnership through further tests of change for this patient population to remove treatment differences.