Comparison of Resource Utilization in Children Discharged Versus Children That Remain Hospitalized Following Chemotherapy for Acute Myeloid Leukemia
Authors: Getz Kelly D , Miller Tamara P. , Seif Alix E. , Li Yimei , Huang Yuan-Shung , Bagatell Rochelle , Fisher Brian T. , Aplenc Richard 
Published: October 2019

Abstract
Treatment for pediatric acute myeloid leukemia (AML) involves multiple courses of intensive chemotherapy leading to prolonged neutropenia with substantive infection risks. Patients are typically hospitalized at each course for the duration of chemotherapy and associated marrow aplasia. Evaluations of early discharge and outpatient supportive care in adult AML patients demonstrate comparable mortality and shorter lengths of stay compared to standard discharge. Similar data in the pediatric setting are limited. We used data from the Pediatric Health Information System (PHIS) to evaluate course-specific mortality and resource utilization in AML patients who were discharged prior to count recovery relative to comparable patients who remained hospitalized.
We used a cohort of children treated for new onset AML at children's hospitals in the US contributing to PHIS. Analyses were restricted to patients considered eligible for discharge prior to count recovery. Patients were categorized at each course as early or standard discharge. Discharges within 3 days after chemotherapy completion were considered early. Course-specific follow-up started on the last day of chemotherapy and continued until the earliest of: start of the subsequent course, death, or 50 days after commencement of chemotherapy. Resource utilization was determined based on daily billing data and reported as days of use per 100 hospital days. Case fatality rates and duration of hospitalization were compared using chi-square and Wilcoxon rank sum tests. Poisson regression with inpatient days as offset was used to compare resource use by discharge status.
The study population included 996 patients representing 2358 courses. Fewer patients were discharged early following Induction I (7%) compared to subsequent courses (22-24%). Rates of early discharge varied greatly by hospital ranging from 0% to 100%. Across courses, patients discharged early experienced 8-12 fewer inpatient days (all p<0.001) despite readmission rates >90%. Case fatality rates were low across courses (0-1.3%) and did not differ significantly by discharge status. However, more early discharge patients required ICU level care at each course (7.2-18.1%) compared to standard discharge patients (2.0%-8.7%; all p <0.02). Table 1 presents resource utilization by discharge status with corresponding rate ratios (RR). Rates of antibiotic, vasopressor, and oxygen therapy use were each consistently elevated for early discharge patients. Following Intensification I and II, blood product use was also higher among those discharged early.
The data suggest a similar overall survival and shorter hospitalization following early compared to standard discharge. However, based on increased rates of vasopressor and antibiotic use, early discharge patients may be at greater risk for life-threatening chemotherapy-related infectious complications.
Table 1: Resource utilization (per 100 hospital days) by Discharge Status Early Discharge Standard Discharge Adjusted1 RR (95% CI) Antibiotics Induction I 153.6 131.5 1.17 (1.00, 1.36)* Induction II 146.7 89.7 1.64 (1.48, 1.81)* Intensification I 144.2 95.1 1.52 (1.38, 1.67)* Intensification II 162.4 117.0 1.39 (1.27, 1.52)* Antifungals Induction I 78.9 91.6 0.87 (0.72, 1.05) Induction II 84.1 90.2 0.93 (0.86, 1.01) Intensification I 79.3 87.9 0.90 (0.82, 1.00) Intensification II 80.6 84.1 0.96 (0.86, 1.07) Antivirals Induction I 6.2 11.6 0.56 (0.20, 1.56) Induction II 4.0 5.9 0.58 (0.41, 1.11) Intensification I 8.7 13.1 0.66 (0.39, 1.12) Intensification II 5.7 13.0 0.44 (0.19, 0.98) Blood Products Induction I 34.6 29.9 1.16 (0.99, 1.35) Induction II 26.9 24.2 1.12 (0.99, 1.26) Intensification I 28.4 20.5 1.38 (1.11, 1.72)* Intensification II 39.1 29.1 1.34 (1.17, 1.55)* Vasopressors Induction I 2.4 0.4 6.47 (2.67, 15.7)* Induction II 3.5 0.7 5.04 (2.13, 12.0)* Intensification I 3.6 0.5 6.62 (2.91, 15.0)* Intensification II 3.8 1.0 3.69 (1.74, 7.83)* Parenteral nutrition Induction I 14.5 17.0 0.85 (0.43, 1.70) Induction II 10.3 9.5 1.09 (0.64, 1.86) Intensification I 7.5 6.1 1.24 (0.76, 2.02) Intensification II 11.0 8.4 1.30 (0.87, 1.96) Supplemental Oxygen Induction I 4.6 0.9 4.95 (1.87, 13.1)* Induction II 2.0 0.5 3.86 (1.89, 7.92)* Intensification I 1.6 0.7 2.33 (1.15, 4.77)* Intensification II 4.7 1.6 2.93 (1.44, 5.93)*
1adjusted for age, race, sex, and insurance status;
*statistically significant

Disclosures
No relevant conflicts of interest to declare.