Sharing Post-AML Consolidation Supportive Therapy with Local Centers Reduces Patient Travel Burden without Compromising Safety and Efficacy of Care
Authors: Hershenfeld Samantha A. , Maki Kimberly , Rothfels Lana , Murray Cindy Susan , Schimmer Aaron D. , Doherty Mary 
Published: October 2019

Abstract
AML (acute myeloid leukemia) is frequently treated with intensive induction and consolidation chemotherapy that often requires prolonged admissions to hospital. Our group and others demonstrated that consolidation chemotherapy for AML can be safely and effectively administered to selected patients on an ambulatory basis. However, this ambulatory care is centralized in quaternary centers, requiring some patients to travel long distances to these specialized centres. Recently, we developed a shared care model where patients receive their consolidation chemotherapy for AML at the specialized quaternary care center, but receive post-consolidation supportive care including blood checks, transfusions, and treatment for febrile neutropenia at their local hospitals. Here, we reviewed the impact of our new model of care with a focus on savings in travel time and distance.
Between 2009-2013, 73 patients with AML (n=61,) or APL (n=12) received post-consolidation care after CR1 at 14 local centers in the province of Ontario. These centers were regional cancer centers staffed by oncologists and/or hematologists experienced in the management of cytopenias and febrile neutropenia. However, these centers did not provide induction or consolidation chemotherapy for AML. Patients were seen at least weekly as out-patients at these hospitals while recovering from their consolidation chemotherapy. These centers were located a median of 70 km (range: 36-190) from the quaternary centre (The Princess Margaret Cancer Centre in Toronto, Canada). The 73 patients received 137 cycles of intensive consolidation where the post-consolidation care was provided by their local centre. The local centers treated a median of 2 patients (range of 1-19 patients) during the time frame evaluated.
Patients receiving shared care had a median age of 57 years (range: 21.7-78.6) and 40 (54.8%) were male. 7 (9.6%) had favourable, 42 (57.5%) had intermediate, 6 (8.2%) had poor and 18 (24.7%) had indeterminate cytogenetic profiles.
Google Maps (www.google.ca/maps) was used to calculate the distance travelled and estimated travel time between the patient's home and the quaternary centre or their local centre. Use of toll roads was permitted to achieve the fastest and shortest distance. Patients in the shared care model travelled a mean distance of 99.5 km ± 57.8 (median: 87.8 range: 28.4-266 km) each way to the quaternary care centre versus 26.3 km ± 33.6 (median: 14.5 range: 0.55-211 km) each way to their local treatment centre (p <0.001 for difference in means by t-test). The estimated mean time to travel from their home to the quaternary center was 71.6 ± 38 minutes (median: 62 range: 29-170) and the estimated time to travel to their local center was 23.3 ± 21.9 minutes (median: 18 range: 2-137) (p <0.001 for difference in means by t-test). Thus, by receiving post-consolidation care locally, patients saved a mean round trip travel distance of 146.5 km ± 99.6 and 96.7 min ± 63.4 of round trip travel time per visit compared to travelling to the quaternary care centre.
To assess the safety and efficacy of the shared care model, we compared the survival of the patients who received shared care to that of the other 344 patients with AML (n=297) or APL (n=47) who received consolidation chemotherapy in CR1 during the same time frame and remained at the quaternary care centre for all of their post-consolidation care. Gender, age and cytogenetic risk did not significantly differ between the shared care group and the group of patients receiving all of their care at the quaternary center (p>0.05). There was no significant difference in overall survival between the 2 groups (p value of log-rank test >0.05). 30, 60, and 90 day survival from start of consolidation chemotherapy was 98.6%, 97.2%, and 95.9% for the patients receiving shared care and 98.8%, 97.1%, and 95.3% for patients receiving all of their care at the quaternary center. Multivariate Cox proportional hazards model revealed no significant increase in hazard of death for the Shared Care patients compared to control when controlling for age, gender, AML vs. APL and cytogenetic prognosis (p value >0.05).
Thus, a collaborative care delivery model utilizing partnerships with regional centres for post-consolidation care in AML reduces patient travel burden while maintaining safety and efficacy.

Disclosures
No relevant conflicts of interest to declare.