Potentially Avoidable Hospitalizations in Older Patients with Acute Myeloid Leukemia (AML)
Authors: El-Jawahri Areej , Keenan Tanya , Abel Gregory , Steensma David P. , LeBlanc Thomas W. , Traeger Lara , Fathi Amir T. , DeAngelo Daniel J. , Wadleigh Martha , Hobbs Gabriela , Amrein Philip C. , Stone Richard M. , Ballen Karen K. , Chen Yi-Bin , Temel Jennifer S. 
Published: October 2019

Abstract
Background: Many older adults (≥60) with AML have a poor prognosis and spend a high portion of their life from diagnosis until death in the hospital. Using a large cohort, we examined the reasons for hospitalizations and identified those which are potentially avoidable.
Methods: We conducted a retrospective analysis of 329 consecutive patients (≥60) diagnosed with AML between 5/1/2005 and 12/31/2011 at two major tertiary care hospitals to examine the reasons for hospitalizations during treatment. Practicing physicians used a consensus-driven medical record review process to identify primary reason for each hospitalization and categorize it as "potentially avoidable" or "not avoidable" based on a novel adaptation of the Graham's criteria for potentially avoidable hospital admissions. We compared the rate of potentially avoidable hospitalizations between older patients receiving intensive chemotherapy (n=197) versus non-intensive chemotherapy (n=132) using multivariate logistic regression analysis controlling for age, gender, marital status, disease risk, comorbidities, and the receipt of stem cell transplantation.
Results: We evaluated 1040 hospitalizations after the diagnosis of AML in 329 unique patients. The median age was 69.9 years [range 60-90] and the median number of hospitalizations was 4.2 [range 0-18]. 33.1% (109/329) of patients underwent stem cell transplantation. The most common primary reasons for hospitalizations were: fever/infection (38.0%), planned hospitalizations for chemotherapy or transplantation (37.7%), and uncontrolled symptoms (9.8%). We identified 180/1040 hospitalizations (17.4%) as potentially avoidable; among these, 47.8% were due to premature hospital discharge, 18.9% could have been managed in the outpatient setting, and 16.1% were due to failure of timely outpatient follow-up. Potentially avoidable hospitalizations represented 12.9% (76/589) and 23.1% (10/451) of hospitalizations among patients who received intensive chemotherapy and non-intensive chemotherapy, respectively. In multivariate logistic regression analysis, the receipt of non-intensive chemotherapy was associated with higher risk of potentially avoidable hospitalization [OR 2.01, 95% CI 1.27-3.20, P = 0.003].
Conclusions: Although many hospitalizations in older patients with AML are unavoidable and driven by the illness course and its treatment, a substantial proportion are potentially avoidable. Patients with AML undergoing non-intensive chemotherapy are at higher risk of having potentially avoidable hospitalization. Future interventions to reduce health care utilization in this population are needed, especially among those who are treated with non-intensive chemotherapy.

Disclosures
Steensma: Incyte: Consultancy; Amgen: Consultancy; Celgene: Consultancy; Onconova: Consultancy. LeBlanc:Boehringer Ingelheim: Membership on an entity's Board of Directors or advisory committees; Epi-Q: Consultancy; Flatiron: Consultancy; Helsinn Therapeutics: Honoraria, Research Funding. Fathi:Agios Pharmaceuticals: Other: Advisory Board participation; Merck: Other: Advisory Board participation; Seattle Genetics: Other: Advisory Board participation, Research Funding. DeAngelo:Amgen: Consultancy; Celgene: Consultancy; Pfizer: Consultancy; Incyte: Consultancy; Novartis: Consultancy; Ariad: Consultancy; Agios: Consultancy; Bristol Myers Squibb: Consultancy. Stone:Merck: Consultancy; Sunesis: Consultancy, Other: DSMB for clinical trial; Novartis: Research Funding; Agios: Consultancy; Amgen: Consultancy; Abbvie: Consultancy; Celgene: Consultancy; Karyopharm: Consultancy; Roche/Genetech: Consultancy; AROG: Consultancy; Pfizer: Consultancy; Juno: Consultancy; Celator: Consultancy. Chen:Bayer: Consultancy, Research Funding.