Induction mortality and resource utilization in children treated for acute myeloid leukemia at free-standing pediatric hospitals in the United States

Authors

  • Marko Kavcic MD,

    Corresponding author
    1. Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
    • The Children's Hospital of Philadelphia, 3501 Civic Center Boulevard, Philadelphia, PA 19104

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    • Fax: (267) 425-0113

  • Brian T. Fisher DO, MSCE,

    1. Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
    2. Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
    3. Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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  • Yimei Li PhD,

    1. Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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  • Alix E. Seif MD, MPH,

    1. Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
    2. Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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  • Kari Torp,

    1. Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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  • Dana M. Walker MD, MSCE,

    1. Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
    2. Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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  • Yuan-Shung Huang MS,

    1. Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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  • Grace E. Lee MD,

    1. Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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  • Sarah K. Tasian MD,

    1. Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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  • Marijana Vujkovic PhD,

    1. Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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  • Rochelle Bagatell MD,

    1. Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
    2. Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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  • Richard Aplenc MD, PhD

    1. Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
    2. Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
    3. Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
    4. Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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Abstract

BACKGROUND:

Clinical trials in pediatric acute myeloid leukemia (AML) determine induction regimen standards. However, these studies lack the data necessary to evaluate mortality trends over time and differences in resource utilization between induction regimens. Moreover, these trials likely underreport the clinical toxicities experienced by patients.

METHODS:

The Pediatric Health Information System database was used to identify children treated for presumed de novo AML between 1999 and 2010. Induction mortality, risk factors for induction mortality, and resource utilization by induction regimen were estimated using standard frequentist statistics, logistic regression, and Poisson regression, respectively.

RESULTS:

A total of 1686 patients were identified with an overall induction case fatality rate of 5.4% that decreased from 9.8% in 2003 to 2.1% in 2009 (P = .0023). The case fatality rate was 9.0% in the intensively timed DCTER (dexamethasone, cytarabine, thioguanine, etoposide, and rubidomycin [daunomycin]/idarubicin) induction and 3.8% for ADE (cytarabine, daunomycin, and etoposide) induction (adjusted odds ratio = 2.2, 95% confidence interval = 1.1-4.5). Patients treated with intensively timed DCTER regimens had significantly greater antibiotic, red cell/platelet transfusion, analgesic, vasopressor, renal replacement therapy, and radiographic resource utilization than patients treated with ADE regimens. Resource utilization was substantially higher than reported in published pediatric AML clinical trials.

CONCLUSIONS:

Induction mortality for children with AML decreased significantly as ADE use increased. In addition to higher associated mortality, intensively timed DCTER regimens had a correspondingly higher use of health care resources. Using resource utilization data as a proxy for adverse events, adverse event rates reported on clinical trials substantially underestimated the clinical toxicities of all pediatric AML induction regimens. Cancer 2013. © 2013 American Cancer Society.

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