No Significant Differences Seen Between Outpatient and Inpatient Neutropenia Management for Pediatric Acute Myeloid Leukemia

A cohort study did not identify strong associations between outpatient or inpatient neutropenia management and increased bacteremia incidence, treatment delays, or worse health-related quality of life for pediatric patients with acute myeloid leukemia.

Among pediatric patients with acute myeloid leukemia (AML), the management of outpatient neutropenia was not associated with a higher bacteremia incidence, treatment delays, or worsened health-related quality of life (HRQOL) when compared with inpatient neutropenia management, according to results from a cohort study published in JAMA Network Open.

There was no significant difference in bacteremia incidence between outpatient management (23.8%) and inpatient management (29.0%) for pediatric patients with AML (adjusted rate ratio, 0.73; 95% CI, 0.56-1.06; P = .08). Moreover, investigators did not observe an association between outpatient management (mean, 30.7 days) and treatment delays vs inpatient management (mean, 32.8 days; adjusted mean difference, -2.2; 95% CI, -4.1 to -0.2; P = .03).

“This cohort study found that outpatient neutropenia management for pediatric AML may be undertaken safely for select patients and may be less burdensome to patients and families than inpatient management,” the investigators wrote. “However, not all chemotherapy courses may be amenable to outpatient management, given current supportive care and health care access in the US, and not all families will experience outpatient management as a preferred strategy.”

Eligible patients were younger than 19 years old at the time of diagnosis with AML. Those who received reduced intensity chemotherapy or only received a hematopoietic stem cell transplantation were ineligible for the cohort study.

Between June 2016 and May 2019, questionnaires were administered at 2 time points to patients who underwent frontline chemotherapy. Socioeconomic information, acute Pediatric Quality of Life Inventory version 4.0 Generic Core Scales, Pediatric Inventory for Parents-Difficulty assessment, Sleep Disturbance Scale for Children-Disorders of Initiating and Maintaining Sleep domain, and a modified Comprehensive Score for Financial Toxicity were all information included in the questionnaires.

The primary end points of this research were course-specific bacteremia incidence, time to next course, and HRQOL. A key secondary end point was course-specific mortality.

A total of 554 patients were included in the primary quantitative analyses. The mean patient age was 8.2 years and 50.9% of eligible patients were boys. Outpatient management included 114 patients and inpatient management had 379 patients. In the outpatient and inpatient cohorts, most patients were White (45.6% and 59.1%) and were primarily diagnosed between 2014 and 2016 in both groups, respectively (47.4% and 42.0%).

During the second intensification, patients who received outpatient management had a higher mortality (5.4%) compared with those who received inpatient management (0.5%; P = .03). However, mortality was comparable with inpatient management during induction I (0.0% and 1.3%; P = .59).

For the HRQOL analysis, which included 97 patients, overall outcomes did not differ between outpatient and inpatient management (mean Pediatric Quality of Life Inventory total score, 70.1 vs 68.7; adjusted mean difference, -2.8; 95% CI, -11.2 to 5.6).

Of the 86 patients who completed qualitative interviews, 86.0% were satisfied with their management experience independent of which strategy they received. Hospital-associated infections and family separation were 2 factors associated with dissatisfaction among patients who received inpatient management. Stress of caring for a neutropenic child at home was the main factor associated with dissatisfaction among patients who received outpatient management.

“The combined use of medical outcomes, [patient-centered outcomes], and qualitative interview data provides dramatically richer and more nuanced data to guide clinicians, patients, and families in the decision-making process around outpatient management. These data will inform implementation studies to operationalize more personalized discharge practices for children receiving AML chemotherapy,” the investigators concluded.

Reference

Getz KD, Szymczak JE, Li Y, et al. Medical outcomes, quality of life, and family perceptions for outpatient vs inpatient neutropenia management after chemotherapy for pediatric acute myeloid leukemia. JAMA Netw Open. Published online October 1, 2021. doi:10.1001/jamanetworkopen.2021.28385