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Some hospitalizations can be avoided for older adults with AML
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A considerable portion of hospital admissions for older patients with acute myeloid leukemia are potentially avoidable, according to results of a retrospective analysis.
Adults aged 60 years or older with AML spend prolonged periods of time in the hospital.
Areej El-Jawahri, MD, assistant in medicine at Massachusetts General Hospital and instructor in medicine at Harvard Medical School, and colleagues assessed the reasons for hospital admissions in older patients with AML treated at two tertiary care hospitals in the United States.
The analysis included patients who received intensive induction chemotherapy, as well as nonintensive treatment. Researchers excluded patients with acute promyelocytic leukemia, individuals who received supportive care alone, and those who were seen for a one-time consultation but received primary treatment elsewhere.
El-Jawahri and colleagues used the Dana-Farber Cancer Institute and Massachusetts General Hospital Leukemia Clinical Research Information Systems database to identify 1,040 hospital admissions between May 1, 2005, and Dec. 23, 2011.
Oncologists reviewed medical records to determine the primary reason for each admission. They used Graham’s criteria for potentially avoidable hospitalizations to determine whether each admission was potentially avoidable.
The most common primary reasons for hospitalization were infection or fever (38%), planned admission for transplantation or chemotherapy (38%), and uncontrolled symptoms (10%).
Researchers characterized 172 of 649 (27%) unplanned hospital admissions as potentially avoidable. From this group, 82 (48%) were determined to be readmissions due to premature hospital discharge, 32 (19%) were due to problems that researchers determined could have been managed in the outpatient setting, and 26 (15%) were due to failure of timely outpatient follow-up.
Mixed logistic regression analysis identified higher education (OR = 1.43; 95% CI, 1.01-2) and receipt of nonintensive induction chemotherapy (OR = 1.97; 95% CI, 1.25-3.1) as predictors of potentially avoidable hospitalizations.
“Most hospital admissions in older patients with acute myeloid leukemia are unavoidable, reflecting the burden of this disease and its potential complications,” El Jawahri and colleagues wrote. “However, a significant proportion of unplanned hospital admissions are potentially avoidable. This work underscores the need for future interventions targeting patients at risk [for] the disease, thereby reducing the hospital admission burden and improving the quality of care in this population.” – by Mark Leiser
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Jonathan M. Gerber
The treatment of acute myeloid leukemia requires a delicate balance between length of inpatient hospitalization and risk of readmission. Older patients with AML are particularly challenging to manage, as they typically have poorer risk disease, more comorbidities, and worse outcomes than their younger counterparts.
El-Jawahri and colleagues bravely tackle the difficult issue of potentially avoidable hospital admissions in patients aged 60 years or older with AML.
The inherently subjective nature of classifying specific admissions as avoidable or unavoidable limits some conclusions. That said, this study highlights the high risk of unplanned hospitalizations — preventable or otherwise — in this complicated patient population. Interestingly, only 31% of patients accounted for all of the potentially avoidable hospital admissions in this patient cohort, with 6% of patients responsible for multiple admissions. Better identification of these at-risk patients may allow for successful interventions to reduce potentially avoidable hospital admissions. Straightforward maneuvers — such as better discharge planning, closer follow-up, more aggressive outpatient rehabilitation services, earlier transition to palliative care when appropriate, and a revised hospice model to better accommodate leukemia management — may yield significant gains.
However, it remains to be seen how many of the potentially avoidable hospitalizations of these patients will truly prove preventable, and whether this will impact outcomes, such as total length of stay, cost and survival. Nevertheless, this certainly warrants further investigation. Beyond the obvious benefits to patients, there will be increasing financial pressures to reduce costly, unplanned hospitalizations as our health care system transitions from a volume-based to a value-based model.
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