Early Mortality as a Quality Indicator in Frontline and Salvage Acute Myeloid Leukemia

Early mortality is a historical measure of quality of care that incorporates patient comorbidities but not disease characteristics and treatment status which increase early mor tality, par ticularly in leukemia, and in the refractory and salvage settings. In 4151 patients with acute myeloid leukemia (AML) analyzed (2893 newly diagnosed, and 1258 in salvage), the 8-week mortality was 13% in frontline therapy and 18% in salvage therapy. A multivariate analysis, which accounted for the independent pretreatment adverse factors for early mortality in AML, still selected salvage status as significantly adverse for 8-week mortality (hazard ratio 1.954; P-value < .001). Thus, quality measure algorithms should incorporate a risk mortality index related to leukemia and a risk mortality index related to the leukemia status (salvage vs. frontline therapy).Background: Early mortality is a historical measure of the quality of care incorporated into many quality measure algorithms that mostly account for patient comorbidities but do not incorporate disease characteristics and treatment status which independently increase early mortality. This is particularly significant in leukemia, especially in the refractory and salvage settings.Study Aim: To define the independent adverse effect of leukemia salvage vs. frontline therapy on early mortality in acute myeloid leukemia (AML) after accounting for the pretreatment independent adverse effects associated with early mortality. Patients and Methods: A total of 4151 patients with AML were analyzed, 2893 newly diagnosed and 1258 in salvage. Univariate and multivariate analyses (MVA) were conducted to determine the independent adverse effects associated with 8-week mortality. Results: The 8-week mortality was 13% in frontline therapy and 18% in salvage therapy. By MVA, older age; therapy-related AML; prior history of myelodysplastic syndrome; poorer performance status; high white blood cell count; lower platelet count; higher percent of peripheral blasts; lower albumin levels; higher bilirubin, creatinine, and lactate dehydrogenase levels; and adverse cytogenetic risk groups were independently associated with a higher 8-week mortality rate. Adding treatment status after accounting for the independent adverse variables still selected salvage status as significantly adverse for 8-week mortality (hazard ratio 1.954; P-value < .001). Conclusions: Quality measure algorithms should incorporate a risk mortality index related to leukemia vs. other tumors and benign conditions and a risk mortality index related to the treatment status of leukemia (salvage vs. frontline therapy).

Automated summary

Early mortality is an important measure of quality of care, but previous studies did not take into account the impact of disease characteristics and treatment status. This study found that salvage therapy in acute myeloid leukemia patients is associated with significantly higher 8-week mortality, even after accounting for other adverse factors.