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

Background – Early mortality is a historical measure of quality of care incorporated into many quality measure algorithms that mostly account for patient co-morbidities 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 versus 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 4,151 patients with AML were analyzed, 2,893 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 < 0.001). Conclusions – Quality measure algorithms should incorporate a risk mortality index related to leukemia versus other tumors and benign conditions, and a risk mortality index related to the treatment status of the leukemia (salvage versus frontline therapy). Micro Abstract Early mortality is a historical measure of quality of care that incorporates patient co-morbidities but not disease characteristics and treatment status which increase early mortality, particularly in leukemia, and in the refractory and salvage settings. In 4,151 patients with AML analyzed (2,893 newly diagnosed, and 1,258 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 < 0.001). Thus, quality measure algorithms should incorporate a risk mortality index related to leukemia, and a risk mortality index related to the leukemia status (salvage versus frontline therapy).