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Published on: October 23, 2020
Multilevel mortality risk factors among pediatric hematology-oncology patients with deterioration
Asya Agulnik1, Maricela Robles-Murguia1, Yichen Chen1
1St. Jude Children's Research Hospital, Memphis, Tennessee, USA.
Insights
Clinical deterioration events in pediatric cancer patients lead to high mortality. Interventions and patient factors, not hospital characteristics, significantly impact survival, highlighting the need for targeted care improvements.
Area of Science:
- Pediatric Oncology
- Critical Care Medicine
- Epidemiology
Background:
- Hospitalized pediatric hematology-oncology patients frequently experience clinical deterioration events (CDEs).
- These events often necessitate intensive care unit (ICU) interventions and are associated with high mortality rates, especially in resource-limited settings.
- Identifying risk factors for CDE mortality is crucial for improving outcomes in these vulnerable patients.
Purpose of the Study:
- To identify independent risk factors for mortality associated with clinical deterioration events (CDEs) in pediatric hematology-oncology patients.
- To analyze patient-level, event-level, and hospital-level factors contributing to CDE mortality.
- To inform targeted interventions for improving survival rates in this population.
Main Methods:
- A prospective registry of CDEs was implemented across 69 hospitals in 18 countries from April 2017 to December 2022.
- CDEs were defined as unplanned transfer to a higher level of care, ICU-level interventions on the ward, or nonpalliative ward death.
- Multilevel modeling was used to analyze registry data and identify independent risk factors for CDE mortality.
Main Results:
- A total of 4134 CDEs were reported in 3319 patients, with an overall event mortality of 26.8%.
- Significant independent risk factors for mortality included patient factors (e.g., disease relapse) and event-level factors (e.g., reason for admission, ICU interventions, laboratory abnormalities, organ dysfunction).
- Hospital-level factors were not found to be significant predictors of CDE mortality.
Conclusions:
- Pediatric hematology-oncology patients experiencing CDEs have a high mortality rate.
- Mortality is primarily influenced by modifiable event-level factors, emphasizing the potential for targeted interventions.
- The findings underscore the need for focused strategies to improve survival in hospitalized children with cancer experiencing critical illness.
Background:
Hospitalized pediatric hematology-oncology patients have frequent clinical deterioration events (CDEs) requiring intensive care unit (ICU) interventions and resulting in high mortality, particularly in resource-limited settings. This study identifies independent risk factors for CDE mortality in hospitals providing childhood cancer care in Latin America and Spain.
Methods:
Centers implemented a prospective CDE registry, defined as unplanned transfer to a higher level of care, use of ICU-level interventions on the ward, or nonpalliative ward death. The authors analyzed registry data from April 2017 to December 2022. The primary outcome was CDEs mortality, defined as death occurring during ICU admission, <24 hours of ICU discharge, or end of ward-based ICU interventions. Multilevel modeling identified event-, patient-, and hospital-level independent risk factors for CDE mortality.
Results:
Among 69 participating hospitals in 18 countries, 4134 CDEs were reported in 3319 pediatric hematology-oncology patients with an event mortality of 26.8% (1108 events). Of all CDEs, 33.7% used ICU interventions on the ward and 87.5% were transferred to a higher level of care. In multilevel modeling, significant independent risk factors for event mortality present at the start of deterioration included patient (disease relapse) and event (e.g., reason for hospital admission, use of ICU intervention on wards, abnormal lactate, platelets, or C-reactive protein, reason for deterioration, and number of organs with dysfunction); hospital factors were not significant predictors of mortality.
Conclusions:
Hospitalized pediatric hematology-oncology patients with CDE have high mortality with significant variability across centers. Mortality, however, is largely driven by modifiable event-level factors, demonstrating the need for targeted interventions to improve survival.
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