title: Volume-Outcome Relationships in Pediatric Acute Lymphoblastic Leukemia: Association Between Hospital Pediatric and Pediatric Oncology Volume With Mortality and Intensive Care Resources During Initial Therapy.
abstract: There are few contemporary studies of volume-outcome relationships in pediatric oncology. Children with acute lymphoblastic leukemia (ALL) are treated at a wide variety of hospitals. We investigated if inpatient hospital volume influences outcomes. The objective of this study was to evaluate the relationship between inpatient pediatric and pediatric oncology volume and mortality and intensive care resources (ICU care). We hypothesized an inverse relationship between volume and these outcomes.
  
  
  
  This was a retrospective cohort study. Patients 0 to 18 years of age in the Pediatric Health Information System or Perspective Premier Database from 2009 to 2011 with ALL were included. Exposures were considered as the average inpatient pediatric and pediatric oncology volume. The primary outcome was inpatient mortality; secondary outcome was need for ICU care.
  
  
  
  The included population comprised 3350 patients from 75 hospitals. The inpatient mortality rate was 0.86% (95% confidence interval, 0.58%-1.2%). In the unadjusted analysis, mortality increased as pediatric oncology volume increased from low (0%) to high volume (1.3%) (P = .009). The small number of deaths precluded multivariable analysis of this outcome. Pediatric and pediatric oncology volume was not associated with ICU care when we controlled for potential confounders.
  
  
  
  Induction mortality was low. We did not observe an inverse relationship between volume and mortality or ICU care. This suggests that in a modern treatment era, treatment at a low-volume center might not be associated with increased mortality or ICU care in the first portion of therapy. This relationship should be evaluated in other oncology populations with higher mortality rates and with longer-term outcomes.
authors.affiliation: Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. Electronic address: wilkesj@email.chop.edu.
authors.forename: Jennifer J
authors.initials: JJ
authors.lastname: Wilkes
authors.affiliation: Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; The Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
authors.forename: Sean
authors.initials: S
authors.lastname: Hennessy
authors.affiliation: The Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
authors.forename: Rui
authors.initials: R
authors.lastname: Xiao
authors.affiliation: Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
authors.forename: Susan
authors.initials: S
authors.lastname: Rheingold
authors.affiliation: Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
authors.forename: Alix E
authors.initials: AE
authors.lastname: Seif
authors.affiliation: Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA.
authors.forename: Yuan-Shung
authors.initials: YS
authors.lastname: Huang
authors.affiliation: Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA; Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA.
authors.forename: Neika
authors.initials: N
authors.lastname: Vendetti
authors.affiliation: Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA; The Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
authors.forename: Yimei
authors.initials: Y
authors.lastname: Li
authors.affiliation: Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
authors.forename: Rochelle
authors.initials: R
authors.lastname: Bagatell
authors.affiliation: Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA; The Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
authors.forename: Richard
authors.initials: R
authors.lastname: Aplenc
authors.affiliation: Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA; The Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA.
authors.forename: Brian T
authors.initials: BT
authors.lastname: Fisher
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003422:Critical Care / Q000706:statistics & numerical data; D005260:Female; D006295:Health Resources / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006760:Hospitalization / Q000706:statistics & numerical data; D006761:Hospitals; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D016017:Odds Ratio; D017063:Outcome Assessment, Health Care; D011159:Population Surveillance; D054198:Precursor Cell Lymphoblastic Leukemia-Lymphoma / Q000453:epidemiology* / Q000401:mortality / Q000628:therapy; D012189:Retrospective Studies
keywords: Leukemia; Patient volume; Pediatric