title: The role of acuity of illness at presentation in early mortality in black children with acute myeloid leukemia.
abstract: Black patients with acute myeloid leukemia (AML) experience higher mortality than White patients. We compared induction mortality, acuity of illness prior to chemotherapy, and insurance type between Black and White patients to assess whether acuity of presentation mediates the disparity. Within a retrospective cohort of 1,122 children with AML treated with two courses of standard induction chemotherapy between 2004 and 2014 in the Pediatric Health Information System (PHIS) database, the association between race (Black versus White) and inpatient mortality during induction was examined. Intensive Care Unit (ICU)-level resource utilization during the first 72 hours following admission for initial AML chemotherapy was evaluated as a potential mediator. The total effect of race on mortality during Induction I revealed a strong association (unadjusted HR 2.75, CI: 1.18, 6.41). Black patients had a significantly higher unadjusted risk of requiring ICU-level resources within the first 72 hours after initial presentation (17% versus 11%; RR 1.52, CI: 1.04, 2.24). Mediation analyses revealed the indirect effect of race through acuity accounted for 61% of the relative excess mortality during Induction I. Publicly insured patients experienced greater induction mortality than privately insured patients regardless of race. Black patients with AML have significantly greater risk of induction mortality and are at increased risk for requiring ICU-level resources soon after presentation. Higher acuity amongst Black patients accounts for a substantial portion of the relative excess mortality during Induction I. Targeting factors affecting acuity of illness at presentation may lessen racial disparities in AML induction mortality.
authors.affiliation: Division of Oncology, The Children's Hospital of Philadelphia, Pennsylvania.|Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Pennsylvania.|Leonard Davis Institute of Health Economics, University of Pennsylvania, Pennsylvania.
authors.forename: Lena E
authors.initials: LE
authors.lastname: Winestone
authors.affiliation: Division of Oncology, The Children's Hospital of Philadelphia, Pennsylvania.|Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Pennsylvania.
authors.forename: Kelly D
authors.initials: KD
authors.lastname: Getz
authors.affiliation: Division of Oncology, The Children's Hospital of Philadelphia, Pennsylvania.|Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Pennsylvania.
authors.forename: Tamara P
authors.initials: TP
authors.lastname: Miller
authors.affiliation: Division of Oncology, The Children's Hospital of Philadelphia, Pennsylvania.|Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Pennsylvania.|Leonard Davis Institute of Health Economics, University of Pennsylvania, Pennsylvania.
authors.forename: Jennifer J
authors.initials: JJ
authors.lastname: Wilkes
authors.affiliation: Division of Oncology, The Children's Hospital of Philadelphia, Pennsylvania.
authors.forename: Leah
authors.initials: L
authors.lastname: Sack
authors.affiliation: Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Pennsylvania.
authors.forename: Yimei
authors.initials: Y
authors.lastname: Li
authors.affiliation: Healthcare Analytics Unit, The Children's Hospital of Philadelphia, Pennsylvania.
authors.forename: Yuan-Shung
authors.initials: YS
authors.lastname: Huang
authors.affiliation: Division of Oncology, The Children's Hospital of Philadelphia, Pennsylvania.|Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Pennsylvania.
authors.forename: Alix E
authors.initials: AE
authors.lastname: Seif
authors.affiliation: Division of Oncology, The Children's Hospital of Philadelphia, Pennsylvania.|Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Pennsylvania.
authors.forename: Rochelle
authors.initials: R
authors.lastname: Bagatell
authors.affiliation: Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Pennsylvania.|Division of Infectious Diseases, The Children's Hospital of Philadelphia, Pennsylvania.|Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Pennsylvania.
authors.forename: Brian T
authors.initials: BT
authors.lastname: Fisher
authors.affiliation: Leonard Davis Institute of Health Economics, University of Pennsylvania, Pennsylvania.|Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Pennsylvania.|Department of Veterans Affairs' Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Pennsylvania.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Epstein
authors.affiliation: Division of Oncology, The Children's Hospital of Philadelphia, Pennsylvania.|Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Pennsylvania.|Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Pennsylvania.|Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Pennsylvania.
authors.forename: Richard
authors.initials: R
authors.lastname: Aplenc
mesh_terms: D000293:Adolescent; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000008:administration & dosage / Q000627:therapeutic use*; D044383:Black People; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D006776:Hospitals, Pediatric / Q000706:statistics & numerical data; D006801:Humans; D060828:Induction Chemotherapy / Q000379:methods / Q000401:mortality*; D007223:Infant; D007348:Insurance, Health / Q000706:statistics & numerical data; D015278:Intensive Care Units, Pediatric / Q000706:statistics & numerical data; D015470:Leukemia, Myeloid, Acute / Q000188:drug therapy / Q000208:ethnology / Q000401:mortality*; D008297:Male; D012189:Retrospective Studies; D012720:Severity of Illness Index; D012959:Socioeconomic Factors; D016896:Treatment Outcome