The Increased Use of Diagnostic Studies over Time in Acute Myelogenous Leukemia Patients

Background:

Guidelines on the clinical management of certain disease processes assists providers in their decision making and in some cases reduce the amount of further testing/imaging that a patient undergoes. Without evidence based guidelines in place, the medical provider relies on previous experience and their clinical judgement in pursuing additional diagnostic studies. In this observational retrospective descriptive analysis, we reviewed 188 inpatient Acute Myelogenous Leukemia (AML) patients between 2002 and 2019 who post-induction presented with objective abdominal symptoms and/or abnormal gastrointestinal laboratory values, as well as correlating the number of diagnostic imaging performed.

Methods:

Data was collected retrospectively from an academic medical hospital database for descriptive analysis. Patients included in the study were those diagnosed with AML between April 2002 and October 2019, underwent induction therapy (i.e 7+3 induction with Idarubicin), and who received abdominal imaging ultrasound or computed tomography (US/CT) within 40 days post induction therapy. Patients who underwent induction therapy between April 2002 and December 2010 was one group, January 2011-October 2019 was the other group. Only the first abdominal image performed with each patient within 40 days post induction therapy was included in our analysis. Individuals who were noted to have cholecystectomies, those without clear induction dates and patients under the age of 16 were excluded whether or not they received abdominal imaging. Access to test result databases are password protected. Results from each subject are codified based on their sample ID and are not traceable to any identifiable subject name.

Results:

76 individuals had induction therapy initiation dates listed that were within April 2002-December 2010. Of those 76, 16 received abdominal imaging: 12 CT abdomen and 5 abdominal ultrasound. 112 individuals had induction therapy initiation dates listed that were within January 2011 and October 2019. Of those 112, 35 received abdominal imaging: 15 CT abdomen and 20 abdominal ultrasound.

Compared to the latter 9 years in regards to imaging performed for abdominal related clinical suspicions, the initial 9 years was observed to have a 51.4% reduction in the number of primary abdominal images (US/CT) performed. The latter 9 year patient population was also noted to have more individuals whose induction dates were listed, therefor included in the analysis; 32.1% larger in size than the first 9 years group.

First 9 years: Each CT abdomen was within normal limits. One abdominal ultrasound was concerning for acute acalculous cholecystitis within this group, in which further investigation was warranted i.e ERCP

Latter 9 years: One CT abdomen was of concern depicting distension of the gallbladder without evidence of cholelithiasis and also visible pericholecystic fluid likely secondary to ascites. Two abdominal ultrasounds were concerning for sludge however without signs of acute cholecystitis nor acute acalculous cholecystitis. These three results were not clinically significant to warrant further investigation

Conclusion:

Evidence based guidelines that correlates clinical presentation with the appropriate timing and indication of diagnostic imaging with AML patients is currently not well known in literature. Due to the lack of guidance, the decision to obtain diagnostic imaging may differ from providers leading to inconsistent care and multiple diagnostic imaging that may not be clinically significant. In this observational retrospective study at this institution, what was discovered was the increased overutilization of abdominal medical diagnostic imaging (US/CT) over the years that grossly did not result with findings that required further investigation or adjustment in AML therapeutic management.