Healthcare Provider Perceptions of Clinically Important Bleeding in Hematological Malignancies: A Qualitative Study

Abstract

Introduction: Acute leukemia (AL) is a rapidly progressive disease. AL and induction chemotherapy lead to an increased risk of bleeding. Bleeding is measured in clinical trials using the World Health Organization (WHO) bleeding scale. The scale defines a clinically significant bleed as a composite outcome of a grade 2 bleed or higher. The use of this composite outcome is problematic, as it does not distinguish minor bleeds, signs or symptoms of bleeding, does not consider the total burden of bleeding and lacks input from healthcare providers and patients. Given this, our objective was to identify healthcare providers' perspectives on the components of clinically important bleeding in AL patients.

Methods: Using qualitative description, we conducted 19 interviews with physicians (n=12), nurses (n=3), and nurse practitioners (n=4) who provide care to AL patients undergoing induction chemotherapy in Canada. Participants were recruited from professional organizations, networks, and social media. Interview data were analyzed using an inductive approach for conventional content analysis.

Results: Healthcare providers identified various factors that were considered to determine the significance or severity of a bleed. Participants assessed factors including the location and amount of blood, the management strategy, the need for intervention, multiple bleeds, changes in vital signs and other patient-specific factors. We developed three categories to differentiate bleeds: those with clinical significance, those with potential for clinical significance, and those without clinical significance. Conclusion: Healthcare providers considered various characteristics when determining the significance and or severity of a bleed. These characteristics were assessed in conjunction with other factors such as the patient's medical condition, bleeding history, and clinical intuition to predict the likelihood of a serious bleed. Future research should explore AL patients’ perspectives of clinically important bleeding to create a definition that is informed by evidence, clinicians, and patients.