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Initial Bone Marrow Aspiration In Childhood Idiopathic Thrombocytopenia: Decision Analysis

R. Klaassen, J. Doyle, M. Krahn, V. Blanchette, G. Naglie
Published 2001 · Medicine

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Purpose Bone marrow aspiration (BMA) is routinely performed before starting steroid therapy in children with idiopathic thrombocytopenia, primarily to rule out leukemia. Methods A decision tree for the initial management of a child older than age 6 months, presenting with idiopathic thrombocytopenia, without blasts on the peripheral smear was constructed. The three strategies are: 1) initial BMA in all patients; 2) initial BMA only in patients at high risk; and 3) empiric therapy for all patients without initial BMA. High-risk criteria include any of: platelet count >50 × 10 9 /L; hemoglobin <100g/L (age younger than 12 months) or <110g/L (age older than 12 months); white blood cell count <5 × 10 9 /L (younger than 6 years) or <4 × 10 9 /L (older than 6 years); or absolute neutrophil count <1.5 × 10 9 /L (younger than 6 years) or <2 × 10 9 /L (older than 6 years). The results are expressed as quality-adjusted life years (QALYs), a measure that estimates the overall life expectancy in years for patients receiving a particular treatment strategy, corrected for the patient's quality of life. Results The base case results are: 1) BMA all = 69.649 QALYs; 2) high-risk BMA = 69.652 QALYs; and 3) empiric therapy = 69.644 QALYs. These results indicate a three-way toss-up because there is less than a 4-day quality-adjusted difference (0.01) between strategies. Conclusion This study indicates that the initial BMA does not significantly change the overall QALYs of a child presenting with thrombocytopenia and, consequently, is not mandatory in every patient before starting steroids.
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