Association of a Digital Clinical Decision Support Platform With Early Outcomes After Pediatric Allogeneic Hematopoietic Cell Transplantation: A Three-Era Guideline Implementation Cohort Study.

BACKGROUND: Practice variation in supportive care contributes to potentially preventable morbidity after pediatric allogeneic hematopoietic cell transplantation (HCT). Digital clinical decision-support platforms may improve care standardization, but outcome data after sustained implementation remain limited. OBJECTIVE(S): To evaluate whether sustained implementation of a digital bedside transplant guideline platform was associated with changes in early clinical outcomes after pediatric allogeneic HCT. STUDY DESIGN: We conducted a single-center retrospective cohort study of first allogeneic HCTs across three eras: pre-platform (2013-2018; n=200), wash-in (2019-March 2023; n=111), and sustained-use (April 2023-2025; n=78), defined by stable clinical adoption. Main outcomes of interest were adjusted inpatient length of stay (LOS) and non-relapse mortality (NRM), with relapse treated as a competing event. LOS was analyzed using gamma regression with log link. NRM was analyzed using cumulative incidence functions and Fine-Gray regression. Models used robust standard errors and adjusted for age, sex, malignant indication, HCT-CI ≥3, conditioning intensity, cord graft, and non-MSD donor. Sensitivity analyses for NRM additionally adjusted for malignant case mix and antithymocyte globulin timing. RESULTS: In the 3-era LOS model, wash-in was unchanged versus pre-platform (ratio 1.006; 95% confidence interval [CI], 0.876-1.136; p=0.927), while sustained-use was 14% shorter (ratio 0.858; 95% CI, 0.749-0.966; p=0.018). Adjusted mean LOS was 53.32 days (95% CI, 48.82-57.82) in the pre-platform era, 53.64 days (95% CI, 48.18-59.10) during wash-in, and 45.74 days (95% CI, 41.41-50.08) during sustained use. NRM cumulative incidence at 24 months was 0.116 in sustained-use versus 0.147 in pre-platform (12 months: 0.087 vs 0.105), but 24-month estimates for the sustained-use cohort were interpreted cautiously because only 14 patients remained at risk at 24 months. Fine-Gray models comparing sustained-use versus pre-platform showed lower NRM (subdistribution hazard ratio [SHR], 0.259; 95% CI, 0.062-1.080; p=0.064), strengthening after adjustment for malignant case mix (SHR, 0.212; 95% CI, 0.054-0.826; p=0.025) and ATG timing (SHR, 0.193; 95% CI, 0.047-0.794; p=0.023). There was no evidence of increased ICU admission (odds ratio [OR], 0.73; p=0.391) or 30-day readmission (OR, 1.30; p=0.457). Overall survival did not differ across eras (log-rank p=0.743). CONCLUSION(S): Sustained adoption of a digital bedside HCT guideline platform was associated with shorter hospital LOS and a consistent signal toward lower NRM without adverse utilization or survival outcomes. The absence of similar improvement during wash-in supports, but does not prove, an implementation-dependent association. Prospective multicenter evaluation with patient-level platform exposure and adherence metrics is warranted.