Increased Health Care Utilization and Costs during Allogeneic Hematopoietic Cell Transplantation for Acute Leukemia and Myelodysplastic Syndromes in Adolescents and Young Adults Compared with Children: A Multicenter Study.
Allogeneic hematopoietic cell transplantation (HCT) is a curative option for patients with acute leukemia and myelodysplastic syndromes (MDS) but is associated with significant cost. Compared with children (age <15 years), adolescents and young adults (AYA; age 15 to 39 years) undergoing HCT have an increased risk for transplantation-related complications. However, whether such complications translate into increased resource utilization and costs during HCT remains unknown. Therefore, we conducted a multicenter database study using the Pediatric Health Information System database, an administrative database containing resource utilization data from 49 US tertiary children's hospitals to compare inpatient costs and resource utilization in children and AYA undergoing HCT for acute leukemia and MDS. The International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify HCT recipients and transplantation-related complications occurring up to 1 year post-HCT. We identified 1693 HCT recipients at pediatric centers between January 2010 and September 2014. Eighty percent of the total costs (from admission for HCT up to 1 year post-HCT) occurred during the initial transplantation admission. During initial admission, although AYA and children had a similar median length of stay (LOS) of 43 days, AYA incurred significantly greater adjusted costs ($338,458 versus $275,723; P < .001) and costs per hospital day ($7122 versus $5838; P < .001). Median total costs and costs per day during subsequent time periods post-HCT were also significantly greater in the AYA group. In multivariable analysis, increasing age at HCT, LOS, use of cord blood or an unrelated donor, occurrence of any graft-versus-host disease, infection, and use of dialysis or mechanical ventilation were significant drivers of increased cost at initial admission. In conclusion, allogeneic HCT for acute leukemia and MDS is associated with higher costs in AYA recipients than in children. Therefore, directing efforts and resources aimed at reducing HCT-related costs may be advantageous in this high-risk group.
Rangarajan HG
，Smith LC
，Stanek JR
，Hall M
，Abu-Arja R
，Auletta JJ
，O'Brien SH
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Healthcare Utilization is High in Adult Patients Relapsing after Allogeneic Hematopoietic Cell Transplantation.
Disease relapse is the leading cause of death for patients with acute leukemia (AL) and myelodysplastic syndrome (MDS) who undergo allogeneic hematopoietic cell transplantation (HCT). Relapse post-HCT is associated with poor prognosis; however, inpatient healthcare utilization of this population is unknown. Here we describe survival, intensity of healthcare utilization, and characteristics associated with high resource use at the end of life (EOL). Adult patients with AL/MDS who underwent HCT at a large regional referral center with subsequent relapse between 2005 and 2015 were included in this retrospective study. We compared the distribution of demographic and clinical characteristics of patients as well as healthcare utilization over 2 years postrelapse and at EOL by postrelapse disease-directed therapeutic interventions. We created a composite score for EOL healthcare utilization intensity by summing the presence of any of the following criteria: death in the hospital, use of chemotherapy, emergency department, hospitalization, intensive care unit, intubation, cardiopulmonary resuscitation, or hemodialysis in the last month of life. Higher scores indicate more intense healthcare use at EOL. Multivariable linear regression analysis was used to determine variables (demographic characteristics, postrelapse treatment group, advance directives documentation, palliative care referral, time to relapse) associated with EOL healthcare utilization intensity. One hundred fifty-four patients were included; median age at relapse was 56 years (interquartile range [IQR], 39 to 63), 55% were men, 79% had AL, and median time from HCT to relapse was 6 months (IQR, 3 to 10). After relapse, 28% received supportive care only, 50% received chemotherapy only, and 22% received chemotherapy plus cell therapy (either donor lymphocyte infusion, second HCT, or donor lymphocyte infusion plus second HCT). With the exception of time until relapse and Karnofsky Performance Status, baseline characteristics (gender, age, race, graft-versus-host disease, year of treatment) did not significantly differ by postrelapse treatment group. One hundred thirty-six patients (88%) died within 2 years of relapse; survival differed significantly by postrelapse treatment group, with those receiving disease-directed treatment showing lower risk of death. Healthcare use in AL/MDS patients after post-HCT relapse was high overall, with 44% visiting the emergency department at least once (22% at least 2 times), 93% hospitalized (55% at least 2 times, 16% at least 5 times), and 38% using the intensive care unit (median length of stay 5, days; IQR, 3 to 10). Use was high even among those receiving only supportive care. For those patients who died, the mean intensity score for EOL healthcare use was 1.8 (standard deviation, 1.8). Most patients (70%) had a marker of high-intensity healthcare utilization at the EOL or died in hospital. In multivariable analysis, an increase in age (estimate -.03 (95% CI, -.06 to -.003) and having AL versus MDS were significantly associated with a decreased EOL healthcare intensity score; no other variables were associated with intensity of EOL healthcare use. Healthcare utilization after post-HCT relapse is associated with receipt of disease-directed therapy but remains high across all groups despite known poor prognosis. Interventions are needed to minimize nonbeneficial treatments and promote goal-concordant EOL care in this seriously ill patient population.
Langston JA
，Sundaram V
，Periyakoil VS
，Muffly L
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