Economic analysis of unrelated allogeneic bone marrow transplantation: results from the randomized clinical trial of T-cell depletion vs unmanipulated grafts for the prevention of graft-versus-host disease

Economic evaluation of hematopoietic stem cell transplantation

Hematopoietic stem cell transplantation is a highly expensive clinical intervention with considerable therapeutic benefit but serious adverse effects on health status in some circumstances. Consequently, it is an important target for economic evaluation in which the monetary costs and clinical consequences of optional treatment strategies are compared. The need for such formal assessment is further demanded by the expanded use of hematopoietic stem cell transplantation globally, including its utilization in developing countries. With respect to costs, those incurred by patients and families are often substantial, while those incurred by hospitals may be inadequately reimbursed. Determination of consequences should not be limited to measurements of clinical effectiveness but rather include adjustments for quality of life. Rigorous economic evaluation can provide hard evidence in deliberations of value for money, especially in the context of limited resources for health care.

Economics of hematopoietic cell transplantation

Given the rapidly rising healthcare costs, it is important to understand the economic costs of hematopoietic cell transplantation (HCT), a procedure that is being used more frequently in the treatment of various hematologic disorders. Studies have reported a wide range of costs for HCT, from $36 000 to $88 000 (USD) for a single autologous transplantation for the initial hospitalization, to $200 000 (USD) or more for a myeloablative allogeneic procedure involving an unrelated donor. Common posttransplantation complications, such as infections and GVHD, have been shown to be significant cost drivers. Comparisons across studies are limited by differences in patient populations, cost ascertainment methods, and length of follow-up. This article summarizes the current state of knowledge about costs and cost-effectiveness of HCT, highlighting the challenges in conducting these studies and identifying important areas for future research. We discuss the need for more value-based assessments of HCT using high-quality approaches to measuring costs and outcomes so that potential future efforts to contain costs are well informed and appropriate.

Outcomes from unrelated donor hematopoietic stem cell transplantation

BACKGROUND

Allogeneic hematopoietic cell transplantation (HCT) offers a curative treatment option for management of a variety of hematologic malignancies. While sibling donors have been the gold standard for adult patients in need of an HCT, not all patients have a suitable family donor. The availability of unrelated volunteer donor registries and alternative stem cell sources has expanded the wide application of this procedure.

METHODS

PubMed and MEDLINE were searched for human trials and the English language from 2001 to 2011. Factors influencing transplantation outcomes involving unrelated donors over the last decade are discussed, and feasible alternative stem cell sources when a matched unrelated donor is not available are reviewed.

RESULTS

HCT using a matched unrelated donor offers outcomes comparable to sibling HCT due to current molecular-based HLA typing and improvements in conditioning regimens and/or supportive care. The primary factor that contributes to improved outcome is the degree of donor-to-recipient HLA matching. The selection of younger unrelated donors has also been associated with improved outcomes in HCT. Evidence supports the universal application of matched unrelated donors even in high-risk leukemia and/or older patients. In adult patients without a matched related donor, other promising options as stem cell source includes mismatched unrelated donors, umbilical cord blood units, and haploidentical donors.

CONCLUSIONS

With current methodologies for molecular HLA typing and supportive care tools, outcomes of transplants with matched unrelated donors are comparable to those achieved with sibling donors. Alternative stem cell donors when a matched unrelated donor is not available are feasible expanding the stem cell donor pool.

Blood stream infection (BSI) and acute GVHD after hematopoietic SCT (HSCT) are associated

BSI and acute GVHD (aGVHD) are serious complications of HSCT. We hypothesized that the two events were not independent of one another. We studied (1) associations between BSI and aGVHD; (2) the impact of BSI and/or aGVHD on death within 100 days after HSCT, employing a retrospective cohort analysis. Risk factor analysis was performed using multivariable Cox proportional hazards analyses. Of 211 subjects undergoing allogeneic HSCT from 1/00–12/05 (58% of whom underwent reduced intensity transplantation), 82 (39%) developed BSI. In 49 patients (23%), grades (gr) 2–4 aGVHD occurred. Early BSI was independently associated with an increased occurrence of subsequent aGVHD gr 2–4. Cytomegalovirus seropositivity was independently associated with decreased occurrence of aGVHD. Acute GVHD gr 2–4 independently predicted subsequent first BSI. Both BSI and aGVHD gr 2–4 were significant independent predictors of death within 100 days after HSCT. There is a strong, independent association between BSI and aGVHD. Potential explanations include the elaboration of cytokines during BSI favoring the development of aGVHD and/or the immunosuppressive treatment of aGVHD favoring the development of BSI. Future studies should be directed at mechanistic investigations of this association.

Costs of allogeneic hematopoietic cell transplantation with high-dose regimens

To characterize the costs of allogeneic hematopoietic cell transplantation with high-dose regimens (HDCT), we analyzed clinical information and costs of 315 HDCT recipients during a 4-year study period beginning in 2000. Multivariate analyses were performed to identify pre- and/or post-HDCT factors predicting higher costs within the first year. Overall survival (OS) at 100 days and 1 year were 80% and 58%, respectively. The median cost and days of hospitalization were $102,574 in 2004 US dollars and 36 days in the hospital for 100 days, and $128,800 and 39 days in the hospital for 1 year. Early costs, defined as costs within the first 100 days, accounted for 84% of total costs within the first year. Inpatient costs comprise 94% of the early costs, but only 61% of the later costs defined as costs incurred between 101 days and 1 year. Of the pre-HDCT factors, unrelated donors and advanced disease risk were significantly associated with increased cost. When post-HDCT events were also considered, these pre-HDCT factors were no longer independently predictive of high cost. Instead, severe complications post-HDCT were associated with higher costs, increasing total costs $20,228 on average. If no complications occurred, the mean cost within the first year was $79,222. These results provide cost estimates for complicated and uncomplicated HDCT procedures, as well as costs for management of specific transplant complications.

Addressing parenting concerns of bone marrow transplant patients: opening (and closing) Pandora's box

Although a significant number of adults undergoing stem cell transplant (SCT) or bone marrow transplantation (BMT) care for dependent children, and these treatments pose significant challenges for families, research has virtually ignored the impact of parenting on patients' quality of life during BMT/SCT and children's responses to having a parent undergo these treatments. Physicians rarely inquire about parenting concerns related to the extended hospitalizations necessitated by these treatments, yet clinical experience suggests that addressing patient concerns about children's reactions to cancer and BMT/SCT can improve the experience of the patient and the patient's family, and help the medical team respond effectively to sources of patients' distress. Parents frequently want to know what reactions to expect from children, thus general developmental information is reviewed, and recommendations given for when professional help for children is warranted. A key way for parents to support their children is with open, honest communication; however, parents often find it extremely difficult to talk about cancer and BMT/SCT with their children. The medical team can assist patients' efforts to communicate with and support their children by asking about a patient's children, providing some targeted information, and discussing the potential impact of treatments on parenting capacity. Inquiring about and addressing parenting concerns may initially seem difficult, but can ultimately facilitate stronger doctor-patient alliances, and more compassionate care.

Costs of allogeneic hematopoietic stem cell transplantation

BACKGROUND

This study aims to determine the total costs after allogeneic hematopoietic stem cell transplantation (ASCT) and factors associated with increases or decreases in costs.

METHODS

We collected all in- and outpatient costs during 5 years in 93 patients who had undergone ASCT in 1998 and 1999 at our unit. The inpatient costs included all those related to a patient from the first day of admission until discharge and then all costs of readmission in the Stockholm area.

RESULTS

The total median cost of five posttransplant years was 139,414 (52,095-345,640) euros (euros) or 167,296 US dollars (the rate of 1 euro is approximately 1.2 US dollars). The costs were highest during the first year-median inpatient and outpatient costs 100,650 euros and 13,066 euros, respectively. The total costs during the first year were higher in patients with acute graft-versus-host disease grades III-IV (relative hazards [RH] 1.35, P = 0.003), bacteremia (RH 1.33, P = 0.005), veno-occlusive disease of the liver (RH 1.32, P = 0.005), prophylaxis with granulocyte colony-stimulating factor (G-CSF; RH 1.31, P = 0.01), acute leukemia (RH 1.32, P = 0.008), and treatment in hospital instead of at home (RH 1.20, P < 0.07). During the early transplant period, a second transplantation (RH 1.28, P = 0.014) and hemorrhagic cystitis (HC; RH 1.24, P = 0.03) were also associated with higher costs. The total 5-year cost declined with longer survival rates (r = 0.4028, P < 0.001) and reduced intensity conditioning (RH 0.79, P=0.024).

CONCLUSION

Higher costs of ASCT were associated with retransplantation, acute leukemia, G-CSF prophylaxis, hospital care, myeloablative conditioning, and major transplant-related complications.