Healthcare Resource Utilization in Autoimmune Hemolytic Anemia Patients: Analysis of 190 Cases from a Single Center

Autoimmune hemolytic anemia (AIHA) is a heterogeneous disease caused by autoantibody directed against erythrocyte antigens. It is usually considered a benign disease, easy to treat, and with low clinical impact. As a matter of fact, about 1/3 of cases present a severe onset and display a relapsing/refractory course that may lead to significant healthcare burden. However, data about healthcare direct and indirect costs and resource utilization are lacking, possibly due to the disease rarity and to the referral of difficult cases to 2ndary and 3rtiary centers.

Here we retrospectively evaluated healthcare utilization in a single center cohort of primary AIHA patients, focusing on anemia severity, transfusion need, use of new highly expensive medications, splenectomy, and healthcare resource utilization (number of admissions and their length, outpatient visits). We studied 190 patients (72 M and 118 F, median age at diagnosis 57.7 yrs, range 2.2-94), followed-up for 4 yrs (0.1-45), classified in warm (W)AIHA (DAT positive for IgG and IgG+C), cold agglutinin disease, CAD (C), mixed (IgG+C with high titer cold agglutinins) and atypical (DAT-, IgA+, wIgM). In addition, hemoglobin levels at onset, hemolytic parameters (LDH, reticulocyte absolute counts, and bone marrow responsiveness index, BMRI), number of relapses, and of therapy lines were considered.

Table 1 shows healthcare utilization indicators for AIHA patients divided according to AIHA type. On the whole, 121/190 (64%) required at least one hospital admission; the median number of hospital admissions was 1 (range 1-8), with 17/121 cases (9%) requiring 3 or more admissions. The higher frequency was observed in C+WAIHA, mixed and atypical cases (p=0.006). The median admission duration was 15 days, with 16 cases (13%) needing more than 30 days of admission. Concerning outpatients, median number of visits per year was 5, but 41/190 (22%) required more than a monthly visit. As regards therapeutic procedures, 103/190 (54%) required at least one transfusion; the median number of all transfusions received was 5, with 11/103 patients (11%) requiring more than 20 transfusions (the established threshold for chelation) and 6 more than 50. The distribution of transfusion need was significantly different among AIHA categories, with higher values observed in C+WAIHA, mixed and atypical cases (p=0.004). Considering transfusions as a function of follow-up length, the median was 2 per year, with 27 cases necessitating 4 or more (one subject about a weekly support). Highly expensive drugs were administered in 65/190 patients (34%), of whom 56 rituximab and 9 bortezomib, and splenectomy performed in 20/190 (11%) of patients. The administration of highly expensive drugs was significantly different among AIHA categories with higher rates observed in CAD and mixed cases (p=0.01). The analysis of hematologic parameters confirms the heterogeneity of the disease, with Hb values being particularly low in mixed and C+WAIHA (p=0.0001); the latter also showed lower absolute reticulocyte counts and BMRI (p=0.005 and p=0.008, respectively). As expected, admissions length and transfusions requirement were negatively correlated to Hb levels at onset (r=-0.26, p<0.001, and r=-0.18, p<0.01, respectively). Moreover transfusion requirement was positively correlated with a more severe hemolytic pattern (high LDH values r=0.21, p<0.01), and negatively with the bone marrow compensatory response (BMRI r=0.15, p<0.05).

In conclusion, notwithstanding AIHA is usually considered a fairly benign disease, the clinical course of difficult cases (roughly 10-15%) require a reliable healthcare resource utilization representing a significant burden on the patient and the medical system.

Table 1

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Table 1

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