Health Care Utilization Is High Amongst Adults Who Relapse Following Allogeneic Hematopoietic Cell Transplantation

Background:

Leukemia relapse is the leading cause of death for patients who undergo allogeneic hematopoietic cell transplantation (HCT). Relapse post-HCT is associated with poor prognosis; however, the in-hospital health care utilization of this population is unknown. Using a cohort of patients who relapsed post-HCT for acute leukemia (AL) and myelodysplastic syndrome (MDS), we describe survival, intensity of health care utilization, and characteristics associated with high resource utilization at the end-of-life (EOL).

Methods:

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 created a composite score for EOL health care utilization intensity summing the presence of any of the following criteria: death in the hospital, the use of chemotherapy, emergency department (ED), hospitalization, intensive care unit (ICU), intubation, cardiopulmonary resuscitation, or hemodialysis in the last month of life. Higher scores indicate more intense health care use at EOL. Chi-square and t-tests were used to assess differences in the distribution of health care utilization by post-relapse treatment. Log-rank test statistic and Kaplan Meier curves were used to evaluate differences in survival. Multivariable linear regression analysis was used to determine variables (demographic characteristics, advance directives documentation, palliative care referral, time to relapse) associated with EOL health care utilization intensity.

Results:

154 patients were included; median age was 55 years (IQR 38-62), 55% were male, 79% had AL. Following relapse, 28% did not undergo any treatment, 50% received chemotherapy only, and 22% received chemotherapy plus cell therapy (either donor lymphocyte infusion (DLI), second HCT, or DLI plus second HCT). With the exception of age, baseline characteristics (gender, race, graft versus host disease, year of treatment) did not significantly differ by post-relapse treatment group. 140 (91%) patients died within two years of relapse; survival differed significantly by post-relapse treatment group (Figure 1). Health care utilization in AL/MDS patients following post-HCT relapse is described in Table 1. Overall utilization was high with 44% visiting the ED at least once (22% >= 2 times), 92% hospitalized (55% >= 2 times; 16% >= 5 times), and 38% using the ICU (median length of stay 5 days; IQR 3-10 days). Utilization was high even among those receiving no additional therapy (Table 1). For those patients who died, the median (range) intensity score for EOL health care use was 2 (0-8). Most (70%) had a marker of high-intensity health care utilization at the EOL or died in hospital. In multivariable analysis, post-relapse chemotherapy plus cell therapy (estimate (95% CI): 1.41 (0.45-2.37) compared to no treatment was associated with more intense EOL health care use; no other variables were associated with intensity of EOL health care use.

Conclusions:

Health care utilization following 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 non-beneficial treatments and promote goal-concordant EOL care in this seriously ill patient population.

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