An Analysis of the Costs Associated with Peripheral Blood Hematopoietic Progenitor Cell Mobilization, Collection and Cryopreservation in Patients with Lymphomas Undergoing Autologous Stem Cell Transplantation
Authors: Hosing Chitra , Smith Veronica R. , Rhodes Beverly A. , Walters Kent H. , Qazilbash Muzaffar H. , McMannis John D. , Alousi Amin M. , De Lima Marcos , Kebriaei Partow , Giralt Sergio , Khouri Issa , Champlin Richard , Popat Uday 
Published: April 2020

Abstract
Peripheral blood hematopoietic progenitor cells (HPC) may be mobilized with cytokines alone or with chemotherapy followed by cytokines. The HPC yield is higher and the failure rate is lower with chemo mobilization. Although cell dose of 2 million CD34+ cells/kg is considered adequate, some authors have shown that patients who receive &lt; 5 million CD 34+ cells/kg have higher resource utilization after transplant. The purpose of this study was to analyze the costs associated with HPC chemo mobilization in patients with lymphomas.
PATIENTS AND METHODS: We analyzed 149 patients with non-Hodgkin’s (N=101) and Hodgkin’s (N=48) lymphomas who underwent HPC chemo mobilization at our institution between 1/03 and 12/04. The retrospective chart review was approved by the IRB. Patients who collected &lt; 2million CD34+ cells/kg in 4 leukapheresis procedures were called failures. The estimated costs were divided into pre apheresis, apheresis, and post apheresis costs. (Source: Cleverly and Associates; www.drugstore.com; Redbook™; Thompson PDR)
RESULTS: A total of 133 patients underwent chemo mobilization. Chemotherapy regimen was ifosfamide, etoposide, G-CSF, +/− rituximab in 98 (74%) patients. The average inpatient stay for chemotherapy administration was 6 days (range, 3–28). Twenty-four patients required readmission for complications of chemotherapy (22/24 for fever/infections) for a median of 5 days (range, 1–12). Patients received G-CSF for a median of 14 days (range, 6–34). All patients received IV hydration while in the hospital and were discharged on prophylactic oral antibiotics. Average number of days on oral antibiotics was 9 (range, 0–16). For successful mobilizers, the median number of apheresis procedures required to reach target HPC dose of 5 million CD34+ cells/kg was 2 (range, 1–7). Thirty patients (out of 149) failed to collect adequate HPC on the first attempt. Of those 12 patients underwent a BM harvest ($2389/harvest), 4 were remobilized with chemotherapy (1 mobilized successfully), 4 patients underwent an allogeneic transplant ($250,000–500,000/transplant) and 3 patients underwent an autologous transplant with suboptimal cell dose (all had prolonged time to engraftment and 1 patient needed an allogeneic transplant for graft failure). Average pre apheresis costs per patient were $1800 (clinic visit, laboratory evaluation, central venous catheter insertion, and chest x-ray to check placement). The average costs of chemotherapy administration, hospitalization, prophylactic antibiotics and G-CSF were $ 29181 (not including rituximab). This is an underestimation as it does not include the costs associated with supportive care, intravenous fluids, readmission etc. The post apheresis costs were $ 2493. These costs do not account for professional fees.
CONCLUSIONS: Although in this present analysis we may have underestimated the actual costs associated with HPC mobilization, the costs are still considerable. Accordingly, the financial implication for transplant centers where reimbursement is DRG (diagnosis related group) or case rate based is significant. Interventions or newer agents that can reduce the failure rate or reduce the number of apheresis procedures required to reach a target HPC dose without increasing the toxicity may reduce the costs associated with transplant especially in patients who do not require chemotherapy for treatment of their primary disease.
National Hospital Average Cost in $ $ N Median (range) Estimated Total Costs per in $ APHERSIS *Based on median body surface area (BSA) of 1.94 (range, 1.35–2.45). N=98 Chemotherapy Administration Daily Room Charge 863.00 6 (3–28) 5178 * Ifosfamide 3.33 g/m2/d × 3 d 372.87/gram 19.38 g 7227 Etoposide 150mg/m2 × 6 d 17.61/10mg 1746 mg 3074 Rituximab 375mg/m2 × 2 d 1315.43/100mg 1455 mg 19140 Daily CBC,diff 93 5 (3–28) 465 Readmission (N=24) 863.00 4315 Daily Room charge 5 (1–12) Daily CBC, diff 93 465 Blood Transfusions (N=64) 494 1.4 (0–6) 692 Platelet transfusions (N=64) 494 1.5 (0–7) 741 G-CSF 528 14 (6–34) 7392 Oral antibiotics Valacyclovir 104 Fluconazole 9 (0–16) 89 Levofloxacin 114 Apheresis procedure 1917.73 2 (1–7) 3835 PB CD34+ analysis 135 2 (estimated) 270 POST APHERESIS Cryopreservation (supplies, labor, storage, sterility) 1246.42/apheresis 2 (1–7) 2493 TOTAL (without rituximab) 36454
Study was sponsored by Genzyme Inc.