Provider and Center Characteristics Of US Transplant Centers and Their Association With Survival After Allogeneic Hematopoietic Cell Transplantation (HCT) In Adults: Results From a National Survey Conducted By The Center For International Blood and Marrow Transplant Research (CIBMTR)
Authors: Majhail Navneet S. , Payton Tammy , Mau Lih-Wen , Le Rademacher Jennifer , Chitphakdithai Pintip , Eckrich Michael , Joffe Steven , Lee Stephanie J. , LeMaistre Charles F. , Loberiza Fausto R. , Logan Brent R. , Murphy Elizabeth A , Parsons Susan K. , Repaczki-Jones Ramona , Rizzo J. Douglas , Robinett Pam , Denzen Ellen 
Published: October 2019

Abstract
The association of transplant provider and center factors with outcomes of allogeneic HCT has not been well described. Potentially modifiable center factors that are found to be associated with better survival could be adopted by centers to improve their quality of transplant care. To study the association of center factors with survival, we (1) conducted a survey of US transplant centers in 2012 to understand their provider and center characteristics, and (2) used patient clinical data submitted by the centers to the CIBMTR for their allogeneic HCTs performed between 2008-2010. The 42 item web based survey was administered to center medical directors and queried about four broad domains: HCT provider characteristics, HCT center resources, institution characteristics and models of care delivery for HCT recipients. Response rate was 79% (85/108 eligible centers). Collectively, the 85 centers represented 1,640 inpatient beds for HCT, 633 HCT physicians and 548 HCT midlevel providers; CIBMTR data for these centers included 11,639 allogeneic HCT recipients over the 3-year time period. We grouped centers into five size categories based on their total allogeneic HCT volume in 2010: ≤ 20 HCT, 21-40 HCT, 41-80 HCT, 81-150 HCT and >150 HCT. Table 1 shows selected provider and center characteristics for our cohort. We also found considerable variation in patient care models among responding centers. For example, the clinical effort of physicians was exclusively dedicated towards care of HCT recipients in 18% of smaller (≤ 20 HCT) centers compared to 80% in larger (>150 HCT) centers. Larger centers were more likely to have a service model with different physicians participating in the inpatient and outpatient care of HCT recipients versus one physician in charge of both inpatient and outpatient care. A greater proportion of larger centers used midlevel providers in the inpatient and outpatient settings and larger centers were more likely to follow patients long-term post-transplant than smaller centers. A variety of care models were identified based on the use of trainees and midlevel providers in the inpatient and outpatient settings, after-hour and emergency care, and care of patients needing ventilator support. The unadjusted 1-year overall survival probabilites for the five center categories were 56% (95% CI, 51-61%), 58% (55-60%), 63% (61-63%), 62% (60-64%) and 66% (64-67%), respectively (log-rank P<0.001). Our study highlights substantial variation in transplant provider and center characteristics and patient care delivery models among US transplant centers. Multivariate analyses will adjust for patient, disease and transplant characteristics to determine whether any center factors, especially those that are potentially modifiable, are independently associated with survival.TableTransplant center characteristics (N=85 centers)Center size (based on 2010 allogeneic HCT volume)≤ 20 HCT21-40 HCT41-80 HCT81-150 HCT>150 HCTCenters222225115Patients (2008-2010)4241490370231022921Teaching hospital59%77%88%100%100%NCI CCC designation13%36%48%82%100%FACT accreditation82%96%100%100%100%Cooperative clinical trial group participation55%82%92%100%100%Hem-onc fellowship59%77%88%100%100%Survivorship clinic22%32%32%36%80%GVHD clinic5%18%16%36%60%No of HCT MDs, median (IQR)3 (3-5)4 (4-6)7 (5-9)7 (6-14)24 (20-27)No of HCT midlevel providers, median (IQR)1 (0-2)5 (2-6)7 (5-12)8 (5-12)20 (16-23)Inpatient nurse to patient ratio ≥1.49%14%16%18%20%HCT pharmacist ≥2 FTE36%37%72%100%100%NCI CCC – National Cancer Institute Comprehensive Cancer Center; FACT – Foundation for Accreditation of Cellular Therapy; GVHD – graft-versus-host disease; IQR – interquartile range; FTE – full time equivalent

Disclosures:
No relevant conflicts of interest to declare.