Costs of Complications after Allogeneic Myeloablative Stem Cell Transplantation.
Authors: Saito Akiko M. , Cutler Corey , Zahrieh David , Ho Vincent T. , Alyea Edwin P. , Soiffer Robert J. , Antin Joseph H. , Lee Stephanie J. 
Published: October 2019

Abstract
Background:
Despite potential life-saving benefits in allogeneic hematopoietic stem cell transplantation (HSCT), some patients in the United States are not able to undergo the procedure because of insurance restrictions or financial limitations. Prior work suggests severe medical complications increase the morbidity, mortality and financial costs of HSCT, but risks of these complications are largely unpredictable based on clinical factors known before HSCT. We aimed to identify factors associated with higher costs.
Methods:
317 patients with hematological diseases underwent myeloablative allogeneic HSCT at the DFCI/BWH between 6/2000 and 6/2004 using Cytoxan and TBI conditioning. Clinical information and inpatient and outpatient costs within 100 days after HSCT were analyzed. The costs of stem cell procurement were excluded. Multivariate analyses were performed using both a baseline model (including factors known before HSCT: graft versus host disease (GVHD) prophylaxis, HLA, donor type, disease type, sex matching, patient age, donor age, stem cell source, cytomegalovirus (CMV) serological status, and year of HSCT), and a full model incorporating all pre and post-transplant factors (baseline factors plus neutrophil engraftment, grade II to IV acute GVHD, veno-occlusive disease (VOD), idiopathic pneumonia/diffuse alveolar hemorrhage (IP/DAH), infection, severe organ toxicity, and in-hospital death).
Results:
With 80% overall survival at 100 days, the median [interquartile range (IQR)] costs and days of hospital stay were respectively $102,574 [78,635–160,174] and 36 [28–47] days. Costs have been shifting towards the outpatient setting since 2002, but inpatient costs still compose 95% of the total costs during the first 100 days. Multivariate analyses are presented in the Table. Use of an unrelated donor and CMV positive serology in either patient or donor were significant predictors of increased costs in the baseline model. In the full model, these two baseline factors were associated with high costs although the results did not achieve statistical significance. Neutrophil engraftment, grade II to IV acute GVHD, VOD, IP/DAH, infection, neurological toxicity, and in-hospital death were the significant clinical factors associated with high costs, increasing total costs by $35,916 to $82,920 per complication. If none of these complications occurred (n=111), the median cost was $78,635 [65,126–100,295].
Conclusion:
Myeloablative allogeneic HSCT is still a costly procedure. Use of an unrelated donor and CMV positive serology predicts higher costs within the first 100 days. While medical benefits drive the search for lower toxicity approaches to HSCT, significant cost savings may also be realized.
Table. Multivariate analysis of costs Variables Baseline model Full model Ratio, P-value Ratio, P-value Incremental costs Donor type unrelated vs related 1.4, <0.01 1.1, 0.07 $24,010 CMV status CMV+ vs CMV− 1.2, <0.01 1.1, 0.07 1$17,799 Grade II to IV acute GVHD yes vs no 1.3, <0.01 $61,324 Recovery of ANC late or not vs early 1.2, <0.01 $46,443 VOD yes vs no 1.4, <0.01 $76,348 IP/DAH yes vs no 1.2, <0.01 $48,057 Infection yes vs no 1.2, <0.01 $35,916 Neurological toxicity yes vs no 1.3, <0.01 $57,786 In-hospital death yes vs no 1.5, <0.01 $82,920