Managing Myelodysplastic Syndromes in the Elderly with Supportive Therapy: Case Cost of Transfusion Therapy When Inpatient Care Is Utilized.
Authors: O’Brien Judith A. , Duran Piedad A. , Caro Jaime 
Published: October 2019

Abstract
Myelodysplastic syndromes (MDS) are a group of disorders characterized by peripheral blood cytopenias secondary to bone marrow dysfunction that can exhibit as refractory anemias, thrombocytopenias, neutropenias and potentially progress to acute myeloid leukemia (AML). They are seen most often in those 60 years and older which can complicate MDS management due to the comorbid conditions often seen in this age group. As such, supportive therapy, which may include packed red blood cell (PRBC) and platelet transfusions, erythropoietin and hematopoietic cytokine support (e.g., G-CSF, GM-CSF) has been historically the standard of care for elderly patients. Infections and bleeding events can be life-threatening for these patients. For this analysis we examined transfusions given to inpatients with MDS at two levels: overnight admission to hospital for transfusion and hospitalization for a bleeding event, refractory anemia, infection or thrombocytopenia when blood products were administered. Discharge data from 2001 reported by roughly 1,000 hospitals in 5 states (CA, FL, MA, MD, WA) and 2004 national physician fee schedules were used to develop hospital care estimates. As there is no unique ICD-9 code that isolates MDS cases, multi-tiered case screening criteria using a combination of principal, secondary and procedure ICD-9 codes were developed to identify relevant cases. Cases were restricted to those 65 years and older, who received PRBC and/or platelets, survived the event and were discharged home. Those with AML, bone marrow or stem cell transplant, traumatic injury, surgical procedures or where admission could have been primarily for a comorbid condition were excluded. Qualifying hospital cases were dichotomized into those with a one night stay for transfusion therapy and those with longer lengths of stay (LOS). Cost estimates are limited to direct medical costs and include accommodations, ancillary and physician services, reported in 2004 US$. Hospital charges were adjusted by a 0.695 cost-to-charge ratio and appropriate medical inflation indices. A total of 1,095 cases were identified. Of those, 777 (71%) were admitted for an MDS-related problem for which transfusion therapy was received. The mean age was 79 years, half were males and 36% were admitted via the Emergency Department (ED). The mean LOS was 3 days (median: 2 days). All patients received PRBC; 13% received platelets. The average cost per stay was $7,079 (median: $4,255) with an average of $1,364 (median: $1,189) attributed to blood product transfusions. Those who appear to have been admitted for overnight transfusion therapy (n=318, 29%) had a mean age of 80 years, 45% were males and 38% were admitted via ED. PRBC were transfused in 98% of cases; 4% received platelets. The mean cost per overnight stay was $2,792 (median: $2,629) with $569 (median: $444) attributable to the transfusions, on average. While the typical location for a blood product transfusion is an outpatient setting, this analysis shows that elderly patients with MDS do utilize inpatient care for event-related and support transfusions. As newer drug therapies become available for treating MDS and the standard of care evolves, the cost-effectiveness of supportive care relative to alternative drug therapy for managing MDS, particularly in the elderly should be examined. Given the substantial cost associated with inpatient care, location of transfusion, as well as the cost of the procedure and the products received should be considered as part of any economic analysis of MDS management.