Abstract

Disease relapse is the leading cause of death for patients with acute leukemia (AL) and myelodyspastic syndrome (MDS) who undergo allogeneic hematopoietic cell transplantation (HCT). Relapse post-HCT is associated with poor prognosis; however, the inpatient health care utilization of this population is unknown. Here we describe survival, intensity of health care utilization, and characteristics associated with high resource utilization at the end-of-life (EOL). 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 compared the distribution of demographic and clinical characteristics of patients as well as health care utilization over two years post-relapse and at EOL by post-relapse disease-directed therapeutic interventions. We created a composite score for EOL healthcare utilization intensity summing the presence of any of the following criteria: death in the hospital, the use of chemotherapy, emergency department, hospitalization, intensive care unit, intubation, cardiopulmonary resuscitation, or hemodialysis in the last month of life. Higher scores indicate more intense health care use at EOL. Multivariable linear regression analysis was used to determine variables (demographic characteristics, post-relapse treatment group, advance directives documentation, palliative care referral, time to relapse) associated with EOL healthcare utilization intensity. 154 patients were included; median age at relapse was 56 years (IQR 39-63), 55% were male, 79% had AL, median time from HCT to relapse was 6 months (IQR 3-10 months). Following relapse, 28% received supportive care only, 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 time until relapse, baseline characteristics (gender, age, race, graft versus host disease, year of treatment) did not significantly differ by post-relapse treatment group. One hundred and thirty-six patients (88%) died within two years of relapse; survival differed significantly by post-relapse treatment group, with those receiving disease directed treatment showing lower risk of death. Health care utilization in AL/MDS patients following post-HCT relapse was high overall with 44% visiting the ED at least once (22% >= 2 times), 93% 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 only supportive care. For those patients who died, the mean (SD) intensity score for EOL healthcare use was 1.8 (1.8). Most (70%) had a marker of high-intensity healthcare utilization at the EOL or died in hospital. In multivariable analysis, post-relapse chemotherapy plus cell therapy (estimate (95% CI): 1.30 (0.35-2.26) 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. 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 nonbeneficial treatments and promote goal-concordant EOL care in this seriously ill patient population.

View details for PubMedID 30959162