Abstract

Readmission within 30 days of hospital discharge has recently become an important topic of discussion and a measure of quality of care. Factors influencing 30-day readmissions and its impact on patient related outcomes are diverse. Allogeneic hematopoietic cell transplantation (allo-HCT) presents a unique medical setting that may be associated with higher readmission rates. We analyzed factors affecting 30-day readmissions, its impact on patient related outcomes and health care costs in allo-HCT patients.

The study group included 91 consecutive patients with hematological malignancies who underwent related (n=44) or unrelated donor (n=47), peripheral blood allo-HCT after conditioning with fludarabine and busulfan +/- thymoglobulin. Subjects were divided into 2 groups; readmission (R-gp), n=35 if they were readmitted within 30 days of hospital discharge after the index hospitalization for a planned allo-HCT, or to no readmission (NR-gp), n=56. The baseline characteristics did not differ between the 2 groups (Table 1). Overall 38% (n=35) required readmission with a median time to readmission of 14 days (range, 1-29). Causes for readmission included documented infections (n=12), cardio-pulmonary complications (n=10), fever (n=6), gastrointestinal disorders (n=4), and graft-versus-host disease (n=3). Median length of stay was 3 days (range, 1-34). In multivariate analysis only documented infection during the index admission predicted 30-day readmission, OR 5.24; 95% CI 1.42-19.32; p=0.01. Caregiver type (spouse vs. others); and number of caregivers (1 vs. >1) did not influence readmission. With a median follow up of 1 year for surviving patients, the estimated overall survival (OS) was 58% and 67% in the R-gp and NR-gp respectively, OR 1.07, 95% CI 0.55-2.06, p=0.85. The 1-yr non-relapse mortality (NRM) in R-gp and NR-gp was 74% and 84% respectively, OR 1.13, 95% CI 0.42-3.03, p=0.80. The median post-transplant hospital charges (inpatient + outpatient) in the R-gp and NR-gp were 85,115.45 USD (mean 93,925.26, range 32,014.86-242,519.35) and 45,083.09 USD (mean 69,142.6, range 10,714.78-485,456.08), p=0.0002.

In conclusion, except for infections during the index admission, no other baseline demographic, social, disease or treatment related factors influenced 30-day readmissions after allo-HCT. 30-day readmission status did not adversely affect OS or NRM, but it significantly increased the 100-day hospital charges. Acknowledging the limitation of our study included its retrospective nature and small sample size, we conclude that 30-day readmission status does not portend poor post transplant outcomes. However, it is associated with higher health care costs.

Table 1

Baseline Patient Characteristics

 Readmission (n=35) Not Readmitted (n=56) P-Value 
Median age (range) 56 (17-72) 54 (22-68) 0.23 
Male (%) 21 (60) 34 (61) 0.99 
Malignancy type, n (%)   0.93 
ALL/AML/MDS 23 (65.7) 39 (70)  
CLL/CML 2 (5.7) 3 (5)  
Hodgkin/NHL/Others 10 (28.6) 14 (25)  
Disease risk, n (%)   0.18 
Low 16 (45.7) 24 (43)  
Intermediate 3 (8.6) 13 (23)  
High 16 (45.7) 19 (34)  
Disease status, n (%)   0.49 
Chemosensitive 23 (66) 41 (73)  
Resistant 12 (34) 15 (27)  
Prior number of therapy, median (range) 2 (1-6) 2 (0-6) 0.65 
Prior radiation therapy, n (%) 2 (6) 8 (14) 0.31 
Prior autologous transplantation, n (%) 2 (6) 6 (11) 0.71 
KPS, median (range) 80 (60-100) 85 (70-100) 0.44 
HCT-CI, median (range) 2 (0-7) 1 (0-5) 0.31 
Patients receiving ATG, n (%) 23 (66) 31 (55) 0.38 
Donor type, n (%)    
Unrelated 19 (54) 28 (50) 0.83 
Related 16 (46) 28 (50)  
HLA mismatch, n (%) §   0.99 
Allele level 1 (2) 3 (5)  
Antigen level 1 (2) 1 (2)  
Infused CD34 cell dose, median (range)  6.5 (2.7-12.8) 6.5 (1.8-15.1) 0.98 
Infused CD3 cell dose, median (range) Ŧ 31.3 (9.6-58.5) 32.4 (11.5-94.5) 0.48 
GVHD prophylaxis, n (%)   0.83 
MTX + calcineurine inhibitor 22 (63) 33 (59)  
MMF + calcineurine inhibitor 13 (37) 23 (41)  
 Readmission (n=35) Not Readmitted (n=56) P-Value 
Median age (range) 56 (17-72) 54 (22-68) 0.23 
Male (%) 21 (60) 34 (61) 0.99 
Malignancy type, n (%)   0.93 
ALL/AML/MDS 23 (65.7) 39 (70)  
CLL/CML 2 (5.7) 3 (5)  
Hodgkin/NHL/Others 10 (28.6) 14 (25)  
Disease risk, n (%)   0.18 
Low 16 (45.7) 24 (43)  
Intermediate 3 (8.6) 13 (23)  
High 16 (45.7) 19 (34)  
Disease status, n (%)   0.49 
Chemosensitive 23 (66) 41 (73)  
Resistant 12 (34) 15 (27)  
Prior number of therapy, median (range) 2 (1-6) 2 (0-6) 0.65 
Prior radiation therapy, n (%) 2 (6) 8 (14) 0.31 
Prior autologous transplantation, n (%) 2 (6) 6 (11) 0.71 
KPS, median (range) 80 (60-100) 85 (70-100) 0.44 
HCT-CI, median (range) 2 (0-7) 1 (0-5) 0.31 
Patients receiving ATG, n (%) 23 (66) 31 (55) 0.38 
Donor type, n (%)    
Unrelated 19 (54) 28 (50) 0.83 
Related 16 (46) 28 (50)  
HLA mismatch, n (%) §   0.99 
Allele level 1 (2) 3 (5)  
Antigen level 1 (2) 1 (2)  
Infused CD34 cell dose, median (range)  6.5 (2.7-12.8) 6.5 (1.8-15.1) 0.98 
Infused CD3 cell dose, median (range) Ŧ 31.3 (9.6-58.5) 32.4 (11.5-94.5) 0.48 
GVHD prophylaxis, n (%)   0.83 
MTX + calcineurine inhibitor 22 (63) 33 (59)  
MMF + calcineurine inhibitor 13 (37) 23 (41)  
*

High resolution HLA typing at the allele level for A, B, C and DRB-1 for all patients.

Cell dose x 106/kg patient body weight

Ŧ

Cell dose x 107/kg patient body weight

Disclosures:

No relevant conflicts of interest to declare.

Author notes

*

Asterisk with author names denotes non-ASH members.