Readmission Following Stem Cell Transplant Decreases Survival

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Infection and fever without a source are the most common causes of readmission following allogeneic hematopoietic stem cell transplantation (HSCT), and being readmitted within 30 days of discharge is associated with a lower 5-year overall survival rate, according to Laura Spring, MD, from the Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Boston, MA.

“A better understanding of the risk factors for readmission in the transplant population will allow for more transitional care and clinical resources to be focused on the highest-risk patients,” said Spring. The United States spent $17.5 billion on readmissions among Medicare beneficiaries in 2010, she noted.

The retrospective review included 495 patients receiving myeloablative conditioning (MAC) and 602 patients receiving reduced-intensity conditioning (RIC) HSCT at Dana-Farber Cancer Institute and Brigham and Women’s Hospital. The 30-day readmission rate was examined in addition to the readmission rate at day 100, a traditional assessment point in transplantation readmission rate.

Following transplantation in the MAC group, the 30-day readmission rate was 26.3% and the day 100 readmission rate was 39.2%. The 30-day readmission rate for RIC was 17.4% and the day 100 rate was 30.7%.

“In both groups, the most frequent reasons for readmission were documented infection, fever without a source, and graft-versus-host disease,” Spring said. Infection was the reason for readmission in approximately 25%, fever in about 19%, and graft-versus-host disease in 15.1% (RIC) and 17.9% (MAC).

Readmission Variables
A multivariate logistic regression model of the probability of being readmitted within 30 days following discharge or by day 100 following transplant was used to examine various disease transplant and sociodemographic variables.

In the RIC group, active disease at the time of transplant was found to be a significant risk factor for readmission both by day 30 following discharge (P=.005) and by day 100 following transplant (P=.0001).

Transplant variables included donor status, type of stem cell product, and infection during the index transplant.

In the ablative group, infection during index admission was a significant risk factor for readmission by day 100 (odds ratio [OR] 1.9; P=.0006).
For the RIC group, a mismatched donor (OR 2.4; P=.029) and infection during index admission (OR 5.8; P<.0001) were significant risk factors for readmission both by day 30 following discharge and by day 100 (donor, OR 2.1; P=.030; infection, OR 4.8; P<.0001).

Among the MAC group, Hispanic/Latino ethnicity was a significant risk factor for readmission by day 100 (OR 4.6; P=.013). For the RIC group, nonprivate insurance was a risk factor at day 30 (OR 1.8; P=.025) and by day 100 (OR 1.6; P=.029).

Decreased Survival With Readmission
Univariate analysis demonstrated that being readmitted in either group was associated with decreased survival.

In a landmark analysis of patients who survived beyond the studied time points, the 5-year overall survival for patients readmitted within 30 days of discharge from the index HSCT in the MAC group was 42%, compared with 56% among patients not readmitted. Similarly, corresponding overall survival in the RIC group was 26% versus 50%.

The 5-year overall survival for those readmitted by day 100 following HSCT in the MAC group was 52% versus 61% among patients not readmitted, and in the RIC group, the corresponding OS was 26% compared with 57%.

“After adjusting for age, donor type, and disease risk index, a multivariate analysis confirmed the association between readmission and lower overall survival,” said Spring. In the multivariate analysis, the risk of death at 5 years was 58% higher in the MAC group with 30-day readmission (P=.0018) and 32.5% higher with readmission within 100 days (P=.068). In the RIC group, 30-day readmission increased the risk of 5-year mortality by 68% (P=.0002), and readmission within 100 days increased it by more than 2-fold (P?.0001).

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