Economic analysis of unrelated allogeneic bone marrow transplantation: results from the randomized clinical trial of T-cell depletion vs unmanipulated grafts for the prevention of graft-versus-host disease

Abstract

Summary:Unrelated-donor marrow transplantation is a potential option for transplant candidates lacking a compatible related donor. The T-cell Depletion Study compared the 3-year disease-free survival for patients receiving T-celldepleted (TCD) donor marrow (n ¼ 203) vs unmanipulated donor marrow with methotrexate and cyclosporine (M/C) (n ¼ 207). Hospital costs during index admission were documented with billing data, while hospital costs during subsequent 6-month follow-up were estimated from case report forms. Patients with index admission billing were included in the analysis (TCD ¼ 119, M/C ¼ 127). Total hospital length of stay (LOS) was similar across groups, with medians 47.0 days for TCD and 52.0 days for M/C (P ¼ 0.72). Total hospital costs were comparable, $145 115 vs $141 981 (P ¼ 0.63) for TCD and M/C, respectively. However, controlling for site and patient characteristics, TCD was associated with a 12.1% reduction in LOS for the index admission (95% CI À19.4%, À4.3%). Independent of treatment, HLA matching (6/6) was associated with an 8.6% (95% CI À17.4%, þ 1.2%) reduction in the index admission LOS, while cost was lower by 15.8% (95% CI À26.7%, À3.3%). Treatment costs were similar for TCD and M/C study groups. Savings on reduced cost for treating acute graft-versus-host disease were likely offset by increase in serious infections in the TCD arm.

Outcomes from Unrelated Donor Hematopoietic Stem Cell Transplantation

“…The universal application of allogeneic transplantation is limited by the cost of the procedure, which increases with the use of unrelated donors. [3][4][5][6] The donor search and the inpatient care during the fi rst 100 days following a transplant account for the majority of the costs, and severe complications post-transplant also increase costs. 5 However, the high degree of effectiveness in certain patients results in a cost-effectiveness ratio that is comparable to that of other accepted complex medical interventions, 3 and its role should be examined in the context of emerging pharmacological interventions.…”

Economics of hematopoietic cell transplantation

“…Lee et al reported significantly lower costs ($113 000 vs $155 000 in 2000 USD, P Ͻ .001) with T celldepleted grafts in a single-center comparative analysis, but the economic substudy of the randomized TCD trial conducted by National Heart, Lung, and Blood Institute found comparable costs between the TCD and unmanipulated donor arms ($145 115 vs $141 981 in 2001 USD, respectively; P ϭ .63). 17,20 The National Heart, Lung, and Blood Institute trial reported that, although TCD of the donor graft reduced the short-term costs, frequent hospitalizations and higher average number of hospital days resulting from infectious complications in the first 6 months after transplantation appeared to offset any savings seen with the initial transplantation stay.…”

“…[17][18][19][20] Many studies exclude costs of donor identification/stem cell procurement and patient evaluation for transplantation eligibility. [21][22][23][24] A few studies have looked at the out-of-pocket cost burden in HCT patients.…”

Increased costs after allogeneic haematopoietic SCT are associated with major complications and re-transplantation

“…Despite the intensive research in the field and high cost of the procedure, there have been very few investigations and publications on the cost of HSCT. [3][4][5][6][7] We have previously reported the total costs over 5 years after HSCT in 93 patients transplanted in 1998 and 1999 at our unit. 8 We found that higher costs of HSCT were associated with acute leukaemia, G-CSF prophylaxis, hospital care as opposed to home care, myeloablative conditioning (MAC) as opposed to reduced-intensity conditioning (RIC) and major transplantrelated complications.…”