Healthcare Utilization and End-of-Life Outcomes in Patients Receiving CAR T-Cell Therapy

Abstract

Background: CAR T-cell therapy has revolutionized the treatment of patients with hematologic malignancies, but it can result in prolonged hospitalizations and serious toxicities. However, data on the impact of CAR T-cell therapy on healthcare utilization and end-of-life (EoL) outcomes are lacking. Methods: We conducted a retrospective analysis of 236 patients who received CAR T-cell therapy at 2 tertiary care centers from February 2016 through December 2019. We abstracted healthcare utilization and EoL outcomes from the electronic health record, including hospitalizations, receipt of ICU care, hospitalization and receipt of systemic therapy in the last 30 days of life, palliative care, and hospice referrals. Results: Most patients (81.4%; n=192) received axicabtagene ciloleucel. Overall, 28.1% of patients experienced a hospital readmission and 15.5% required admission to the ICU within 3 months of CAR T-cell therapy. Among the deceased cohort, 58.3% (49/84) were hospitalized and 32.5% (26/80) received systemic therapy in the last 30 days of life. Rates of palliative care and hospice referrals were 47.6% and 30.9%, respectively. In multivariable logistic regression, receipt of bridging therapy (odds ratio [OR], 3.15; P=.041), index CAR-T hospitalization length of stay >14 days (OR, 4.76; P=.009), hospital admission within 3 months of CAR T-cell infusion (OR, 4.29; P=.013), and indolent lymphoma transformed to diffuse large B-cell lymphoma (OR, 9.83; P=.012) were associated with likelihood of hospitalization in the last 30 days of life. Conclusions: A substantial minority of patients receiving CAR T-cell therapy experienced hospital readmission or ICU utilization in the first 3 months after CAR T-cell therapy, and most deceased recipients of CAR T-cell therapy received intensive EoL care. These findings underscore the need for interventions to optimize healthcare delivery and EoL care for this population.

Natural language processing in clinical neuroscience and psychiatry: A review

“…The ultimate goal was to create a general-purpose, open-source biomedical NLP tool that can be used for other applications; such tools can then be used to work on specific pathologies. This is the case of Johnson et al ( 52 ), who used ClinicalRegex 5 to examine social support in patients with aggressive hematologic malignancies. Khapre et al ( 53 ) and McDonald et al ( 54 ) similarly used General Architecture for Text Engineering (GATE), 6 an open-source NLP toolkit, to study symptoms in women with severe mental illness (i.e., psychotic and bipolar disorders) and in people with mood instability and/or sleep disturbance, respectively.…”

“…The ultimate goal was to create a general-purpose, open-source biomedical NLP tool that can be used for other applications; such tools can then be used to work on specific pathologies. This is the case of Johnson et al (52), who used ClinicalRegex 5 to examine social support in patients with aggressive hematologic malignancies. Khapre The above tools have highlighted two major problems in the development of NLP tools, namely:…”

Early integration of palliative care for patients with haematological malignancies

“…CAR-T cell therapy is an additional treatment modality with activity in indolent as well as aggressive HMs and data as to quality of life at the EOL with these treatments is only beginning to emerge. 32 Physical and psychological challenges are prominent in this group as well. Multiple myeloma is notorious for causing bone pain and spontaneous fractures 33 while lymphomas may behave as solid tumours compressing adjacent organs or nerves causing a variety of symptoms.…”

“…Stem cell transplantation, a severely debilitating and dangerous intervention, can attain long term remission and even cure in a significant minority of patients and thus persists as a wild card treatment option in the eyes of both patients and clinicians. CAR‐T cell therapy is an additional treatment modality with activity in indolent as well as aggressive HMs and data as to quality of life at the EOL with these treatments is only beginning to emerge 32 …”

Barriers to Chimeric Antigen Receptor T-Cell (CAR-T) Therapies in Clinical Practice

“…Considering the potential side effects and the fact that not all patients will stay in remission after CAR-T therapy, many patients will need care in addition to the CAR-T treatment itself. A retrospective study examining post-CAR-T HCU in patients with lymphoma found that 28.1% of patients were admitted to the hospital at least once within 3 months of receiving CAR-T therapy, and 15.5% of patients had at least one intensive-care admission within 3 months of receiving therapy [ 39 ]. Another study examined HCU pre- and post-CAR-T administration in DLBCL patients and found that there were fewer ambulatory and emergency department visits in the months following CAR-T as compared to the months before; although patients are returning to the hospital, HCU-related costs were significantly lower after treatment [ 40 ].…”