Recognizing Risk Factors Associated With Unplanned 30-Day Readmissions in Hematopoietic Cell Transplantation: An Opportunity to Develop Cost-Containment Strategies

Stakeholders ranging from patients, physicians, health care systems, state and federal policy makers, legislators, third party payers, and employers are focused on the unsustainable rate of growth in health care costs.¹ As of 2017, health care expenditures in the United States totaled $3.5 trillion. This represents 17.9% of the nation’s gross domestic product and translates into a per-capita expenditure of $10 739—the highest level of health care spending of any nation on earth.² Some estimates suggest that nearly one-third of this spending produces care that delivers negligible value.³ The rate of inflation for cancer care is particularly dramatic, with 1 study⁴ projecting a 27% increase in costs between 2010 and 2020. As patients and families assume a greater portion of these rising costs through cost sharing, resulting patient medical bankruptcies have become a real consequence of modern cancer care.^5,6

In response to the dramatic increase in health care costs, public and private payers have proposed pay-for-performance and value-based-payment models that are meant to transfer performance-based upside and downside financial risk to clinicians and health care systems. The Centers for Medicare & Medicaid Services efforts to reduce hospital readmission rates is one of these strategies that have been implemented as a means of both decreasing costs and increasing clinician and health care system accountability to measurable health care outcomes. For instance, the Centers for Medicare & Medicaid Services currently imposes penalties on hospitals with high 30-day unplanned readmission rates for cardiac, surgical, and other conditions.^7,8 One of the limitations of these performance-based reimbursement models is that they must be based on robust data to set performance benchmarks that clinicians and health care systems can reasonably achieve through high-quality care and iterative improvements in care delivery.

Recipients of hematopoietic cell transplant (HCT), including both autologous (auto) and allogeneic (allo) transplants, represent a population with a relatively high risk of 30-day readmission, mostly due to profound myelosuppression and/or prolonged immune suppression.

In addition, organ failure may develop owing to the therapeutic intensity of ablative conditioning regimens and contribute to the risk of readmission. There are limited data, however, on the rate of readmission following HCT and the risk factors associated with increased readmission rates. An association between HCT center volume and survival outcomes has been previously described.⁹ Loberiza and colleagues⁹ identified a higher transplant-associated mortality and treatment failure risk, after adjusting for relevant patient-, disease-, and transplant-related characteristics, when patients received allo-HCT in centers performing 5 or fewer procedures per year.

Dhakal and colleagues¹⁰ add materially to our understanding of HCT-related hospital readmissions. The authors report 30-day readmission rates of 11.6% for auto-HCT and 24.4% for allo-HCT for adults at US hospitals. The median time to readmission was 5.5 days for auto-HCT and 9.3 days for allo-HCT. The authors also found that infection-related complications were the most common reason for readmission.

The authors’ findings are based on an analysis of data from the Nationwide Readmission Database (NRD) for 2012 to 2014.¹⁰ The authors identified volume thresholds for low-volume centers (defined by the authors as those performing <78 auto-HCT or <58 allo-HCT per year), medium-volume centers, and high-volume centers (≥187 auto-HCT or ≥158 allo-HCT per year). Low-volume centers composed most of the study sample. Low-volume centers accounted for 78% of the centers performing auto-HCT and 76% of those performing allo-HCT. High-volume centers composed only 6% of centers performing both auto-HCT and allo-HCT. Notwithstanding concerns about accuracy and validity of the methods used to define volume activity cutoffs, the authors found that low transplant activity was a statistically significant variable associated with an increased risk for 30-day readmission.¹⁰ The authors also found that HCT-related readmission costs were significantly higher for low-volume centers vs costs at either medium- or high-volume centers. There are, however, some data limitations worth noting in this analysis. The NRD is a complex database that tracks discharges rather than patient-level data. This limits the ability to link individual patient clinical and demographic risk to readmissions outcomes data. In addition, the NRD captures annual (calendar year) data, which led the authors to exclude the month of December for each year of their analysis.

The authors further identified infections, febrile neutropenia, and gastrointestinal symptoms as the leading reasons for auto-HCT readmission. The leading reasons for allo-HCT readmissions included infection, gastrointestinal symptoms, febrile neutropenia, and graft-vs-host disease. The authors speculate that lower readmission rates achieved by higher–HCT volume centers may be explained, in part, by better patient selection as well as increased care proficiency by more experienced clinicians and ancillary staff. In our opinion, although the impact of factors such as transplant physician training and experience, expertise of the multidisciplinary care team, and the effectiveness of ancillary service members cannot be ignored, the authors’ assertion that this is the basis for superior readmissions data is not supported by their data.

The importance of this study should not, however, be underestimated. The authors have advanced our understanding by creating robust baseline readmissions data and identifying the key reasons for readmission in this population. These data may serve as the basis for readmission metric development for HCT centers. It is worth noting that some of the identified risk factors are not modifiable. These include transplant center volume, which may depend on the surrounding population density and geographic location, and, for allo-HCT, the higher risk associated with disease histology and use of umbilical cord blood as the hematopoietic cell source. The lack of modifiability of these factors, however, should not translate into a lack of action in creating more effective postacute management models for patients undergoing HCT.

Indeed, identification of an association between performance and volume and the authors’ careful enumeration of the key reasons for readmission should empower both low-volume and high-volume centers to develop more effective care infrastructure, multidisciplinary care coordination, and standard operating procedures directed at optimal management of potentially avertable treatment-related complications. Although the care of patients undergoing HCT, particularly those undergoing allo-HCT, is logistically complex, management of infection, neutropenia, and HCT-related organ toxic effects (particularly gastrointestinal toxic effects) following HCT represent real avenues for improvement in care delivery.

At a time in which there is immense pressure on clinicians and health care systems to become increasingly effective stewards of health care costs, Dhakal and colleagues¹⁰ provide an important first step toward empowering these efforts. Patients undergoing HCT represent one of the most complex, highest-risk oncology populations served in the United States. These baseline data and information related to the causes of readmission help to identify genuine, realistic opportunities for HCT center improvement through improved care delivery infrastructure, increased availability of resources such as rehabilitation programs, better infection surveillance and management programs, improved patient compliance and care engagement, and more robust outpatient care for high-risk patients. In the aggregate, such improvements may optimize continuity of care and improve recovery as patients transition from inpatient to outpatient transplant settings.

While acknowledging the need to validate the findings of this study, the authors bring to light important data that should support the development of cost-containment strategies that could empower HCT physicians and transplant centers to move us unequivocally toward more effective, more efficient, and more value-based care for patients undergoing HCT.

Published: July 5, 2019. doi:10.1001/jamanetworkopen.2019.6463

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Kharfan-Dabaja MA et al. JAMA Network Open.

Corresponding Author: Joseph C. Alvarnas, MD, Department of Hematology/Hematopoietic Cell Transplantation, City of Hope National Medical Center, 1500 E Duarte Rd, Duarte, CA 91010 (jalvarnas@coh.org).

Conflict of Interest Disclosures: Dr Kharfan-Dabaja reported serving as a consultant for Daiichi Sankyo and Pharmacyclics and participation in the speaker bureaus of Seattle Genetics, Alexion Pharmaceuticals, and Incyte Corporation outside the submitted work. No other disclosures were reported.