Late Hospitalizations in Long-Term Survivors of Hematopoietic Cell Transplantation (HCT): Report From the Bone Marrow Transplant Study (BMTSS).

Abstract 807

Long-term survival is now an expected outcome after HCT. However, high intensity chemo-radiotherapy for conditioning, coupled with prolonged immune suppression after HCT are associated with the risk of developing endocrinopathies (diabetes), musculoskeletal disorders (osteonecrosis, osteoporotic fractures), and cardiopulmonary complications (congestive heart failure, pulmonary fibrosis), which could necessitate hospitalization for their management. Although hospitalization needs in the immediate post-HCT period are well-described, details for long-term survivors are lacking. An in-depth study of hospitalization patterns among long-term HCT survivors would help healthcare providers and patients/caregivers in developing resources for the long-term care of survivors. This study describes the prevalence and patterns of late hospitalization among long-term HCT survivors; compares this outcome with siblings; and identifies subpopulations at increased risk. Data are derived from the BMTSS, and include 1022 individuals, who had undergone HCT between 1974 and 1998, and survived at least two years, and 309 unaffected siblings. Primary diagnoses included AML, CML, ALL, HL, NHL, and SAA. Median age at HCT was 35 years (range 0.4-69); median time since HCT 7.3 years (2-28); 55% had received an allogeneic HCT. A total of 436 (43%) survivors required one or more hospitalizations in the two years prior to study participation, compared with 29% of the siblings (p<0.001). Age-, sex-, race/ethnicity-, SES-, education-, and insurance-adjusted analysis revealed that HCT survivors were at a 1.7-fold (95%CI=1.3-2.3) increased risk of hospitalizations compared with their siblings. Among HCT survivors, the prevalence of hospitalizations declined with time since HCT (2-5 years: 49%; 6-10 years 39%; and 11+ years 37%, p for trend<0.001). Multivariate analysis adjusted for sociodemographic factors including health insurance showed that compared with autologous HCT survivors, allogeneic HCT survivors were more likely to report late hospitalizations (related donor: odds ratio [OR]=3.2, 95%CI, 1.1-9.4; unrelated donor: OR=4.1, 95%CI=1.3-13.5); age at HCT >45 years was associated with a higher risk of late hospitalizations (OR=2.3, 95% CI=1.3-4.0); and, patients with chronic graft vs. host disease (cGvHD) were more likely to report late hospitalizations (OR=1.5, 95%CI=1.0-2.1). The major reasons for hospitalization included gastrointestinal (GI) problems (n=93), ocular complications (n=58), infection (n=51), endocrine dysfunction (n=41), musculoskeletal complications (n=40), cardiac (n=37), and pulmonary (n=33) events. After adjusting for SES and insurance status, older age at HCT was associated with hospitalization for musculoskeletal (OR=9.9, 95%CI, 1.1-88.2) and GI problems (OR=3.9, 95%CI, 1.5-10.1); survivors of allogeneic HCT were more likely to be hospitalized for endocrinopathies (related HCT: OR=7.4, 95%CI, 1.4-38.9; unrelated HCT: OR=3.8, 95% CI, 0.4-37.6) and GI problems (related HCT: OR=7.57, 95%CI, 1.8-31.5; unrelated HCT: OR=9.67, 95% CI=1.9-49.6); and patients with cGvHD were more likely to be hospitalized for infection (OR=2.7, 95%CI, 1.2-6.0), ocular (OR=2.8, 95%CI, 1.2-6.4) and pulmonary problems (OR=2.7, 95%CI, 1.0-7.4). This study demonstrates that over 40% of long-term HCT survivors require late hospitalizations; that older individuals, those who underwent allogeneic HCT and those who developed cGvHD continue to be at an increased risk for late hospitalizations; and that attention needs to focus on instituting targeted follow-up to proactively minimize the need for these hospitalizations. Furthermore, ongoing healthcare issues emphasize the requirement for comprehensive health insurance coverage, even many years after HCT.