High-Intensity Healthcare Utilization and Costs Among Older 10+y Survivors of Allogeneic Blood or Marrow Transplantation (BMT): A Report from the BMT Survivor Study-2 (BMTSS-2)

Background: BMT survivors carry an inordinately high burden of long-term morbidity - a burden that increases as the survivor population ages as well as with time from BMT. This high burden places the survivors at high risk for hospitalizations and emergency room (ER) visits - referred to here as high-intensity healthcare utilization. However, the prevalence and predictors of high-intensity healthcare utilization by older (≥65y) BMT survivors who are 10+y from BMT and the costs remain unstudied. We used a multi-institutional study (BMTSS-2) to address this gap.

Methods: We ascertained self-reported high-intensity healthcare utilization in the 2y prior to study participation from allogeneic BMT survivors who were ≥65y at study participation and had survived 10+y from BMT (n=82). Using Poisson regression with robust variance estimator, we compared utilization from the older cohort with a younger cohort (40-64y at study) of 10+y allogeneic BMT survivors (n=177), as well as an older cohort (65+y at study) of non-BMT siblings (n=217). Finally, we compared the average costs of ER visits and hospitalizations per patient among the three cohorts, using national age-adjusted estimates from CDC.

Results: The median age of the older BMT cohort at study was 68y (65.0-89.3); the median length of follow-up was 16.4y (11.0-36.5) from BMT. The median age of the younger BMT cohort was 56.3y (40.2-64.9), with a median follow-up of 17.7y (5.4-40.5) from BMT. The median age of the sibling comparison group was 69.3y (65.0-90.5). The 3 cohorts were comparable with respect to gender, race/ethnicity, education and income. The prevalence of high-intensity healthcare utilization was greatest in the older BMT cohort at 65%, followed by the younger BMT cohort at 44% and lowest among the siblings at 34%. Older BMT Survivors vs. Siblings : After adjusting for age, gender, race, education, income, health status, health concerns and insurance, older survivors were 1.47 times more likely to report a high-intensity visit (95%CI, 1.09-1.20, p=0.011) when compared with siblings. Older vs. Younger BMT Survivors : After adjusting for sociodemographic factors, as well as primary cancer diagnosis, years since BMT, chronic graft vs. host disease (GvHD), health status, health concerns, and number of chronic health conditions, older BMT survivors were 1.32 times more likely to report a high-intensity visit (95%CI, 0.99-1.75, p=0.06) when compared with the younger BMT cohort. Older BMT Survivors : Among older BMT survivors, significant risk factors included lower household income and impaired health status. Compared to survivors with income greater than $75,000, those with income less than $20,000 were marginally more likely to report high-intensity visits (PR=1.51, 95%CI, 0.99-2.30, p=0.057). Compared to survivors reporting excellent or very good health status, the prevalence of high-intensity visit were 1.9 times greater for those with good health status (95%CI, 1.01-3.70, p=0.05) and 2.2 times greater for those reporting fair/poor health status (95%CI, 1.14-4.11, p=0.018). Estimated Costs : Assuming that the patients had one high-intensity visit in the 2y prior to study, a conservative estimate of the average cost of high-intensity visits per person was at least $13,810 for the older BMT survivors, $7,498 for the younger BMT survivors and $5,696 for the siblings.

Conclusion: Sixty-five percent of older allogeneic BMT survivors who are 10+y from BMT report high-intensity healthcare utilization; they are more likely to utilize high-intensity health care than younger survivors and same-age sibling controls. This high-intensity healthcare translates into a highly conservative 2.4-fold higher healthcare costs for the older BMT survivors when compared with a similarly-aged non-BMT comparison group. A coordinated effort among healthcare providers is necessary to ensure efficient and cost-effective anticipatory care for long-term BMT survivors to prevent high-intensity healthcare utilization several years after BMT.