New Orleans, LA—Infection and fever without a source are the most common causes of readmission after allogeneic hematopoietic stem-cell transplantation (HSCT), and being readmitted within 30 days of discharge is associated with a lower 5-year overall survival (OS) rate, according to Laura Spring, MD, of the Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Boston.
“A better understanding of the risk factors for readmission in the transplant population will allow for more transitional care and clinical resources to be focused on the highest-risk patients,” said Dr Spring at ASH 2013. The United States spent $17.5 billion on readmissions among Medicare beneficiaries in 2010, she noted.
This single-institution, retrospective review included 495 patients receiving myeloablative conditioning (MAC) and 602 patients receiving reduced intensity conditioning (RIC) HSCT at the Dana-Farber Cancer Institute and Brigham and Women’s Hospital. The 30-day readmission rate was examined in addition to the readmission rate at day 100, a traditional assessment point in transplantation readmission rate.
The readmission rate was 26.3% at 30 days and 39.2% at 100 days in the MAC group. In the RIC group, the 30-day readmission rate was 17.4% and the 100-day rate was 30.7%.
“In both groups, the most frequent reasons for readmission were documented infection, fever without a source, and graft-versus-host disease,” Dr Spring said. Infection was the reason for readmission in approximately 25%, fever in approximately 19%, and graft-versus-host disease in 15.1% (RIC) and 17.9% (MAC).
A multivariate logistic regression model was used to assess the probability of being readmitted after transplant.
Active disease at the time of transplant was a significant risk factor for readmission by day 30 postdischarge (P = .005) and at day 100 (P = .001) in the RIC group.
Infection during index admission was a significant risk factor for readmission by day 100 (odds ratio [OR], 1.9; P = .006) in the MAC group.
For the RIC group, a mismatched donor and infection during index admission were significant risk factors for readmission by day 30 after discharge and by day 100.
Hispanic/Latino ethnicity was a significant risk factor for readmission at day 100 (OR, 4.6; P = .013) in the MAC group. Non–private insurance was a risk factor at day 30 (OR, 1.8; P = .025) and at day 100 (OR, 1.6; P = .029) in the RIC group.
Decreased Survival with Readmission
Univariate analysis demonstrated that being readmitted in either group was associated with decreased survival.
In a landmark analysis of patients who survived beyond the studied time points, the 5-year OS for patients readmitted within 30 days of discharge from the index HSCT in the MAC group was 42% compared with 56% among patients not readmitted. Similarly, OS in the RIC group was 26% versus 50%, respectively.
The 5-year OS for patients readmitted by day 100 after HSCT was 52% versus 61% of those not readmitted in the MAC group, and 26% versus 57% in the RIC group.
“After adjusting for age, donor type, and disease risk index, a multivariate analysis confirmed the association between readmission and lower overall survival,” said Dr Spring.
The risk of death at 5 years was 58% higher with 30-day readmission (P = .001) and 32.5% higher with readmission within 100 days (P = .068) in the MAC group. In the RIC group, the risk of death was 68% (P = .002) with 30-day readmission and increased more than 2-fold (P ≤.001) with 100-day readmission.