Health Care Utilization and End of Life (EOL) Outcomes in Patients Receiving CAR T-Cell Therapy

Background: CAR T-cell therapy has altered the landscape of treatment options for patients with hematologic malignancies, but it can result in prolonged hospitalizations and serious toxicities. Yet, data are lacking regarding the impact of CAR T-cell therapy on health care utilization and EOL outcomes.

Methods: We conducted a retrospective analysis of 236 patients who received CAR-T cell therapy at two tertiary care centers from 2/2016-12/2019. We abstracted health care utilization outcomes from the Electronic Health Record (EHR) including hospitalizations during the first 3 months following CAR T-cell therapy, and receipt of intensive care unit (ICU) care. Using the EHR, we also collected data on EOL outcomes among the deceased cohort: 1) place of death; 2) hospitalization in the last 30 days of life; 3) receipt of chemotherapy in the last 30 days of life; and 4) palliative care consultation and hospice referrals. Using multivariable logistic regression models adjusting for covariates, we also assessed factors associated with hospitalization in the last 30 days of life and hospice referral.

Results: Patients had a median age of 62.5 years (range: 19-82) and the majority were male (145/236, 61.4%). The most common diagnosis was de novo diffuse large B cell lymphoma (DLBCL) (101/236, 42.8%) and most patients received axicabtagene ciloleucel (axi-cel) (192/236, 81.4%). The median length of stay for CAR T-cell therapy hospitalization was 15 days (range: 7-91), and 15.5% (36/232) of patients required an ICU admission within 3 months of CAR T-cell therapy. The hospital readmission rate within 3 months of CAR T-cell therapy was 28.1% (65/231). Among the deceased cohort, 58.3% (49/84) were hospitalized in the last 30 days of life, 32.5% (26/80) of patients received chemotherapy in the last 30 days of life, and 68.5% (37/54) of patients died in a hospital or health care facility. The rate of palliative care consultation was 47.6%. Only 30.9% of patients were referred to hospice, and the majority (60/80, 75.0%) had a hospice length-of-stay < 7 days. In multivariable logistic regression, receipt of bridging therapy (OR=3.15, p=0.041), length of stay > 14 days (OR=4.76, p=0.009), hospital admission within 3 months of CAR T-cell infusion (OR=4.29, p=0.013), and indolent lymphoma transformed to DLBCL (OR=9.83, p=0.012) were associated with likelihood of hospitalization in the last 30 days of life. In multivariable logistic regression, palliative care consultation was associated with likelihood of hospice referral (OR=3.18, p=0.044).

Conclusions: A substantial minority of patients receiving CAR T-cell therapy experienced hospital readmission or ICU utilization in the first three months after CAR T-cell therapy, and the majority of deceased CAR-T cell recipients received intensive EOL care. The majority of deceased CAR-T recipients did not receive a palliative care consultation or hospice referral. These findings underscore the need for interventions to optimize health care delivery and EOL care for this population.