Pre-Transplant Patient-Reported Outcomes Are Associated with Health Care Utilization and Transplant-Related Complications at One-Year Post-Transplant

Background: Hematopoietic cell transplantation (HCT) is a potentially curative therapy for patients with many hematologic conditions but is often associated with early- and long-term complications that negatively impact patients´ quality of life and may require rehospitalization. While there is increasing recognition of the importance of patient-reported outcomes (PROs) in HCT, data are limited in exploring the association between PROs and the risk of HCT-related complications including health care utilization during the first year after HCT.

Methods: We conducted a secondary data analysis of 610 autologous or allogeneic HCT recipients enrolled in three supportive care studies conducted at three tertiary care academic centers from 2011 to 2022. We examined patient-reported psychological distress (Hospital Anxiety and Depression Scale [HADS]), quality of life (Functional Assessment of Cancer Therapy- General [FACT-G]), and fatigue (FACT-Fatigue). From the medical record, we extracted: 1) the number of days hospitalized during the first year after HCT, 2) the number of days alive and out of the hospital during the first year after HCT, and 3) the cumulative incidence of acute and chronic graft-versus-host disease (GVHD) among allogeneic HCT recipients. We used multivariable linear regression models to examine the association between baseline PROs and time spent in the hospital. We conducted multivariable Poisson regression to examine the association between PROs and days alive and out of the hospital during the first year. We adjusted all models by age, gender, performance status, race, marital status, education level, HCT-Comorbidity Index (HCT-CI) and type of HCT. We also used multivariable logistic regression models to examine the association between PROs and acute and chronic GVHD risk among allogeneic HCT recipients. We adjusted these analyses by age, sex, performance status, HCT-CI, and donor type. We controlled all models for the receipt of palliative care intervention as per the original trials.

Results: Participants had a median age of 58 years (range: 18 -78 years), 43% (265/610) were female, and the majority were White (82% [498/610]) and married (71% [432/610]). Overall, 47.2% (288/610) of patients received an autologous HCT, 26.7% (163/610) a myeloablative allogeneic HCT, and 26.1% (159/619) a reduced-intensity allogeneic HCT. Among allogeneic HCT recipients, 45% (145/322) developed acute GVHD, and 40% (128/320) had chronic GVHD. The median HCT hospitalization length of stay was 21 days (range: 9-160 days). Upon discharge, 38.7% (236/610) were readmitted within the first year. Overall, median number of days spent in the hospital during the first year post-HCT was 24 days (range: 9-262 days). Patients were alive and out of the hospital for a median of 341 days (range: 103-356 days). In multivariable analyses, worse baseline fatigue (B=-.262 p=0.007) and lower baseline quality of life (B=-.192 p=0.009) were associated with more days spent in the hospital during the first-year post-transplant. Worse baseline depression (B=.523, p=0.092) was associated with more days spent in the hospital, but this did not reach statistical significance. In multivariable Poisson regression, lower baseline anxiety (B=-.001, p=0.034), depression (B=-.002, p<.001), and fatigue (B=.001, p<.001), and greater baseline quality of life (B=.001, p<.001) were associated with increased days alive and out of the hospital during the first-year post-transplant. In multivariate logistic regression, worse baseline depression (B=.018, p=0.049) and fatigue (B=-.006, p=0.034) were associated with an increased risk of acute GVHD. Worse baseline anxiety (B=.014 p=.084) and quality of life (B=-.004 p=.050) were associated with increased risk of acute GVHD, but this did not reach statistical significance. Baseline PROs were not associated with the risk of developing chronic GVHD.

Conclusion: Baseline PROs prior to HCT are associated with increased health care utilization and post-transplant complications including the risk of acute GVHD and days spent in the hospital in the first year post-HCT. Integrating PROs as part of the pretransplant assessment has the potential to identify patients at risk of worse HCT outcomes.