Economics and Outcome After Hematopoietic Stem Cell Transplantation: A Retrospective Cohort Study

• Hematopoietic stem cell transplants (HSCTs) are expensive; economics plays a role on use and outcome.
• 102,549 patients treated with HSCT in 404 European centers between 1999 and 2006 were investigated.
• Center program duration, patient volume, accreditation and country economics were associated with survival.
• Effects were significant, clinically relevant but distinct for allogeneic and autologous HSCT.Hematopoietic stem cell transplantation (HSCT) is lifesaving but expensive; it's more frequently used in richer countries. We asked whether economics impact on outcome. For 102,549 patients treated with an allogeneic or autologous HSCT in 404 European centers between 1999 and 2006 survival was significantly better in centers with longer program duration and a higher patient volume. Survival was better in economically advantaged countries. Data indicate distinct, significant, systematic, and clinically relevant effects on long-term disease and complication management by country- and center-specific economic factors. It is likely that these effects apply to other forms of complex treatments.

Hematopoietic stem cell transplantation (HSCT) is a lifesaving expensive medical procedure. Hence, more transplants are performed in more affluent countries. The impact of economic factors on patient outcome is less defined. We analyzed retrospectively a defined cohort of 102,549 patients treated with an allogeneic (N = 37,542; 37%) or autologous (N = 65,007; 63%) HSCT. They were transplanted by one of 404 HSCT centers in 25 European countries between 1999 and 2006. We searched for associations between center-specific microeconomic or country-specific macroeconomic factors and outcome. Center patient-volume and center program-duration were significantly and systematically associated with improved survival after allogeneic HSCT (HR 0·87; 0·84–0·91 per 10 patients; p < 0·0001; HR 0·90;0·85–0·90 per 10 years; p < 0·001) and autologous HSCT (HR 0·91;0·87–0·96 per 10 patients; p < 0·001; HR 0·93;0·87–0·99 per 10 years; p = 0·02). The product of Health Care Expenditures by Gross National Income/capita was significantly associated in multivariate analysis with all endpoints (R2 = 18%; for relapse free survival) after allogeneic HSCT. Data indicate that country- and center-specific economic factors are associated with distinct, significant, systematic, and clinically relevant effects on survival after HSCT. They impact on center expertise in long-term disease and complication management. It is likely that these findings apply to other forms of complex treatments.