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Palliative care (PC) benefits patients undergoing hematopoietic stem cell transplantation (HSCT), but it remains underutilized. Although transplant physicians report concerns regarding how patients perceive PC, HSCT recipients’ perceptions about PC remain unaddressed. We conducted a multisite, cross-sectional survey of autologous and allogeneic HSCT recipients 3 to 12 months after transplant to assess their familiarity, knowledge, and perception of PC, as well as their unmet PC needs. We computed a composite score of patients’ perceptions of PC and used a generalized linear regression model to examine factors associated with these perceptions. We enrolled 69.6% (250/359) of potential participants (median age = 58.1; 63.1% autologous HSCT). Overall, 44.3.8% (109/249) reported limited knowledge about PC and 52% (127/245) endorsed familiarity with PC. Most patients felt hopeful (54%) and reassured (50%) when they heard the term PC; 83% saw referral as a sign their doctor cared about what was happening to them. In multivariate analyses, patients who were more knowledgeable about PC were more likely to have positive perceptions of PC (B = 7.54, standard error = 1.61, P < .001). Patients’ demographics, HSCT features, quality of life, and symptom burden were not significantly associated with perceptions of PC. HSCT recipients have positive perceptions of PC, though many have limited knowledge about its role. Patients who were more knowledgeable about PC were more likely to have positive perceptions of PC. These data do not support transplant physicians’ negative concerns about how patients perceive PC and underscore the need to further educate patients and transplant physicians about PC.

PURPOSE Administrative claims data provide real-world service utilization of acute myeloid leukemia (AML) treatment, but lacks insight into treatment delays or barriers. The National Marrow Donor Program (NMDP)/Be The Match Search (Search) data contains information on donor search, but lacks information on treatment received if allogeneic hematopoietic cell transplant (HCT) is not performed. We hypothesized that linking these two data sets would create a rich resource to define factors associated with receiving HCT that could not be evaluated with either data set alone. METHODS A subset of 2010-2016 Medicare administrative claims data was linked with Search data. A total of 5,351 patients with AML age 65-74 years (HCT = 607, no HCT = 4,744) were identified using Medicare. These patients were then linked to 93,800 records with a donor search between 2009 and 2016. Patient date of birth, sex, disease, ZIP code, transplant center/hospital, and diagnosis date were used for matching. Exploratory analysis was conducted to identify predictors associated with receiving HCT for patients with AML who received a search. RESULTS The data sets were successfully linked, showing high sensitivity and specificity. The final cohort included 5,085 patients with AML (HCT = 533, no HCT = 4,552). Of 97 patients who received HCT without a matched search, more than 85% received a related donor HCT. Of those not receiving HCT, 609 had a matched NMDP search and 3,943 did not have a matched NMDP search. Multivariate analysis showed time to search, age, diagnosis year, race/ethnicity, and neighborhood education status associated with receiving HCT. CONCLUSION Methods herein demonstrate the feasibility of linking Search and Medicare data. Similar methods may be applied to answer critical questions regarding barriers to HCT, thereby identifying areas to improve access to care.

Background: Outcomes after hematopoietic cell transplantation (HCT) for acute myeloid leukemia (AML) are better when HCT is performed during first complete remission (CR1). This study aimed to identify and address knowledge gaps that affect the timely referral of patients for HCT consultation. Methods: A mixed-methods educational needs assessment included a national survey and focus groups consisting of hematologists/oncologists. An educational intervention of 3 webinars addressed identified knowledge gaps. Results: A total of 150 hematologists/oncologists were recruited for the survey, of whom 20 participated in focus groups. Physicians in practice 0 to 10 years were 4.2 times more likely to refer for HCT consultation in CR1 than those with >10 years in practice (P=.0027). Physicians seeing ≤10 patients with AML in the past year were 3.7 times more likely to refer for HCT consultation in CR1 than those seeing >10 patients (P=.0028). Knowledge gaps included (1) improper classification of molecular/cytogenetic results for risk stratification, (2) lack of understanding that disease stage impacts outcomes, and (3) use of chronologic age alone for referral decision-making. Combined attendance for the webinars was 1,098 clinicians; >74% of participants indicated that they would apply the knowledge they gained in clinical practice. Trends were observed toward improvement in identifying favorable-risk AML, from 48% to 60% (n=85; P=.12); improvement in identifying 2 poor-risk cytogenetic/molecular abnormalities, with the percentage of respondents indicating chromosome 7 deletion increasing from 51% to 70% (n=53; P=.05) and that of respondents indicating TP53 mutation increasing from 42% to 62% (n=62; P=.03); and improvement in identifying which patients with AML aged >60 years were most likely to benefit from HCT based on cytogenetic/molecular features, with the percentage of correct responses increasing from 66% to 81% (n=62; P=.07). Conclusions: The webinars met the educational needs of learners and improved knowledge gaps. This study provided novel insights into the learning needs of clinicians who care for patients with AML and a roadmap for future educational interventions.

Allogeneic hematopoietic cell transplantation (alloHCT) is a highly specialized procedure. We surveyed adult transplant centers in the United States (US) and then used data reported to the Center for International Blood and Marrow Transplant Research (CIBMTR) (2008–2010) to evaluate associations of center volume, infrastructure, and care delivery models with survival post alloHCT. Based on their 2010 alloHCT volume, centers were categorized as low-volume (≤40 alloHCTs; N = 42 centers, 1900 recipients) or high-volume (>40 alloHCTs; N = 41 centers, 9637 recipients). 100-day survival was 86% (95% CI, 85–87%) in high-volume compared with 83% (95% CI, 81–85%) in low-volume centers (difference 3%; P

Although organizations such as Centers for Disease Control and Prevention and American Academy of Pediatrics have published guidelines favoring the resumption of in-person schooling during the coronavirus disease 19 (COVID-19) pandemic, there is no specific guidance on hematopoietic cell transplantation (HCT) recipients' safe return to school. We conducted a cross-sectional survey of pediatric HCT physician members of the Pediatric Transplantation and Cellular Therapy Consortium practicing in the United States to describe current return-to-school practices during the COVID-19 pandemic for HCT recipients. A total of 122 respondents (response rate, 30.6%) from 60 transplant centers in 32 US states completed the survey. Most of the respondents (76%) recommended that HCT recipients consider a remote or hybrid school option at this time if possible. If not possible, the respondents recommended a return to in-person school if the patient is at least 12 months post-transplantation or off immune suppression, while taking school safety measures and local COVID-19 cases into account. These results provide valuable guidance for the HCT community, patients, and caregivers on important topics to consider while making return-to-school decisions.

Compared with privately insured patients, recipients of Medicaid have been reported to have worse outcomes in several clinical conditions and following various surgical and medical procedures. However, the relationship between health insurance status and allogeneic hematopoietic cell transplantation (alloHCT) outcomes among patients with sickle cell disease (SCD) is not well described. We sought to compare alloHCT outcomes between patients with SCD who underwent alloHCT while enrolled on Medicaid versus those who underwent alloHCT while covered by private health insurance. We conducted a retrospective multicenter study using data reported to the Center for International Blood and Marrow Transplant Research. US patients enrolled on Medicaid or private insurance who underwent a first alloHCT for SCD between 2008 and 2018 were eligible for this study. The primary outcome was event-free survival (EFS), defined as time to death or graft failure. Secondary outcomes included overall survival (OS), graft failure, acute graft-versus-host disease (GVHD), and chronic GVHD. Univariate analysis was performed using the Kaplan-Meier method for EFS and OS. The proportion of patients with graft failure, acute GVHD, and/or chronic GVHD was calculated using the cumulative incidence estimator to accommodate competing risks (ie, death). Cox regression was used to identify factors associated with EFS, OS, graft failure, and acute and chronic GVHD. A total of 399 patients (Medicaid, n = 225; private insurance, n = 174) were included in this study. The median duration of follow-up was 34 months (range, 1.0 to 134.7 months) for the Medicaid group and 38.7 months (range, 0.3 to 139.3 months) for the private insurance group. Compared with the patients with private insurance, those on Medicaid had a significantly lower 3-year EFS (75.4% [95% confidence interval (CI), 69.4% to 81%] versus 82.2% [95% CI, 76.9% to 87.8%]; P = .0279) and a significantly higher 3-year cumulative incidence of graft failure (17.2% [95% CI, 12.5% to 22.5%] versus 10.5% [95% CI, 6.4% to 15.4%]; P = .0372). There were no significant between-group differences in 3-year OS (P = .6337) or in the cumulative incidence of acute GVHD (P = .4556) or chronic GVHD (P = .6878). Cox regression analysis after adjusting for other significant variables showed that the patients enrolled on Medicaid had a lower EFS (hazard ratio [HR], 2.36; 95% CI, 1.44 to 3.85; P = .0006) and a higher cumulative incidence of graft failure (HR, 2.57; 95% CI, 1.43 to 4.60; P = .0015), with no significant between-group differences in OS (HR, 0.99; 95% CI, 0.47 to 2.07; P = .9765), acute GVHD (HR, 0.94; 95% CI, 0.59 to 1.49; P = .7905), or cGVHD (HR, 0.98; 95% CI, 0.65 to 1.48; P = .9331). That EFS is worse in patients on Medicaid compared with privately insured individuals following alloHCT for SCD provides the rationale for research to better understand the mechanisms by which insurance status impacts alloHCT outcomes among patients with SCD.

Allogeneic hematopoietic cell transplantation (HCT) is a standard therapy for patients with intermediate to high-risk acute myeloid leukemia (AML) and is associated with improved long-term disease-free survival. Disparity exists in access to HCT among different patient populations and requires further study. In this study, we compared HCT rates for AML among different regions in the state of Virginia and identified geographic and socioeconomic factors associated with the likelihood of receiving HCT. We conducted a retrospective, cohort study of patients 18 to 74 years of age diagnosed with AML in Virginia from 2013 to 2017 as reported to the Virginia Cancer Registry (VCR); the VCR was further linked with the Center for International Blood and Marrow Transplant Research database for identification of patients who had undergone HCT within 2 years of diagnosis. Socioeconomic data were generated from the VCR and the American Community Survey. Univariate and multivariable logistic regression models were used to examine selected socioeconomic factors of interest, including patient-level information such as sex, age, race, marital status, and primary insurance payer, as well as factors associated with geography, including the Social Vulnerability Index (SVI) and percentage of African Americans residing in the region. In Virginia, 818 patients were diagnosed with AML from 2013 to 2017, and, of these, 168 patients (21%) underwent HCT within 2 years of diagnosis. Median age was lower in the HCT cohort (55 years) versus the non-HCT cohort (64 years) (P.001). There was a higher proportion of married patients in the HCT cohort (67%) versus the non-HCT cohort (53%) (P = .005). The rate of HCT varied by geographic region (P = .004). The multivariable analyses (without including SVI) showed decreased likelihood of HCT with increasing age (odds ratio [OR], .96; 95% confidence interval [CI], .95 to .98). Patients from regions that had a greater than 25% African American population were less likely to undergo HCT (OR, .58; 95% CI, .38 to .89). Patients who were not married were less likely to undergo HCT compared with married patients (OR, .56; 95% CI, .36 to .88). Patients with government-sponsored insurance as the primary payer were less likely to undergo HCT compared with patients with private insurance (OR, .49; 95% CI, .32 to .77). Patients living in Zip Code areas with a greater percentage of population with a bachelor's or graduate degree were more likely to undergo HCT (OR, 1.02; 95% CI, 1.00 to 1.03). In a separate multivariate model with SVI, patients residing in a Zip Code with higher SVI were less likely to undergo HCT (OR, .37; 95% CI, .16 to .82). From 2013 to 2017, we found that the likelihood of a patient undergoing HCT in Virginia for AML within 2 years of diagnosis was negatively associated with increasing age, percent of African Americans residing in the region, not-married relationship status, government-sponsored insurance as primary payer, higher SVI, and decreased percent of population with a bachelor's or graduate degree. Resources should be directed toward at-risk patient populations to remove barriers to improve access to HCT. The SVI can be used to identify communities at risk nationwide.

Hematopoietic cell transplantation (HCT) is a complex and potentially life-threatening treatment option for patients with hematologic malignant and non-malignant diseases. Advances have made HCT a potentially curative treatment option for patients 65 years of age and older (older patients), and patient education resources should be adapted to meet their needs. To better understand the information needs of older patients and their caregivers for HCT treatment decision-making, the National Marrow Donor Program® (NMDP)/Be The Match® conducted a qualitative comprehensive needs assessment. Focus groups, offered in person or by phone, were conducted with older HCT patients and primary caregivers of older HCT patients at three transplant centers in the USA that were selected based on the number of older adults treated and geographic diversity. The one-hour, semi-structured discussions were recorded and transcribed verbatim. The analysis was performed with the NVivo 10 software for identification of conceptual themes. Five telephone and six in person focus groups of patients (n = 35) and caregivers (n = 10) were conducted. Themes that emerged included the following: (1) the need for tailored resources with age-specific recovery expectations; (2) the need for the right amount of information at the right times; and (3) the benefit of peer support. Effective patient education supports learning and treatment decision-making. As HCT increasingly becomes a treatment option for older patients, tailored educational resources are needed. These focus group results can inform and guide the development of new educational resources for older adults with hematologic diseases considering and planning for HCT.

The primary objective of this study was to predict healthcare cost trajectories for patients with newly diagnosed acute myeloid leukemia (AML) receiving allogeneic hematopoietic cell transplantation (alloHCT), as a function of days since chemotherapy initiation, days relative to alloHCT, and days before death or last date of insurance eligibility (LDE). An exploratory objective examined patients with AML receiving chemotherapy only. We used Optum’s de-identified Clinformatics® Data Mart Database to construct cumulative cost trajectories from chemotherapy initiation to death or LDE (through 31 December 2014) for US patients aged 20–74 years diagnosed between 1 March 2004 and 31 December 2013 (n = 187 alloHCT; n = 253 chemotherapy only). We used generalized additive modeling (GAM) to predict expected trajectories and bootstrapped confidence intervals (CIs) at user-specified intervals conditional on dates of alloHCT and death or LDE relative to chemotherapy initiation. Expected costs (in 2017 values) for a hypothetical patient receiving alloHCT 60 days after chemotherapy initiation and followed for 5 years were $US572,000 (95% CI 517,000–633,000); $US119,000 (95% CI 51,000–192,000); $US102,000 (95% CI 0–285,000); $US79,000 (95% CI 0–233,000), for years 1–4, respectively, and either $US494,000 (95% CI 212,000–799,000) or $US108,000 (95% CI 0–230,000) in year 5, whether the patient died or was lost to follow-up on day 1825, respectively. Rates of cost accrual varied over time since chemotherapy initiation, with accelerations around the time of alloHCT and death. GAM is a potentially useful approach for imputing longitudinal costs relative to treatment initiation and one or more intercurrent, clinical, or terminal events in randomized controlled trials or registries with unrecorded costs or for dynamic decision–analytic models.

BACKGROUND: Barriers and facilitators to adoption of results of clinical trials are substantial and poorly understood. We sought to examine whether the results of the randomized, multicenter Blood and Marrow Transplant Clinical Trials Network (BMT CTN) 0201 study comparing peripheral blood (PB) with bone marrow (BM) stem cells for unrelated donor (URD) hematopoietic cell transplantation (HCT) changed practice from PB to BM graft utilization, and explored factors that impact graft selection and translation of research results into practice. METHODS: Difference between utilization of URD BM and PB in the two years before and after publication of results in 2012 was examined using observational data collected by the Center for Blood and Marrow Transplant Research (CIBMTR). A web-based survey of transplant physicians was conducted to understand the change in physician-reported personal and center preferred URD graft. FINDINGS: No significant change in utilization of BM versus PB grafts occurred after 2012. Both BMT CTN participating and non-participating centers continued to use PB. 92% respondents were aware of the study results; 18% reported a change in personal and 16% reported a change in their center’s practice of requesting BM instead of PB for URD HCT. Patient characteristics and the perception that engaging local champions to increase the evidence uptake were factors associated with personal or center change in practice. INTERPRETATION: Despite awareness of the trial results, fewer than a fifth of HCT physicians reported practice change in response to the BMT CTN 0201 results. Observational data confirmed no discernible change in practice.

BACKGROUND Despite its established benefits, palliative care (PC) is rarely utilized for hematopoietic stem cell transplant (HSCT) patients. We sought to examine transplant physicians' perceptions of PC. METHODS We conducted a cross-sectional survey of transplant physicians recruited from the American-Society-for-Blood-and-Marrow-Transplantation. Using a 28-item questionnaire adapted from prior studies, we examined physicians' access to PC services, and perceptions of PC. We computed a composite score of physicians' attitudes about PC (mean = 16.9, SD = 3.37) and explored predictors of attitudes using a linear mixed model. RESULTS 277/1005 (28%) of eligible physicians completed the questionnaire. The majority (76%) stated that they trust PC clinicians to care for their patients, but 40% felt that PC clinicians do not have enough understanding to counsel HSCT patients about their treatments. Most endorsed that when patients hear the term PC, they feel scared (82%) and anxious (76%). Nearly half (46%) reported that the service name 'palliative care' is a barrier to utilization. Female sex (β = 0.85, P = .024), having

Blood or marrow transplant (BMT) is a potentially curative treatment for numerous cancers and non-malignant disorders. BMT is a resource-intense treatment process, requiring patients to comprehend difficult health information and navigate a complex healthcare system. Linguistic and cultural barriers create additional challenges for patients with limited English proficiency (LEP) who may need translated information and interpretive services to make an informed decision about treatment. To identify information needs and gaps in language services for BMT patients with LEP, the National Marrow Donor Program® (NMDP)/Be The Match® administered a cross-sectional, web-based survey to 139 transplant centers (TCs) across the United States (U.S.). The survey yielded a 59% response rate. Findings show a significant need for translated patient education materials, especially in Spanish, Chinese, and Arabic, and practice gaps in the use of appropriate interpreters. Nearly one third of respondents indicated using family and friends to interpret for patients. The inability to locate educational resources in a specific language, lack of available bilingual staff, lack of a formal, centralized tracking system, and outdated tracking systems also pose significant barriers to meeting the language needs of BMT patients with LEP.

The importance of patient-reported outcomes (PROs) in cellular therapies, including hematopoietic cell transplantation (HCT) is highlighted in this study. Longitudinal collection of PROs in a registry is recommended for several reasons, yet to date, PROs are not routinely collected from HCT patients to augment clinical registry data. The aim of this study was to determine the feasibility of electronic PRO data collection by a national clinical outcomes registry, by assessing differences between who does and does not report PROs. We conducted a cross-sectional pilot collection of PROs from HCT recipients after treatment using computer-adapted tests from the Patient-Reported Outcome Measurement Information System (PROMIS). We implemented centralized data collection through the Center for International Blood and Marrow Transplant Research (CIBMTR) among patients who underwent HCT for myelodysplastic syndromes (MDS), were at least 6 months post-HCT, and spoke English or Spanish. The main objective was identifying patient, disease, and transplant-related differences associated with completion of electronic PROs. Patients were excluded from analysis if they were determined to be ineligible (deceased, did not speak English or Spanish, refused to be contacted by the CIBMTR). A total of 163 patients were contacted and potentially eligible to participate; of these, 92 (56%) enrolled and 89 (55%) completed the PRO assessment. The most frequent reason for incomplete surveys was inability to contact patients (n = 88), followed by declining to participate in the study (n = 37). There were no sociodemographic or age differences between those who completed the PRO survey (n = 89) and eligible nonresponders (n = 155). Patient scores were within 3 points of the US average of 50 for all symptoms and areas of function except physical functioning. Responders and nonresponders did not exhibit meaningfully different sociodemographic characteristics. Difficulty contacting patients posed the greatest barrier and also provided the greatest opportunity for improvement. Once enrolled, survey completion was high. These results support standardizing centralized PRO data collection through the CIBMTR registry.

Introduction: Allogeneic hematopoietic cell transplantation (alloHCT) is the only potentially curative treatment available for acute myelogenous leukemia (AML). It is a medically complicated and resource intensive procedure for which there are patient-, provider- and system-related factors that may impact its utilization. While Medicare coverage for alloHCT may help address a major financial barrier to access, there is still an unmet need due to other factors. This study intended to examine trends and factors associated with utilization of alloHCT and to estimate unmet need for alloHCT among Medicare beneficiaries with AML. Methods: This retrospective cohort study included all patients with a diagnosis of AML identified in the Medicare claims data from 2010 through 2016. Primary patient selection criteria included: primary or secondary diagnosis of AML, age limit (65-74), and continuous enrollment (for at least 180 days after AML diagnosis in Part A and Part B fee-for-service programs). To study trends in utilization, the transplant rates were calculated as the number of patients who received an alloHCT within 180 days and one year of diagnosis (numerator) divided by the total number of patients diagnosed with AML within each diagnosis year (denominator). Transplant rates within one year of diagnosis were further adjusted by patient characteristics, including age group, sex, race, residential region, and Elixhauser Comorbidity Index (ECI). A multivariable logistic regression was utilized to identify factors associated with the likelihood of receiving alloHCT within one year of diagnosis. Two approaches were applied to estimate unmet need for alloHCT. The first approach (Approach 1) used claims data to identify the potential need for alloHCT among patients who achieved complete remission for at least 90 days; patients who achieved 90-day remission but did not receive alloHCT at any time point were considered to have unmet need. In the second approach (Approach 2), the total number of patients diagnosed with AML in the claims data was run through the National Marrow Donor Program (NMDP) methodology , which takes estimates of risk level, response to treatment, comorbidity, and early mortality into consideration. Overall estimated need and unmet need from 2010-2015 and over different time periods were evaluated for both approaches. Results: Among the 5,974 patients diagnosed with AML from March 1, 2010 through June 30 th, 2016, 1226 patients (21%) received an alloHCT by the end of 2016. Trend analysis results suggest that utilization of alloHCT increased from 2010 to 2016 (P < 0.0001) (Figure 1). The likelihood of receiving alloHCT within one year of diagnosis was found to be associated with diagnosis year, age, race, geographic region, ECI, and population-level median household income (Table 1). Both approaches estimated that approximately 36% of the diagnosed patients were in need of alloHCT between 2010 and 2015. The overall unmet need was estimated as 59% and 43% based on the claims data approach and the NMDP methodology, respectively. Despite the differences in estimated unmet need between the two approaches, the unmet need for alloHCT was found to trend down over time (Figures 2 & 3). Discussion and Conclusions: Medicare coverage facilitates access to the health care system and receipt of health services when a need for treatment or care is recognized. Utilization of alloHCT has increased over time among Medicare beneficiaries with AML. However, there are persistent differences in utilization of alloHCT by age, race, geographic region, comorbidity, and socioeconomic status, indicating disparities in access to alloHCT among this population. The results of estimated need and unmet need for alloHCT may be affected by the lack of cytogenetics and molecular information in administrative claims. To minimize this limitation, we used NMDP methodology for validation and found a similar estimation of potential need for alloHCT and downward trend in unmet need. Although the unmet need for alloHCT for AML has improved over time, policy efforts, research, and continued education are needed to close the gap between the actual utilization of alloHCT and unmet need for this potentially curative treatment. Figure 1 Figure 1. Disclosures Saber: Govt. COI: Other.

Background: Acute myeloid leukemia (AML) requires timely access to treatment for best patient outcomes. Despite available treatment options, including chemotherapy or allogeneic hematopoietic cell transplantation (alloHCT), some older patients do not receive any active therapy, particularly those aged 65-74. Although previous studies have analyzed costs and resource use associated with AML, little is known about the use of specific services by treatment approach, like HLA typing, palliative or hospice care, clinical trial participation, or cancellation of alloHCT within the first year of AML diagnosis. This study aimed to identify and analyze service utilization of specified services for patients age 65-74 diagnosed with AML on Medicare, by treatment approach (chemotherapy alone [chemo], chemotherapy and alloHCT [alloHCT], and no chemotherapy or alloHCT [no chemo]). Methods: Administrative claims data from the Center for Medicare and Medicaid Services (CMS) from 2010 to 2016 were used for analysis. Patients aged 65-74 diagnosed with AML between 2010 and 2015 and enrolled in fee-for-service (Part A and B) Medicare for at least one year after diagnosis or until death, were included. Chemo, alloHCT and specified services (HLA typing, palliative or hospice care, and clinical trial participation) or HCT cancellation were identified using diagnosis and procedure codes; at least one claim for the specified service had to be present in the first year after diagnosis. Overall survival (OS) within one year of diagnosis by treatment approach was calculated using Kaplan-Meier survival curves. Results: A total of 5533 patients met eligibility criteria: 783 (14.1%) received alloHCT; 4117 (74.4%) received chemo; and 633 (11.4%) received no chemo within the first year of diagnosis. Patients in all treatment groups had an HLA-typing claim: 48.7% in the alloHCT cohort, 5.9% in the chemo alone cohort, and Conclusions: This study used a population-based approach to identify specific service utilization by treatment approach. Due to the fast progression of AML, timely receipt of treatment and services is critical. Patients in all three treatment groups had claims for HLA typing, palliative or hospice care, HCT cancellation, and clinical trial participation. Palliative or hospice care occurred most frequently in the no chemo cohort and occurred more closely to diagnosis, compared to the alloHCT and chemo cohorts. Clinical trial participation occurred most commonly in the alloHCT cohort, though occurred sooner in the chemo cohort. Claims data is collected for billing rather than research and has some inherent limitations; treatment approach was defined using the presence of codes in the data, not on disease severity and cytogenetics, which is not available in the claims data. Specified service utilization might be underestimated due to missing information or coding errors. Additionally, the potential for bundling of services in claims may limit the ability to identify specific services and may undercount these services, illustrated by the fact that less than 50% of the alloHCT group had a claim for HLA typing. Despite these limitations, claims data is an important source of resource and service utilization. Further analysis will be done to study referral patterns upon diagnosis, to determine predictors of service utilization and timing of care and to expand the timeframe of observation beyond one-year. Study results will be used to help inform strategies to improve timely access to services and treatment to help improve care, and ultimately outcomes, for patients diagnosed with AML. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Background: Palliative care (PC) benefits patients with cancer and those undergoing hematopoietic stem cell transplantation (HSCT), but remains under-utilized in HSCT. While transplant physicians have substantial concerns regarding how patients perceive PC, studies examining HSCT recipients' perceptions of PC are lacking. Methods: Between 11/2020-4/2021, the CIBMTR Survey Research Group conducted a multi-site cross-sectional survey of adult autologous and allogeneic HSCT recipients at 11 transplant centers in the United States who were 3-12 months post-transplant to assess their experience, knowledge, and perceptions of PC. Using validated questionnaires, we assessed patients' familiarity with PC, knowledge and perception of PC, unmet PC needs, quality of life, and symptom burden. We computed a composite score of patients' perceptions of PC (mean = 48.8, SD = 12.2). We used a generalized linear regression model to examine factors associated with patients' perceptions of PC. Results: Of 359 potentially eligible patients, 250 (69.6%) enrolled in the study and 249 were eligible for analysis. Median participant age was 58.1 years (IQR 16.6). Most were white (85.9%), non-Hispanic or Latino (95.2%), and male (53.0%). Overall, 63.1% underwent autologous HSCT. The most common diagnoses were multiple myeloma (42.2%), lymphoma (22.1%), leukemia (16.9%), and MDS/MPN (12.4%). Overall, 44.2% (110/249) of patients reported limited knowledge about PC and 51.0% (127/249) endorsed being familiar with PC. Most patients stated that when they hear the term PC, they feel hopeful (54%), and reassured (50%) while a minority reported feeling scared (21%), stressed (22%), or depressed (15%) [Figure 1]. Most endorsed that when a PC referral is suggested for them, they think their doctor really cares about what is happening to them (83%), and only 7% of patients stated that when a PC referral is suggested, they think their doctor has given up on them [Figure 2]. In multivariate analyses, patients who were more knowledgeable about PC were more likely to have a positive perception of PC (B = 7.54, SE=1.61, P < 0.001) compared to those who had less knowledge about PC. Patients with postgraduate education were more likely to have a negative perception of PC (B = -5.55, SE=2.60, P = 0.034) compared to those with high school education or less. Patients' demographics, HSCT type, diagnosis, unmet PC needs, quality of life, and symptom burden were not statistically significantly associated with their perceptions of PC. Conclusions: A substantial proportion of HSCT recipients report limited knowledge and familiarity with PC. Most patients reported positive perceptions of PC, and those who were more knowledgeable about PC were more likely to have positive perceptions of PC. These data do not support transplant physicians' concerns about how patients perceive PC and underscore the need for future interventions to further educate patients about PC to overcome barriers to PC utilization in HSCT. Figure 1 Figure 1. Disclosures Burns: Astellas Pharma Inc.: Research Funding; Medac GmbH: Research Funding; Sanofi: Research Funding; OncoImmune: Research Funding; Fate: Research Funding; Bristol Meyers Squibb: Research Funding; PrioThera: Research Funding; Kyowa Kirin International: Research Funding. Murthy: CRISPR Therapeutics: Research Funding. LeBlanc: Amgen: Consultancy, Other: travel; Pfizer: Consultancy, Other: Advisory Board; AstraZeneca: Consultancy, Honoraria, Other: Advisory board, Research Funding; Flatiron: Consultancy, Other: Advisory board; Agios: Consultancy, Honoraria, Other: Advisory board; Travel fees, Speakers Bureau; BMS/Celgene: Consultancy, Honoraria, Other: Travel fees, Research Funding, Speakers Bureau; Daiichi-Sankyo: Consultancy, Honoraria, Other: Advisory board; AbbVie: Consultancy, Honoraria, Other: Advisory board; Travel fees, Speakers Bureau; Helsinn: Consultancy, Research Funding; Duke University: Research Funding; Jazz Pharmaceuticals: Research Funding; UpToDate: Patents & Royalties; NINR/NIH: Research Funding; CareVive: Consultancy, Other, Research Funding; Otsuka: Consultancy, Honoraria, Other; American Cancer Society: Research Funding; Seattle Genetics: Consultancy, Other: Advisory board, Research Funding; Astellas: Consultancy, Honoraria, Other: Advisory board; Heron: Consultancy, Honoraria, Other: advisory board.

Autologous hematopoietic stem cell transplantation (auto-HCT) is a complex procedure that can be performed in both inpatient (IP) and outpatient (OP) care settings. We examined reimbursement, service utilization, and patient financial responsibility among Medicare beneficiaries with multiple myeloma who underwent auto-HCT in the IP and OP settings using a merged dataset of the Center for International Blood and Marrow Transplant Research observational database and Centers for MedicareMedicaid Services Medicare administrative claims data. Selection criteria included first auto-HCT, time from diagnosis to auto-HCT18 months, and continuous enrollment in Medicare Parts A and B for 30 days before HCT index claims and 100 days post-HCT or until death. Total reimbursement and patient responsibility were adjusted for patient and disease characteristics using a weighted generalized linear model. The final cohort comprised 1640 patients, 1445 (88%) who received IP-HCT and 195 (12%) who received OP-HCT. The adjusted total mean reimbursement was higher for IP-HCT compared with OP-HCT ($82,368 [95% CI, $77,643 to $87,381] versus $46,824 [95% CI, $43,567-$50,325]; P.0001). Adjusted total mean patient responsibility was $4736 for IP-HCT (95% CI, $4731 to $5133) and $6944 for OP-HCT (95% CI, $6296 to $7658) (P.0001). Within 100 days post-HCT, 107 of the 195 OP-HCT recipients (55%) had at least 1 subsequent admission, compared with 348 of the 1445 IP-HCT recipients (24%). Reimbursement, service utilization, and financial responsibility varied by HCT setting. As the number of Medicare beneficiaries who undergo auto-HCT increases, coverage policy needs to consider how location of services leads to variations in the financial burden for both hospital systems and patients.

Background The economics of allogeneic hematopoietic cell transplantation (alloHCT) for older patients with acute myeloid leukemia (AML) affects clinical practice and public policy. To assess reimbursement, utilization, and overall survival (OS) up to 1 year post-alloHCT for Medicare beneficiaries aged 65 years or older with AML, a unique merged dataset of Medicare claims and national alloHCT registry data was analyzed. Methods Patients diagnosed with AML undergoing alloHCT from 2010 to 2011 were included for a retrospective cohort analysis with generalized linear model adjustment. One-year post-alloHCT reimbursement included Medicare, secondary payer, and beneficiary copayments (no coinsurance) (inflation adjusted to 2017 dollars). Cost-to-charge ratios were applied to estimate department-specific inpatient costs. Cox proportional hazards regression models were utilized to identify risk factors of 1-year OS post-alloHCT. Results A total of 250 patients met inclusion criteria. Mean total reimbursement was $230 815 (95% confidence interval [CI] = $214 381 to $247 249) 1 year after alloHCT. Pharmacy was the most- costly inpatient service category. Adjusted mean total reimbursement was statistically higher for patients who received cord blood grafts (P = .01), myeloablative conditioning (P Conclusions This merged dataset allowed adjustment for a richer set of patient- and HCT-related characteristics than claims data alone. The finding that nonmyeloablative conditioning was associated with lower reimbursement and improved OS 1 year post-alloHCT warrants further investigation.

Young adult (YA) survivors of allogeneic hematopoietic cell transplantation (HCT) are at risk for late psychosocial challenges, including the inability to return to work post-HCT. Work-related outcomes in this population remain understudied, however. We conducted this study to assess the post-HCT work status of survivors of allogeneic HCT who underwent HCT as YAs and to analyze the patient-, disease-, and HCT-related factors associated with their work status at 1 year post-HCT. Using Center for International Blood and Marrow Transplant Research data, we evaluated the post-HCT work status (full-time, part-time work, unemployed, or medical disability) of 1365 YA HCT survivors who underwent HCT between 2008 and 2015. Percentages of work status categories were reported at 4 time points: 6 months, 1 year, 2 years, and 3 years post-HCT. Percentages of post-HCT work status categories at the 1-year time point were also described in relation to survivors' pre-HCT work status categories. Factors associated with 1-year post-HCT work status (full-time or part-time work) were examined using logistic regression. From 6 months to 3 years post-HCT, the percentage of survivors working full-time increased from 18.3% to 50.7% and the percentage working part-time increased from 6.9% to 10.5%. Of patients in full-time work pre-HCT, 50% were unemployed or on medical disability at 1 year post-HCT. Female sex (odds ratio [OR], 0.55; 95% confidence interval [CI], 0.40 to 0.77), HCT Comorbidity Index score ≥3 (OR, 0.57; 95% CI, 0.39 to 0.82), pre-HCT unemployment (OR, 0.37; 95% CI, 0.24 to 0.56), medical disability (OR, 0.44; 95% CI, 0.28 to 0.70), development of grade III-IV acute graft-versus-host disease (OR, 0.52; 95% CI, 0.34 to 0.80), and relapse within 1 year post-HCT (OR, 0.34; 95% CI, 0.21 to 0.56) were associated with a lower likelihood of employment at 1 year post-HCT. Compared with myeloablative conditioning (MAC) with total body irradiation (TBI), MAC without TBI (OR, 1.71; 95% CI, 1.16 to 2.53) was associated with a greater likelihood of employment at 1 year post-HCT. Graduate school-level education (OR, 2.47; 95% CI, 1.49 to 4.10) was also associated with a greater likelihood of employment at 1 year post-HCT. Although the work status among YA HCT survivors continued to improve over time, a substantial subset became or remained unemployed or on medical disability. These findings underscore the need for effective interventions to support return to work in this population.

e18862 Background: Hematopoietic cell transplantation (HCT) is a medically complicated, expensive and resource intensive medical technology. High health care costs are usually associated with high Out-of-Pocket (OOP) costs. In this population-based study, using deidentified administrative claims data from OptumLabs Data Warehouse, we describe total and patient level costs for one-year pre and post HCT and describe the characteristics of those with top 25% cost. Methods: Patients who had undergone an autologous or allogeneic HCT in 2015 to 2019 and had continuous health plan coverage for one year prior and post the index date-the date of the first claim for HCT, were included. We examined total costs, patient paid (OOP) and plan paid costs for one year before and after HCT. We also examined inpatient, outpatient, and pharmacy costs for the one year before and after the HCT. Logistic regression models examined factors including age, gender, race/ ethnicity, Charlson comorbidity index, geographic region and costs in the year prior to HCT (baseline costs) for their association with high total costs and high OOP costs (top 25%). Results: A total of 3,346 patients (2,344 commercial plan (CPE) and 1,002 under Medicare Advantage plan (MAPE) enrollees) were included in the study. Median one year post HCT costs for CPE was $ 612,517 (IQR 413,348- 960,456) and for MAPE was $ 521,000 (IQR 347,388-736,685). Median one year post HCT OOP costs were $ 5,407 (IQR 1,584 -10,000) in CPE and $7,199 (IQR 3,485 -16,396) in MAPE group. 625 subjects in the CPE and 253 subjects in MAPE group had overall costs in the top 25%. Median baseline costs were $482,107 vs. $846,943 in the low vs. high cost group in CPE and $278,656 vs. $343,633 in MAPE. There was a low correlation between OOP costs and overall costs (r = 0.17 for CPE and 0.15 for MAPE; p < 0.05). Younger age (OR for age 0.98; p < 0.001) and higher baseline costs (OR1.89; p < 0.001) predicted top 25% total costs post HCT in the CPE group. Not being African American (OR for African American 0.5; p = 0.02) and higher baseline costs (OR 1.07; p < 0.001) predicted top 25% total costs post HCT in MAPE group. Age (OR 0.97; p < 0.001), not being African American (OR 0.5; p = 0.001) and high baseline costs (OR 1.44; p < 0.001) also predicted higher OOP costs in the CPE group. The only factor that was associated with lower likelihood of OOP costs in top 25% in MAPE group was being Hispanic (OR 0.6; p = 0.004). Conclusions: HCT is an expensive treatment modality. High costs prior to HCT are associated with high post HCT costs both for patients on commercial and Medicare Advantage plan. The magnitude of correlation between patient level and total costs was low, likely due to differences in benefit plan. A careful assessment of benefits and costs of HCT is needed for providing high-value care and allow optimum allocation of the finite resources while minimizing patient level financial burden.

Health literacy is an important construct in health care that affects patient outcomes and overall health. The impact of limited health literacy in cancer care is wide, and it can affect patients' ability to make treatment decisions, follow directions on a prescription label, or adhere to neutropenic precautions. This article describes strategies and tools for nurses to use when developing written patient education resources in their daily practice.

Hematopoietic cell transplantation (HCT) is a treatment for hematologic malignancies and disorders. Patients who receive HCT can face long-term physical and psychosocial effects. Survivorship care guides (care guides), which describe screening and preventive care practices were mailed to allogenic HCT recipients at clinically important timepoints (6, 12, and 24 months after HCT). The primary objective of this study was to evaluate how patients perceived and used the care guides. A cross-sectional, time-series survey was sent to all National Marrow Donor Program/Be The Match allogeneic HCT recipients from September 2012 to November 2016 after the care guides were sent; patients or caregivers could respond. Respondents who returned all 3 surveys were included (554 patients; 65 caregivers), for an overall response rate of 13% (maintenance rate of 45%). The majority of patients and caregivers strongly agreed or agreed that the care guides helped them understand that post-HCT care is important to staying healthy and that they were more familiar with recommended tests at check-up appointments. Most patients who did not share the care guides with their doctors at any of the timepoints believed their doctor knew which tests were needed. Results from this study can help inform and guide development of future tools and evaluations of educational resources for patients after HCT. Tools and educational resources, such as survivorship care guides, have the potential to help empower patients to be more knowledgeable and to understand and advocate for their survivorship care needs.

Introduction: Hematopoietic cell transplantation (HCT) is a standard therapy for patients with intermediate to high-risk acute myelogenous leukemia (AML), associated with improved long-term disease-free survival. Virginia is a diverse state, with rural and urban areas, including wealthy and disadvantaged counties. In this study, we compared HCT rates among different regions in the state of Virginia, and analyzed the impact of race/ethnicity, urban vs rural location, primary insurance payor, and socioeconomic status on access to HCT. Methods: We conducted a retrospective, cohort study of patients age 18-75 diagnosed with AML in Virginia from 2013-2017 as reported to the Virginia Cancer Registry (VCR); the VCR was further linked with the Center for International Blood and Marrow Transplant Research (CIBMTR) database for identification of patients who had undergone HCT within two years of diagnosis. Socioeconomic data were generated from the VCR and the American Community Survey (ACS). Univariate and multivariable logistic regression models were used to examine several socioeconomic factors of interest, including patient-level information such as sex, age, race, marital status, primary insurance payor, and distance to closest transplant center as well as factors associated with geography, including specific regions (see Figure 1) and percentage of African Americans residing in the region (see Figure 2). Results: There were 818 patients diagnosed with AML in Virginia from 2013-2017, and of these, 168 (21%) underwent HCT within two years of diagnosis. Median age was lower in the HCT cohort vs. the non-HCT cohort, 55 vs. 64 (p= Conclusion: From 2013-2017, only 21% of patients with AML in Virginia underwent HCT within two years of diagnosis. We found that the likelihood of undergoing HCT is associated with age, percent of African Americans residing in the region, marital status, primary insurance payor, and percent of population with a bachelor or graduate degree. Our findings suggest geographic and socioeconomic factors are likely barriers to access to HCT. The decreased rate of HCT in regions with a higher percent of African-Americans may reflect structural racism, both due to factors outside and within the medical community. Resources should be devoted to specific interventions addressing disadvantaged populations, including early human leukocyte antigen (HLA) typing, caregiving resources, increased diversity of donor pool, and improved insurance coverage. Future studies will evaluate access to HCT after referral to HCT centers as well as racial disparity in access to HCT across the United States. Disclosures Balkrishnan: Merck and Co.: Consultancy. Devine:Magenta Therapeutics: Consultancy.

Hematopoietic cell transplantation (HCT) is a complex and potentially life-threatening treatment option for patients with hematologic malignant and non-malignant diseases. Advances have made HCT a potentially curative treatment option for patients 65 years of age and older (older patients), and patient education resources should be adapted to meet their needs. To better understand the information needs of older patients and their caregivers for HCT treatment decision-making, the National Marrow Donor Program® (NMDP)/Be The Match® conducted a qualitative comprehensive needs assessment. Focus groups, offered in person or by phone, were conducted with older HCT patients and primary caregivers of older HCT patients at three transplant centers in the USA that were selected based on the number of older adults treated and geographic diversity. The one-hour, semi-structured discussions were recorded and transcribed verbatim. The analysis was performed with the NVivo 10 software for identification of conceptual themes. Five telephone and six in person focus groups of patients (n = 35) and caregivers (n = 10) were conducted. Themes that emerged included the following: (1) the need for tailored resources with age-specific recovery expectations; (2) the need for the right amount of information at the right times; and (3) the benefit of peer support. Effective patient education supports learning and treatment decision-making. As HCT increasingly becomes a treatment option for older patients, tailored educational resources are needed. These focus group results can inform and guide the development of new educational resources for older adults with hematologic diseases considering and planning for HCT.

Hematopoietic cell transplantation (HCT) often involves a long hospitalization and recovery period, with patients generally required to have a caregiver. This study aimed to identify transplant center (TC) requirements for a caregiver, describe challenges that impact caregiver availability, and identify potential solutions. An exploratory sequential mixed-methods approach was used. Qualitative data was obtained from focus groups of TC social workers in the United States (US) (three focus groups; n = 15 total participants). Results informed the development of a national, web-based survey that was administered to the primary social worker contact at TCs in the National Marrow Donor Program (NMDP)/Be The Match Network (n = 133). Respondents included social workers from adult (n = 47) and pediatric (n = 19) TCs (response rate = 49%). The majority (89%) of both adult and pediatric TCs required a caregiver for a patient to proceed to transplant, but requirements varied in length of time, formality, transplant type, and HCT setting. Regardless of transplant type or patient population, social workers identified loss of caregiver income as the greatest challenge to caregiver availability, with the most common solution being allowing patients to have multiple caregivers throughout the transplant course. Caregiver availability is an important concern for patients considering and receiving HCT, and may be a barrier proceeding to HCT when a caregiver is unavailable. Results from this study highlight caregiver availability barriers and solutions of TCs across the US. These results can inform TCs about other center experiences with caregiver availability and identify potential practice changes for individual TCs.

Hematopoietic cell transplantation (HCT) is a complex procedure that requires availability of adequate infrastructure, personnel, and resources at transplantation centers. We conducted a national survey of transplantation centers in the United States to obtain data on their personnel, infrastructure, and care delivery models. A 42-item web-based survey was administered to medical directors of transplantation centers in the United States that reported any allogeneic HCT to the Center for International Blood and Marrow Transplant Research in 2011. The response rate for the survey was 79% for adult programs (85 of 108 centers) and 82% for pediatric programs (54 of 66 centers). For describing results, we categorized centers into groups with similar volumes based on 2010 total HCT activity (adult centers, 9 categories; pediatric centers, 6 categories). We observed considerable variation in available resources, infrastructure, personnel, and care delivery models among adult and pediatric transplantation centers. Characteristics varied substantially among centers with comparable transplantation volumes. Transplantation centers may find these data helpful in assessing their present capacity and use them to evaluate potential resource needs for personnel, infrastructure, and care delivery and in planning for growth.

A projected shortage of hematopoietic cell transplantation (HCT) health professionals was identified as a major issue during the National Marrow Donor Program/Be The Match System Capacity Initiative. Work-related distress and work–life balance were noted to be potential barriers to recruitment/retention. This study examined these barriers and their association with career satisfaction across HCT disciplines. A cross-sectional, 90-item, web-based survey was administered to advanced practice providers, nurses, physicians, pharmacists, and social workers in 2015. Participants were recruited from membership lists of 6 professional groups. Burnout (measured with the Maslach Burnout Inventory subscales of emotional exhaustion and depersonalization) and moral distress (measured by Moral Distress Scale—Revised) were examined to identify work-related distress. Additional questions addressed demographics, work–life balance, and career satisfaction. Of 5759 HCT providers who received an individualized invitation to participate, 914 (16%) responded; 627 additional participants responded to an open link survey. Significant differences in demographic and practice characteristics existed across disciplines (P < .05). The prevalence of burnout differed across disciplines (P < .05) with an overall prevalence of 40%. Over one-half of pharmacists had burnout, whereas social workers had the lowest prevalence at less than one-third. Moral distress scores ranged from 0 to 336 and varied by discipline (P < .05); pharmacists had the highest mean score (62.9 ± 34.8) and social workers the lowest (42.7 ± 24.4). In multivariate and univariate analyses, variables contributing to burnout varied by discipline; however, moral distress was a significant contributing factor for all providers. Those with burnout were more likely to report inadequate work–life balance and a low level of career satisfaction; however, overall there was a high level of career satisfaction across disciplines. Burnout, moral distress, and inadequate work–life balance existed at a variable rate in all HCT disciplines, yet career satisfaction was high. These results suggest specific areas to address in the work environment for HCT health professionals, especially the need for relief of moral distress and a greater degree of personal time. As the creation of healthy work environments is increasingly emphasized to improve quality care and decrease costs, these findings should be used by HCT leadership to develop interventions that mitigate work-related distress and in turn foster recruitment and retention of HCT providers.

Background While HCT provides the best chance for cure for eligible patients with AML, barriers limit the number able to receive HCT. Virginia (VA) has some of the wealthiest and poorest counties in the country. We hypothesize that there are geographic variations in the rate and estimated unmet need of HCT for patients with AML in VA. Understanding geographic differences may help improve access to HCT. Methods All patients aged 20-74 years diagnosed with AML in 2013-2015 were identified by the VA Department of Health and classified by residence into 8 regions: Southwest, Southside, Valley, Central, Northern, Richmond, Eastern, and Hampton Roads. Socioeconomic (SES) factors including sex, age, race, marital status, education, employment, income, and health insurance were examined by region. Number of patients receiving first HCT by region were obtained from CIBMTR data. Unmet need was calculated by estimating the number of potential patients for HCT and subtracting the actual number of HCTs (Besse et al., 2015). Results 690 patients were diagnosed with AML in VA between 2013 and 2015; 153 first HCTs were reported to CIBMTR during the same time period. The rate of HCT and unmet need varied among the different geographic regions (Figure 1). The only SES factor that correlated with HCT rate was race/ethnicity (P=0.0334). The Southside, which had a higher percentage of non-Hispanic Black or African American population (31%), had a lower HCT rate (8%) compared to the Northern region, which had a Black or African American population of 12%, but a HCT rate of 29% (Figure 2). The Northern region had the highest median income ($105,000) and one of the highest rates of proceeding to HCT (29%) (Figure 3). In contrast, the Southside, which had the lowest median income ($40,000), had only 8% of patients proceeding to HCT and an estimated unmet need of 88%. Private vs public insurance, marital status, education, and gender did not correlate with HCT rates. Conclusions There are geographic differences in rates of HCT for patients with AML in VA. Regions with a higher non-Hispanic Black or African American population had lower rates of receiving HCT. Further study is needed to determine if the decreased rates in regions with a higher non-Hispanic Black or African American population are related to donor availability or SES barriers. Future steps to eliminate these SES barriers will be vital to increase the access of patients receiving a potentially curative HCT in VA.

Background CIBMTR previously showed that centralized PRO collection from patients treated at multiple transplant centers (TC) was feasible; however, consenting by sites and the paper mode of collection were logistically challenging. CIBMTR built an electronic system (ePRO), and we report our initial experience. Methods This was a cross-sectional study of patients ≥55 years old with MDS who underwent allogeneic transplant. Additional inclusion criteria were: ≥6 months from transplant, English/Spanish speaking, an active email address. Lists of potentially eligible patients were sent to TCs to confirm eligibility and provide contact details. All further patient contact (email/phone) was then made by the CIBMTR Survey Research Group (SRG). SRG contacted patients by phone to describe the study, then obtained consent electronically. PRO measures were delivered using computerized adaptive testing (CAT). Results TCs provided contact information on 188/273 (69%) potentially eligible patients. The biggest reason for lack of confirmation of eligibility was an inability by the TC to contact the patient (Figure 1). Of the 188, SRG contacted and confirmed eligibility in 164 (87%). 90/164 (55%) enrolled, and 80 (89%) have completed PROs. A median time of 15 minutes (IQR 11.3-20.7) was required for PRO completion. 62 patients did not enroll: 28 lost to follow-up after initial contact and 34 actively declined to participate. Reasons for declining to participate included: lack of interest in research, technology issues, health reasons and study specific concerns. SRG made fewer contact attempts for those who participated (Table 1). Conclusions We show that while the ePRO system is an efficient mechanism to consent patients and collect PRO, many patients do not reach the enrollment stage. The biggest reason for this is lack of initial or subsequent contact, which was noted at every stage (both TC and SRG). It is unknown whether this is due to passive decline by the patient, or to incorrect contact details. Additionally, relying on the TC to provide contact details (engaging TCs as IRB approved-research sites) was time-consuming and inefficient. CIBMTR has moved to central IRB study approval, and begun to collect contact details proactively, achieving a truly centralized mechanism which should allow CIBMTR to establish contact with patients early in the transplant process. Maintaining engagement through the ePRO may help to address ongoing logistic challenges.

The primary aim of this study was to describe healthcare costs and utilization during the first year after a diagnosis of acute myeloid leukemia (AML) for privately insured non-Medicare patients in the United States (US) aged 50-64 years who were treated with either chemotherapy or chemotherapy and allogeneic hematopoietic cell transplantation (alloHCT). MarketScan (Truven Health Analytics) adjudicated total payments for inpatient, outpatient and prescription drug claims from 2007-2011 were used to estimate costs from the health system perspective. Stabilized inverse propensity score weights were constructed using logistic regression to account for differential selection of alloHCT over chemotherapy. Weighted generalized linear models (GLM) adjusted costs and utilization (hospitalizations, inpatient days and outpatient visit-days) for differences in age, sex, diagnosis year, region, insurance plan type, Elixhauser Comorbidity Index (ECI) and 60-day pre-diagnosis costs. Because mortality data were not available, models could not be adjusted for survival times. Among 29,915 patients with a primary diagnosis of AML, a total of 985 patients met inclusion criteria (774 [79%] receiving chemotherapy alone and 211 [21%] alloHCT). Adjusted mean one-year costs were $280,788 for chemotherapy and $544,178 for alloHCT. Patients receiving chemotherapy alone had a mean of 4 hospitalizations, 52.9 inpatient days and 52.4 outpatient visits in the year following AML diagnosis; patients receiving alloHCT had 5 hospitalizations, 92.5 inpatient days and 74.5 outpatient visits. Treating AML in the first year after diagnosis incurs substantial health care costs and utilization with chemotherapy alone and with alloHCT. Our analysis informs health care providers, policy makers and payers so they can better understand treatment costs and utilization for privately-insured patients age 50-64 with AML.

Introduction: Inpatient services are the leading drivers of cost for autologous hematopoietic cell transplantation (HCT), and the number of Medicare beneficiaries who receive autologous HCT is increasing. Using a merged dataset of Center for International Blood and Marrow Transplant Research (CIBMTR) transplant and outcomes data and Centers for Medicare and Medicaid Services (CMS) Medicare administrative claims data, we examined reimbursement and service utilization among Medicare beneficiaries with multiple myeloma (MM) who received IP and OP autologous HCT. Methods: This was a multicenter retrospective cohort study. A total of 11,358 HCT recipients from 2010-2012 were identified in the CMS Medicare database; 9,055 (80%) were linked with CIBMTR data. Selection criteria included first HCT for MM, diagnosis-to-HCT time between 0 and 18 months, and continuous enrollment for 30 days prior to index and 100 days post-HCT or until death. For IP-HCT, the index period for reimbursement and service utilization was day of admission for HCT through discharge date. For OP-HCT, the index period was day -2 through HCT date to capture the conditioning regimen. Total IP and OP service days from 30 days prior to index and 100 days post-HCT, and subsequent admissions post the HCT index period were calculated. Total reimbursement consisted of all payments made to providers (Medicare payments for Part A & B services, secondary payer, and patient responsibility of deductibles, coinsurance, and copayments), which was adjusted by a weighted generalized linear model (GLM). Patient responsibility was assessed separately and adjusted by the same GLM. Kaplan-Meier method was used for overall survival (OS) analysis; potential factors associated with OS were adjusted by Cox regression modeling. Results: The final cohort comprised 1,640 patients; 1,445 (88%) received IP-HCT (126 centers) and 195 (12%) OP-HCT (24 centers). Patient characteristics, functional status, disease status, and HCT year were similar between groups except a higher percentage of IP-HCT recipients were 70 years and older (IP-HCT: 31%, OP-HCT: 19%; P=0.0003), and a lower percentage of IP-HCT recipients received full dose melphalan 200 mg/m2 (IP-HCT: 68%, OP-HCT: 90%; P=0.0036). There was a significant difference between the cohorts in the utilization of IP services (IP-HCT group: median 19 days, OP-HCT group: 4 days; P < 0.0001) and OP services (IP-HCT group: median 16 days, OP-HCT group: 33 days; P < 0.0001) at day 100. Adjusted total mean reimbursement for the IP-HCT group ($83,380 [95% CI: $78,958-$88,051]) was higher than the OP-HCT group ($55,721 [95% CI: $38,595-$80,446]) (P= 0.0301) (Figure). Factors associated with total reimbursement in the GLM were transplant setting, age, sex, comorbidity index, diagnosis-to-HCT time, and melphalan dose. Adjusted total patient responsibility for the IP-HCT group was $4,567 (95% CI: $4,210- $4,955) and $7,372 ($4,218- $12,884) (P=0.0902) for the OP-HCT group. Within 100 days post-HCT, 107/195 (55%) OP-HCT recipients had at least one subsequent admission, compared to 348/1,445 (24%) IP-HCT recipients (P < 0.0001). OS at 100 days was high for both HCT settings and adjusted OS was not significantly different by transplant setting (IP-HCT 98% [95% CI: 97%-99%]; OP-HCT 99% [95% CI: 98%-100%; P=0.1903) Conclusions: Reimbursement and service utilization varied by HCT setting for Medicare beneficiaries with MM. Total reimbursement for 100 days post-HCT was $27,659 higher for IP-HCT than OP-HCT, after adjusting for patient and HCT-related characteristics. After the HCT index period, approximately 1 in 4 IP-HCT recipients required re-hospitalization within 100 days, whereas 1 in 2 OP-HCT recipients required subsequent hospitalization. Many factors influence the decision between IP or OP autologous HCT, including: center experience, severity of disease, patient co-morbidities, access to caregivers, proximity of lodging, cost to the patient, and reimbursement for services to the hospital system. The CIBMTR-CMS merged database is a new resource to support ongoing efforts to inform transplant centers and healthcare systems about provision of care options in the Medicare population. Figure. Figure. Disclosures Ganguly: Janssen: Consultancy; Amgen: Consultancy; Seattle Genetics: Speakers Bureau; Daiichi Sankyo: Research Funding.

10116Background: Despite the benefits of PC for patients undergoing HCT, transplant recipients rarely utilize PC. We assessed transplant physicians’ attitudes about PC and perceived barriers to PC ...

Characteristics of patients with chronic kidney disease who survive to end-stage renal disease may change over time, affecting subsequent outcomes and costs. We examined trends in older incident hemodialysis patient characteristics and analyzed first-year post-dialysis therapy initiation medical costs.Retrospective cohort study.All US incident hemodialysis patients agedor =67 years at dialysis therapy initiation from January 1, 1995, to December 31, 2005, with Medicare Part A and Part B in the prior 2 years.Year of dialysis therapy initiation.Changes in patient characteristics and first-year costs.Mean and median values for continuous variables and percentages of categorical variables; first-year total medical costs measured per person per year. Observed costs were adjusted using Medicare Price Indices and patient case-mix.Median age at dialysis therapy initiation increased from 74.9 to 77.0 years from 1995 (n = 19,044) to 2005 (n = 31,796; P0.001). Diabetes prevalence increased from 54.2% to 64.1% (P0.001). Median estimated glomerular filtration rate increased from 8.0 to 11.2 mL/min/1.73 m(2), and median hemoglobin level increased from 9.4 to 10.2 g/dL. Obesity increased from 8.9% to 22.9% (P0.001). First-year observed costs increased by 37.9%; however, inflation-adjusted and case-mix-inflation-adjusted costs were stable. Important adjusters for costs are inability to ambulate/transfer, baseline serum albumin level, primary end-stage renal disease cause, comorbid peripheral vascular disease, and baseline hospital days.Population agedor =67 years at dialysis therapy initiation and results may not generalize to the overall hemodialysis population.From 1995 to 2005, incident hemodialysis patients agedor =67 years became older, sicker, and more obese with significantly increased estimated glomerular filtration rates and hemoglobin levels at dialysis therapy initiation. Increased first-year post-dialysis therapy initiation costs became stable over time after adjustment for price inflation; case-mix-inflation-adjusted costs remained constant, possibly because of mixed changes in patient characteristics.

Taiwan has the world's highest incidence and second highest prevalence of end-stage renal disease (ESRD), particularly in older age groups. However, the transition from chronic kidney disease (CKD) to death or ESRD remains unclear. This study aimed to investigate the impact of late-stage CKD on all-cause and cause-specific mortality by identifying the CKD population.This was an observational cohort study (n = 35 529), mean age 75.7 years (SD = 5.3), of participants in the Elderly Health Examination Program (EHEP) in Kaohsiung City, Taiwan, between 2002 and 2004. Estimated glomerular filtration rate (eGFR) was calculated by the simplified modified diet in renal disease equation. Proportional hazard ratios (HR) of mortality associated with late-stage CKD were assessed by Cox regression.The crude prevalence rate of CKD stages 3-5 was 39.4%; 1840 participants (5.18%) died within 2-year follow-up, a mortality rate of 20.3 per 1000 person-years overall and 16.4 per 1000 person-years in the reference group. Higher HR for all-cause and cause-specific mortality were found in the groups with decreased eGFR. Compared with the reference group (eGFR60 mL/min/1.73 m(2)), adjusted HR for all-cause mortality were 1.5, 2.1 and 2.6 for groups with eGFR 30-44, 15-29 and15 mL/min/ 1.73 m(2), respectively (P0.001). Higher HR of mortality due to cardiovascular or renal diseases were also significantly associated with decreased eGFR (P0.05).Late-stage CKD is a significant risk factor for mortality, especially due to cardiovascular and renal diseases, in elderly Taiwanese. Given the higher prevalence rate of late-stage CKD in the study area, CKD patient mortality was relatively lower, which might reflect underestimation of renal function for patients at early stages of CKD, or partly explain the high ESRD population.