The Cost of Dying: Charges before Day 100 Predictive of Overall Survival

'Value' is an increasingly important quality in stem cell transplant. The cost of therapy is a more recent focus in the value discussion, though is hampered by lack of data. This study reports single center data for a large volume of patients undergoing allogeneic stem cell transplant, examining the relationship between 'charges' and survival. Charges identified in this study were the inpatient charges generated from the initiation of conditioning to day 100 post-transplant or death, whichever came first. In this study charges are being used comparatively to identify relative costs – but because economic efficiency is not necessarily related to reimbursement, the total payment amounts from insurers are not considered here. Patients who underwent allogeneic SCT at OHSU January 2010 -December 2013 were included. Data included all inpatient charges except physician fees. Mann—Whitney testing was used to compare median charges in patients who lived versus died. In comparing each of the cost groupings, the individual groups were compared using the Kruskall-Wallace test for non-parametrically distributed data. Additional analysis included comparison of charges by regimen (Myeloablative (MA): targeted busulfan/Cytoxan, targeted busulfan/TBI), Reduced Intensity (RI)(Fludarabine/Melphalan) and Non-Ablative (NA) (Busulfan/Fludarabine/TBI) using 1-way ANOVA testing. 309 patients were included in the analysis, of whom 162 were alive at the time of analysis. For those who died, the median 100 day charges (with 25%ile – 75%ile range) were $283K ($186K-$490K) and for those who survived, were 206K ($165K-$202K)(p<0.001). In comparing cost by 200K increments, median survival is shortest in the highest charge groups. Patients in the lowest charge group lived the longest before dying. Statistically, the groups differed significantly among themselves (p=0.0076) though when groups were compared via a post-test, only the difference between the $0-200K group and the $400-600K groups was significant at the p<0.05 level. Median charges per day of life for those patients who died before day 100 were $3870 for NA (CI 95% $6736-11331), $8863 for RI (CI 95%: $ 6736-11331), $8174 for MA (CI 95%: $6714-11244). Increasing charges do not correlate with increasing survival. This is counter-intuitive to economic values where increasing payment is expected for a more desirable product. There are a minimal number of long term survivors in patients whose charges were greater than 600K in the first 100 days, suggesting near futility of high charge transplant maneuvers. Further study to identify the drivers of the increased charges and correlation with pre-transplant variables are underway.View Large Image Figure ViewerDownload Hi-res image Download (PPT)