An Analysis of the Costs Associated with Peripheral Blood Hematopoietic Progenitor Cell Mobilization, Collection and Cryopreservation in Patients with Lymphomas Undergoing Autologous Stem Cell Transplantation

Abstract

Peripheral blood hematopoietic progenitor cells (HPC) may be mobilized with cytokines alone or with chemotherapy followed by cytokines. The HPC yield is higher and the failure rate is lower with chemo mobilization. Although cell dose of 2 million CD34+ cells/kg is considered adequate, some authors have shown that patients who receive < 5 million CD 34+ cells/kg have higher resource utilization after transplant. The purpose of this study was to analyze the costs associated with HPC chemo mobilization in patients with lymphomas.PATIENTS AND METHODS: We analyzed 149 patients with non-Hodgkin's (N=101) and Hodgkin's (N=48) lymphomas who underwent HPC chemo mobilization at our institution between 1/03 and 12/04. The retrospective chart review was approved by the IRB. Patients who collected < 2million CD34+ cells/kg in 4 leukapheresis procedures were called failures. The estimated costs were divided into pre apheresis, apheresis, and post apheresis costs. (Source: Cleverly and Associates; www.drugstore.com; Redbook™; Thompson PDR)RESULTS: A total of 133 patients underwent chemo mobilization. Chemotherapy regimen was ifosfamide, etoposide, G-CSF, +/− rituximab in 98 (74%) patients. The average inpatient stay for chemotherapy administration was 6 days (range, 3–28). Twenty-four patients required readmission for complications of chemotherapy (22/24 for fever/infections) for a median of 5 days (range, 1–12). Patients received G-CSF for a median of 14 days (range, 6–34). All patients received IV hydration while in the hospital and were discharged on prophylactic oral antibiotics. Average number of days on oral antibiotics was 9 (range, 0–16). For successful mobilizers, the median number of apheresis procedures required to reach target HPC dose of 5 million CD34+ cells/kg was 2 (range, 1–7). Thirty patients (out of 149) failed to collect adequate HPC on the first attempt. Of those 12 patients underwent a BM harvest ($2389/harvest), 4 were remobilized with chemotherapy (1 mobilized successfully), 4 patients underwent an allogeneic transplant ($250,000–500,000/transplant) and 3 patients underwent an autologous transplant with suboptimal cell dose (all had prolonged time to engraftment and 1 patient needed an allogeneic transplant for graft failure). Average pre apheresis costs per patient were $1800 (clinic visit, laboratory evaluation, central venous catheter insertion, and chest x-ray to check placement). The average costs of chemotherapy administration, hospitalization, prophylactic antibiotics and G-CSF were $ 29181 (not including rituximab). This is an underestimation as it does not include the costs associated with supportive care, intravenous fluids, readmission etc. The post apheresis costs were $ 2493. These costs do not account for professional fees.CONCLUSIONS: Although in this present analysis we may have underestimated the actual costs associated with HPC mobilization, the costs are still considerable. Accordingly, the financial implication for transplant centers where reimbursement is DRG (diagnosis related group) or case rate based is significant. Interventions or newer agents that can reduce the failure rate or reduce the number of apheresis procedures required to reach a target HPC dose without increasing the toxicity may reduce the costs associated with transplant especially in patients who do not require chemotherapy for treatment of their primary disease.National Hospital Average Cost in $ $N Median (range)Estimated Total Costs per in $APHERSISChemotherapy AdministrationDaily Room Charge863.006 (3–28)5178* Ifosfamide 3.33 g/m2/d × 3 d372.87/gram19.38 g7227Etoposide 150mg/m2 × 6 d17.61/10mg1746 mg3074Rituximab 375mg/m2 × 2 d1315.43/100mg1455 mg19140Daily CBC,diff935 (3–28)465Readmission (N=24)863.004315Daily Room charge5 (1–12)Daily CBC, diff93465Blood Transfusions (N=64)4941.4 (0–6)692Platelet transfusions (N=64)4941.5 (0–7)741G-CSF52814 (6–34)7392Oral antibiotics Valacyclovir104Fluconazole9 (0–16)89Levofloxacin114Apheresis procedure1917.732 (1–7)3835PB CD34+ analysis1352 (estimated)270POST APHERESISCryopreservation (supplies, labor, storage, sterility)1246.42/apheresis2 (1–7)2493TOTAL (without rituximab)36454*Based on median body surface area (BSA) of 1.94 (range, 1.35–2.45). N=98Study was sponsored by Genzyme Inc.