Daily Dosing of Busulfan in Allogeneic Hematopoietic Cell Transplantation Reduces Costs with Equivalent or Superior Outcomes

Abstract

Introduction Higher costs of healthcare in the United States have not consistently been associated with improved health outcomes or quality of care, necessitating interventions to improve value-based care. We identified busulfan dosing frequency during preparation for allogeneic hematopoietic cell transplantation (HCT) as a potential target for optimization. To improve patient convenience and decrease the cost of the busulfan preparative regimen, our institution changed busulfan dose frequency from every 6 hours (q6h) to once-daily dosing (q24h). We examined differences in costs and patient outcomes between these two protocols. Methods In June 2017, our institution transitioned from q6h to q24h busulfan dosing. We compared patients who received inpatient busulfan and cyclophosphamide (BU/CY) preparative regimens for allogeneic HCT from one year prior to one year after implementation of the dosing change. The primary outcomes were difference in cost, day +90 mortality, and day +90 relapse. Secondary outcomes included hospital length of stay and peak serum total bilirubin level. Two-sided T-test and Chi-squared analyses were conducted to compare these outcomes between the two treatment groups. Results There were a total of 104 patients (age 49 ± 11 years, 55% male) who received the preparatory BU/CY regimen before allogeneic HCT from June 1, 2016 to June 1, 2018 (Table 1). Of these, 43% (N=45) received q24h busulfan. There were fewer men in the q24h busulfan cohort (42%) compared to the q6h busulfan cohort (64%, p=0.024), but there were no other significant differences between the treatment groups (Table 1). There was an average cost savings of $12,554.34 per patient who received q24h busulfan compared to q6h busulfan. There was a significantly lower day +90 mortality in the q24h busulfan cohort compared to the q6h busulfan cohort (0% vs 10%, p=0.028, Table 2). There were no differences in relapse at day +90 or hospital length of stay. Conclusions Busulfan dosing during preparation for allogeneic HCT represents a target for improving value-based care in the inpatient setting. At our institution, patients who received a q24h busulfan dosing regimen had similar or superior outcomes with those receiving q6h dosing, with a reduction in annual hospital drug charges of approximately $500,000. This retrospective study serves as a proof of concept for the adoption of q24h busulfan dosing as a standard of care to improve value-based care in allogeneic HCT.