Prolonged hospitalization for hematopoietic cell transplantation (HCT): Characteristics, risk factors and associations with patient-reported and clinical outcomes.

Background: Patients hospitalized for hematopoietic cell transplantation (HCT) may experience prolonged length of stay (PLOS). However, the associations between PLOS and patient-reported outcomes (PROs) during and after HCT hospitalization is unknown.

Objectives: We aimed to evaluate the associations of pre-HCT demographic and disease characteristics and PROs with PLOS, as well as the associations between PLOS and trajectory of PROs and risk of rehospitalization in the first year post-HCT.

Study design: We conducted a secondary analysis of data from adult patients with hematologic malignancies undergoing HCT who were enrolled in a prospective observational study or one of two randomized clinical trials evaluating integrated specialty palliative care during HCT hospitalization. PLOS was defined as ≥ 30 continuous days for allogeneic HCT and ≥ 21 continuous days for autologous HCT. Quality of life (QOL; FACT-BMT), symptom burden (ESAS), anxiety and depression symptoms (HADS and PHQ-9), and posttraumatic stress symptoms (PCL) were measured at time of admission (i.e., prior to HCT), 2 weeks, and 3- and 6- months post-HCT. Multivariate logistic regression was used to assess the association between pre-HCT PROs and PLOS adjusting for relevant covariates. Linear mixed effects models were used to characterize the trajectory of PROs by PLOS during and after HCT. Cox proportional hazards regression was used to evaluate differences between length of stay groups in time to readmission or death in the first year post-HCT.

Results: 606 patients (mean age=55.7 years [18.3-78.0 years]; 56.6% male; 81.5% White; 53.1% allogeneic HCT) were included. Patients with PLOS were younger (mean 53.3 vs 56.6 years, p=0.004), in complete remission prior to HCT (52.8% vs 46.3%, p=0.02), diagnosed with acute leukemia (34.2% vs 26.1%, p<0.001), and underwent allogeneic HCT (62.1% vs 49.9%, p<0.0001). In multivariate analyses, worse pre-HCT QOL (OR 0.99, p=0.003), symptom burden (OR 1.02, p=0.01) and depressive symptoms (OR 1.07, p=0.01) were associated with higher risk of PLOS. Patients with PLOS reported worse QOL at two weeks (∆ = -12.3, p<0.0001), three months (∆ = -6.9, p=0.002), and six months post-HCT (∆ =-4.8, p=0.02) compared to those without PLOS. Patients with PLOS reported greater symptom burden at two weeks (∆ =10.2, p<0.0001) and three months (∆ = 3.9, p=0.04), but not six months post-HCT (∆ = 0.5, p=0.79). Patients with PLOS reported higher depression burden at two weeks (∆ = 2.5, p<0.0001) and three months (∆ = 1.1, p=0.03), but not six months post-HCT (∆ = 0.6, p=0.19). Patients with PLOS experienced shorter time to death or re-admission in the first year post-HCT (median 221 days vs not reached, HR 1.7; CI 1.3-2.2, p<0.001).

Conclusions: Pre-HCT PROs including QOL, symptom burden, and depressive symptoms were associated with PLOS. Moreover, patients with PLOS go on to experience worse QOL, symptom burden and depressive symptoms up to 6 months post-HCT and are at an increased risk of mortality and greater healthcare utilization. Patients with PLOS may have unique needs compared to the usual HCT population and may benefit from augmented supportive care during and after HCT.