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Utilisation and outcomes of allogeneic hematopoietic cell transplantation in Ontario, Canada, and New York State, USA: a population-based retrospective cohort study

Objective Allogeneic haematopoietic cell transplantation (HCT) is a potentially curative treatment for haematologic and oncologic diseases. There is a perception that the United States of America (USA) offers greater access to expensive therapies such as HCT. Alternatively, Canada is thought to suffer from protracted wait times, but lower spending. Our objective was to compare HCT utilisation and short-term outcomes in Ontario (ON), Canada, and New York State (NY), USA. Design, setting and participants We conducted a population-based cohort study using administrative health data to identify all residents of ON and NY who underwent allogeneic HCT between 2012 and 2015. Primary and secondary outcome measures The primary outcome measures were age and sex standardised HCT utilisation rates, in-hospital mortality, hospital length of stay (LOS) and readmission rates in ON and NY. Secondary outcomes included comparing ON and NY HCT recipients with respect to demographic characteristics and patient wealth (using neighbourhood income quintile). Results We identified 547 HCT procedures in ON and 1361 HCT procedures performed in NY. HCT recipients in ON were younger than NY (mean age 49.0 vs 51.6 years; p<0.001) and a lower percentage of ON recipients resided in affluent neighbourhoods compared with NY (47.2% vs 52.6%; p=0.026). Utilisation of HCT was 14.4 per 1 million population per year in ON and 26.7 per 1 million per year in NY (p<0.001). The magnitude of the ON–NY difference in utilisation was larger for older patients. In-hospital mortality, LOS and readmission rates were lower in ON than NY in both unadjusted and adjusted analyses. Conclusions We found significantly lower utilisation of HCT in ON compared with NY, particularly among older patients. Higher in-hospital mortality in NY relative to ON requires further study. These differences are thought provoking for patients, healthcare providers and policy-makers in both jurisdictions.


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The number of HCTs being performed globally has been increasing for the past 81 decade as a consequence of a growing and ageing population, expansion of HCT to 82 include older patients, and new indications for HCT to include certain non-malignant 83 conditions such as hemoglobinopathies (1,6,7,8,9). Increasing demand for HCT is 84 challenging for payers because of the estimated costs of $80,000-200,000 for the initial 85 transplant and short-term (90-day) follow-up (10,11,12).

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Despite general agreement on the indications for HCT and relatively similar 87 cancer incidence rates across countries (13,14,15), there are very few empirical studies 88 comparing utilization of HCT in different countries (16,17,18). Many of these studies are 89 older and few include data from either Canada or the US.

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We sought to compare utilization and short-term outcomes for HCT in Ontario  95 affords the opportunity to compare HCT in two countries with many similarities (a 96 common border, close geopolitical relationships, racially diverse populations) but also 97 striking differences in terms of culture, financing, and delivery of health care services 98 (23).

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Our a priori hypothesis was that NY would have higher per-capita utilization of 100 HCT than ON and that HCT utilization would be higher in both jurisdictions amongst 101 residents from wealthier neighborhoods. We also hypothesized that patients receiving 102 HCT in NY would have a shorter hospital length of stay (LOS), higher readmission rates 103 but similar short-term mortality.

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Comorbid conditions present during the index hospitalization were identified 125 using the Quan ICD-10 adaptation of the Elixhauser comorbidity coding scheme, which 126 maps ICD-10 coded comorbidities to ICD-9 (26).

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Our primary data source for NY was the 2012-2015 State Inpatient Database 128 (SID) which has been used extensively in prior research (27,28). The SID contains 147 HCT, patients who underwent their HCT in 2011 but were subsequently discharged in 148 2012, and patients whose index stay was implausibly short (< 1-day) because this 149 would be incompatible with receiving an HCT. We excluded patients who had received a

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Third we compared per-capita utilization of HCT (procedures per 1,000,000 169 population per year) for adults in Ontario and NY. The numerator for these calculations 170 was the total number of allo-HCTs performed in each jurisdiction while the denominator 171 was the number of adults age > 18-years in each jurisdiction derived from census data.    Table 3). The Ontario-NY 217 difference in utilization was relatively small among younger adults (e.g., 3.9 fewer HCTs 218 per-million in Ontario as compared to NY among adults age <50 years), but increased 219 progressively with increasing age (Figure 1, Table 3).

Other information
Funding 22 Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on which the present article is based *Give information separately for exposed and unexposed groups.   148 We excluded patients with missing age or sex, age >105 years at the time of their HCT, 149 patients who underwent their HCT in 2011 but were subsequently discharged in 2012, 150 and patients whose index hospital stay was implausibly short (< 1-day) because this

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In conclusion, we found that ON has significantly lower utilization of HCT 369 compared to NY, particularly at older age. We also observed significantly higher 370 mortality in NY that did not appear to be explained by differences in age. Overall our 371 results provide much needed information on HCT utilization and outcomes that should 372 be considered by healthcare providers and policy makers in both jurisdictions.                     Insert Project Objectives as listed in the approved ICES Project PIA The objective of this study is to examine 3 outcomes: 1) utilization; 2) short-term health services outcomes; 3) hospital length of stay for Allogeneic Hematopoietic Cell Transplantation. We will compare outcomes in Ontario (ON) and New York (NY) for patients hospitalized for allogeneic stem cell transplant (allo-SCT) during calendar years 2012-2015.
Primary hypotheses: 1. Hypothesis 1: Per-capita utilization of allo-HCT will be higher in NY compared to ON 2. Hypothesis 2: Ontario will have a lower percentage of acute care hospitals performing HCT compared to NY 3. Hypothesis 3: In-hospital mortality will be similar in ON and NY 4. Length of stay (LOS) will be longer in ON compared to NY, but readmission rates will be lower in ON compared to NY Secondary hypotheses 5. In both ON and NY a higher proportion of SCTs will be performed on patients residing in the top neighborhood-level income quintile and a lower proportion will be performed for patients residing in the lowest income quintile (ie., proportion will not be 20% for each of the 5 income quintiles) 6. Indications for HCT will be similar between ON and NY 7. In New York we will see wide variation in HCT by different insurance types (Medicare, uninsured, private insurance, etc).

Project Team Member(s) Responsible for Project Dataset Creation and/or Statistical Analysis (list all):
The person(s) named (ICES Analyst, Appointed Analyst, Analytic Epidemiologist, PI, and/or Student) are responsible for creating the Project Dataset(s) and/or statistical analysis

Michael Paterson Vicki Ling John Matelski Matthew Cheung Samantha Hershenfeld
Confirmation that DCP is consistent with Project Objectives: The following individuals must confirm that the ICES Data provided for in this DCP is relevant (e.g., with respect to cohort, timeframe, and variables) and required to achieve the Project Objectives stated in the ICES Project PIA prior to initial Project Dataset creation: 1) o n l y Project Cohort 3. Age < 18 or > 105 years 4. Death on or prior to the Index (procedure) Date 5. Patients who underwent their index procedure prior to January 1, 2012 (meaning admitted in 2011 but discharged in 2012) 6. Patients who received HCT during the 2-years prior to study initiation (e.g. January 1, 2010-December 31, 2011) because the index procedure in such patients could represent a complication of earlier procedure. 7. Patients with hospital length-of-stay of < 1-day 8. Patients who reside outside of region (New York State only as our Ontario data would not have such out-of-province patients) 9. HCT admissions should be excluded if HCT is listed in any procedure field except for the primary (first) procedure field 10. Repeat HCTs for a single individual that are <180 days after the first HCT as the repeat procedure could represent a complication of earlier procedure. We will focus on differences in utilization, population demographics and short-term outcomes of HCT recipients in NY versus ON.       o n l y o n l y   1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47 o n l y

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The overall utilization of HCT was significantly lower in ON than NY (14.4 vs 26.7 224 HCTs per-million adult population per-year[p<0.001]) ( Table 3). The ON-NY difference 225 in utilization was relatively small among younger adults (e.g., 4.9 fewer HCTs per-226 million in ON as compared to NY among adults age <50 years), but increased 227 progressively with increasing age (Figure 1, Table 3).