The Impact of Continuity of Care On Survival Outcomes After Allogeneic Hematopoietic Stem Cell Transplantation (HCT)

Continuity of care (COC) is acknowledged as a core quality measure in medicine. There is a little literature known about the impact of COC on OS after allogeneic hematopoietic stem cell transplantation Allo-HCT.

Method

Between July 2009 and May 2012, 74 consecutive Allo-HCT were performed at our center. The patient's clinical care for the first consecutive 41 patients was shared between the physicians independent of primary transplant physician (Non- COC). We hypothesized that COC improve OS after Allo-HCT and the subsequent 33 patients (COC) were followed by their transplant physician both as in-patient and outpatient. Physician's contribution into the care of each individual patient was calculated from physicians billing visits. Patient characteristics are shown in table I. Graft vs. host disease (GVHD) prophylaxis was Calcineurin inhibitor with MTX/Mycophenolate with the addition of Thymoglobulin for MUD and mismatched RD.

Results:

The average contribution of the primary transplant physician into their patients care during the first year post-transplant was 49% vs. 80% for Non-COC and COC groups respectively (P=0.01). There was no difference in patient characteristics between COC and Non-COC groups except for older patients in Non-COC. With median duration of follow up of 815 days for Non-COC and 320 days for COC groups, the 1- year OS was 56% vs. 75%  respectively (P=0.07). Similarly, there was a trend toward improved DFS for COC (1-year DFS of 68% vs. 48%, P=0.11). Both cumulative incidence of relapse and treatment related mortality (TRM) at 1-year were lower in COC compared to Non-COC groups; 9% vs. 25% and 17% vs. 25% respectively. The cumulative incidence of grade II –IV acute GVHD was 64% for Non-COC vs. 46% COC respectively. There was more patients with grade III/IV aGVHD; 13/41 (32%) in Non-COC compared to 6/33(18%) in COC, however this difference was not statistically significant (p=0.27). Additionally, there was no difference in OS in patients with grade III/IV aGVHD in Non-COC (13 patients) vs. COC (6 patients), P=0.85. In contrast, Patients without grade III/IV aGVHD had a statistical OS advantage in favor of COC (27 patients) vs. Non-COC (28 patients) with one year OS of 90% vs. 68% respectively, P=0.05. Cumulative incidence of chronic GVHD at one year was 77% for COC and 48% for Non-COC patients, P=0.02.

Conclusion:

Continuity of care may favorably improve OS after Allo-HCT. COC did not improve OS in patients with severe aGVHD but may result in OS advantage in patients with grade II aGVHD. Personnel knowledge of the patients and promptness in initiating GVHD therapy in COC group may have contributed to the improved OS in patients with grade II aGVHD.  Similarly, the more intense immune suppression for patients with severe GVHD in NCOC group may have contributed to higher relapse and TRM observed.