The Cost of Pediatric Unrelated HSCT

Allogeneic unrelated hematopoietic stem cell transplants (HSCT) are complex procedures that need adequate hospital infrastructure, a competent team, high-cost procedures and medications. Most transplants that are performed in Brazil are paid by the government. The national health system reimburses the hospital U$ 35,801.00 as a flat rate. The government has recently increased this amount by 60% but there are not national studies to use to evaluate the appropriateness of this amount. The objective of this study was to retrospectively evaluate the cost of ten consecutive unrelated donor HSCT performed in our institution. Methods: The project was approved by our IRB (CEP-UNIFESP #1875/11) and granted waiver to request consent. The costs were evaluated from the first appointment until one year after transplant or death divided as 1) pre-HSCT, 2) conditioning therapy, 3) from the day of transplant until first discharge, 4) until D+100, 5) until D+180, and 6) until D+360. The costs included medications, supplies, blood transfusions, laboratory, imaging and the cost of the ward. Housing and out-of pocket costs or loss of income were not evaluated. Patients were scored 1 to 3 according to the Pediatric EBMT score. Results: Ten consecutive children 2-14 years of age underwent unrelated donor HSCT from June, 2010 to May, 2011. Diagnoses were ALL (4). AML (3), lymphoma (2), and aplastic anemia (1). Three patients had early disease and others were in advanced phases of the disease. Eight were CMV positive. Five had marrow and five cord blood transplants. The median interval to transplant was 3.7 years from diagnosis and 80 days from referral. The patients remained hospitalized for a median of 80 days (21-50). Median time to engraftment was D+22 (12-56) and six had complications and needed Intensive Care support. Of the 10 children, seven were discharged but three eventually relapsed and died, overall survival is 50%. The median total cost during the first year was U$118,908.00 (mean U$ 139,861.00) – 44% of that spent within the first 100 days post HSCT. The first admission had a median total cost of U$ 64,385.00 (14,400 – 166,792). Total costs were approximately 40% higher than the direct cost. The highest costs were blood products and medications. No relationship was found between cost and age, gender, graft source of Pediatric EBMT-score. Conclusion: Unrelated-donor HSCT is an expensive procedure and the government only partially reimburses its cost. Even with a 60% increase in reimbursement there will be a deficit in more than half of the procedures. We are working to increase the amount paid for specific complications and will have to continue to find alternative resources to pay for the transplants.