ALBERT

Description: Introduction: Immune thrombocytopenia (ITP) is an autoimmune phenomenon causing increased destruction and insufficient platelet production. ITP can be a healthcare burden due to prolonged treatment (medical and sometimes surgical = splenectomy) required to prevent the relapse and frequent hospitalizations for management of complications such as epistaxis, gastrointestinal bleeding (GIB) or intracranial hemorrhage (ICH). In addition, septicemia and coagulation disorders can occur related to therapy. In this study we analyzed demographics among inpatient admissions with ITP and the variation of length of stay (LOS) and mortality with different complications. Methods: We performed a retrospective cohort analysis of the National Inpatient Sample 2014 Database (HCUP-NIS). Patients were included in the study if they had a primary or secondary diagnosis of ITP and age 〉18 years. We performed descriptive statistics to characterize the cohort in terms of personal demographic factors (age, race, sex, insurance type, community level income level), hospital characteristics (size, region, teaching status, and urban or rural location). The cohort was classified on based on splenectomy status using procedure diagnosis code. The cohort was further analyzed for complications such as coagulation disorders, GIB, ICH, septicemia and epistaxis using their principal diagnosis. Furthermore, we also looked at the variation in LOS and mortality among them. Univariate and multivariate regression analysis were performed to determine statistical significance. All analyses applied the HCUP-NIS weights. Results: There were 11,535 patients in the cohort. Most were white (64.4%), females (57.95%), and aged 〈 60 years (55.6%). A significant proportion were covered by Medicare (41.33%). Most care was delivered in large hospitals (55.17%), that were disproportionately urban (94.4%) or teaching (70.61%) institutions. The greatest segment of patients were in the South Atlantic region (20.8%). Epistaxis occurred in 15.3% of patients, GIB in 3.12%, ICH in 0.41%, and septicemia in 0.99%. The mean LOS was 4.73 days (95% CI 4.49 to 4.97). Mean LOS was highest in patients with septicemia (12.3 days), followed by GIB (8.98 days) and ICH (7.99 days), and epistaxis and coagulation disorders (6 days each). LOS was significantly shorter in patients who had undergone splenectomy (AMD -10.67 95% CI-18.32 to -3.03), and longer with septicemia (AMD 9.06 95% CI 1.84 to 16.27). Compared to Medicare, other insurances statuses had shower LOS: uninsured (AMD -6.60 95% CI -10.76 to -1.39), Medicaid (AMD -3.57 95% CI -7.07 to -0.086), and private (AMD -2.67 95% CI -5.39 to 0.037). Risk of death was much higher with GIB (OR 227 95% CI 7.63 to 6757.48, p=0.002) and ICH (OR 100.88 95% CI 10.27 to 990.91, p

Description: Introduction: Hematopoietic stem cell transplantation (HSCT) or bone marrow transplantation (BMT) is performed to treat hematologic malignancies such as acute lymphocytic leukemia (ALL), acute myeloid leukemia (AML), multiple myeloma (MM), chronic lymphocytic leukemia (CLL), chronic myeloid leukemia (CML), myelodysplastic syndrome (MDS), lymphomas (HL and NHL) and hemophagocytic lymphohistiocytosis (HLH). Inpatient data on the characteristics of patients receiving BMT, the distribution of BMT among the above mentioned hematological cancers and their outcomes is lacking. This study analyzes patient and hospital characteristics of patients undergoing BMT, in addition the study describes resource utilization and outcomes of BMT among various hematological cancers. Methods: We performed a retrospective cohort analysis of the National Inpatient Sample 2014 Database (HCUP-NIS). Patients were included in the study if they had a procedure diagnosis of BMT and a medical diagnosis of acute or chronic leukemia (ALL, AML, CLL, CML), lymphoma (HL and NHL), MM, MDS or HLH. HSCT or BMT includes both Allogeneic and Autologous Stem Cell Transplant however we did not differentiate one from the other since BMT in MM is almost universally auto stem cell transplantation. We performed descriptive statistics to characterize the cohort in terms of personal demographic factors (age, race, sex, insurance type, community level income level), indication for HSCT, hospital characteristics (size, region, teaching status, and urban or rural location), and timing of admission (weekend or weekday). We performed univariate analyses using these variables to determine the associations with LOS and mortality. All analyses apply the HCUP-NIS weights. Results: The cohort comprised of 18,275 patients who underwent HSCT. Most patients were male (59.1%), white (70.4%), aged 51-70 years (53.9%), and covered by private insurance (57.0%). Nearly a third (31.3%) lived in communities with the highest quartile of household incomes. The most common diagnosis associated with HSCT was MM (27.6%), followed by AML (15.6%). Most HSCT was performed at large hospitals (74.5%); only 0.1% were performed in rural and 1.1% at non-teaching hospitals. Average length of stay (ALOS) was 25.54 days (95% CI 24.19 to 26.89) and the mean total charges (per hospitalization) were $346,555 (95% CI $310,465 to $382,645) and net charge was $6.33 billion. Several factors were associated with lower ALOS: age (AMD -0.31, 95% CI -0.37 to -0.24), Charlson index (AMD -0.85, 95% CI -1.60 to -0.12), private insurance coverage (AMD -3.65, 95% CI -5.25 to -2.067) and self pay status (AMD -13.56, 95%CI -17.13 to -10.00). Urban (AMD 6.74, 95% CI 1.01 to 12.48), and teaching hospitals (AMD 8.31 95% CI 2.88 to 13.72) had longer ALOS. Only Hispanic race (OR 0.23 95% CI 0.068 to 0.77) and Charlson index (OR 1.2 95% CI 1.04 to 1.39) were associated with mortality. Multivariate analysis did not show any significant associations of mortality with age, race, geographic region, hospital size, median household income, type of insurance, timing of admission, or teaching or location status of hospitals. Discussion: MM accounted for the most significant portion of HSCT in 2014, although its incidence is lower than that for leukemia and lymphoma. This may partly be because autologous stem cell transplantation (ASCT) after high dose chemotherapy is the mainstay of MM treatment. In contrast to other hematological malignancies, some MM patients may also undergo tandem transplantation. Most HSCT recipients were covered under private insurance, and a significant proportion of them came from communities with the highest quartile of median household incomes. This suggests that socioeconomic status influences access to HSCT therapy, likely related to out of pocket costs. In addition, social determinants of health including health literacy, access to health care may play a role. Surprisingly, ALOS decreased with increasing age and Charlson comorbidity index. Reasons are unclear but may be related to increased or earlier mortality. Additional studies could help to elucidate this relationship. Figure. Figure. Disclosures Bussel: Rigel: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; Momenta: Consultancy; Uptodate: Honoraria; Protalex: Consultancy; Amgen Inc.: Consultancy, Research Funding; Prophylix: Consultancy, Research Funding. Marks:Odonate: Membership on an entity's Board of Directors or advisory committees; Seattle Genetics: Equity Ownership; Lilly: Membership on an entity's Board of Directors or advisory committees; Heron: Membership on an entity's Board of Directors or advisory committees; UPMC: Employment.

Description: Introduction: Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disease in which impaired natural killer and cytotoxic T-cell function results in excessive immune activation. It is predominantly seen in children; most of the available data comes from the pediatric population so it cannot be generalized to adult HLH. Treatment of HLH usually involves either treating the underlying cause in the secondary form (i.e. malignancy with chemotherapy, rheumatologic with immune suppression) or chemotherapy and stem cell transplantation for primary, familial etiology, multiple courses of intensive chemotherapy, with stem cell transplantation for relapse and familial disease. Recently, increasing adult HLH cases have been reported. The goal of this study is to describe the association between patient factors, geography, hospital resource utilization, and mortality among adult HLH patients. Methods: We performed a retrospective cohort analysis of the National Inpatient Sample 2012, 2013 and 2014 Databases (HCUP-NIS). Patients were included in the study if they had a principal diagnosis of HLH and were older than 18 years. We used descriptive statistics to characterize the cohort in terms of personal demographic factors (age, race, sex, insurance type, community-level income level), hospital characteristics (size, region, teaching status, and urban or rural location), and admission timing (weekend or weekday). We performed univariate and multivariate regression to analyze the association of the following factors with length of stay and mortality: age, sex, Charlson index, hospital region (Northeast NE, Midwest MW, South, West), income, insurance, hospital size, weekend versus weekday, hospital location (rural versus urban), teaching status. All analyses applied the HCUP-NIS weights. Results: The cohort comprised 760 patients, the majority of whom were male (57.9%), aged 21-30 years (26.3%), white (56.3%), and treated in large (78.9%) and/or teaching (92.1%) hospitals, third quartile for median household income (30.4%), covered by private insurance (43.4%), and treated in the southern US (32.2%). Per hospitalization, the average total hospital charges were $210,526 (95% CI $176,251 to $244,801) and the average length of stay (ALOS) was 18 days (95% CI 16 to 20). On multivariate analysis, ALOS was significantly longer with patients at teaching hospitals (AMD 5.10 95% CI 0.57 to 9.64, p=0.03) or with self-pay status (AMD 29.05 95% CI 21.62 to 36.48, p

Description: Introduction: Multiple myeloma (MM) requires hospitalization for chemotherapy, stem cell transplantation, and for disease or treatment-related complications. Although there is data regarding overall incidence and mortality of MM, less is known about the patterns of hospital utilization and inpatient mortality. The purpose of this study was to describe the characteristics of patients hospitalized in 2014 for a primary diagnosis of MM, and factors associated with length of stay (LOS) and inpatient mortality. Methods: We performed a retrospective cohort analysis of the National Inpatient Sample 2014 Database (HCUP-NIS). Patients were included in the study if they had a principal diagnosis of MM and were aged 18 years or older. We used descriptive statistics to characterize the cohort in terms of personal demographic factors (i.e., age, race, sex, insurance type, community-level income level), hospital characteristics (i.e., size, region, teaching status, and urban or rural location), and admission timing (i.e., weekend or weekday). We performed univariate analyses and multivariate analysis using these variables to determine the associations with LOS and mortality. All analyses apply the HCUP-NIS weights. Results: The cohort comprised 16,890 patients. Most were white (63.7%), males (54.7%), and aged 61 years or older (64.8%). Nearly half (49.2%) were insured by Medicare. Hospitalizations were uniformly distributed across socioeconomic groups based on median household income by zip code. Care was delivered most often in large hospitals (69%) and urban teaching hospitals (81.5%). The greatest proportion of patients received care in the South (37.2%) and the least in the West (15.7%). Mean hospital charge was $ 113272 (95% CI $104651 to $121893) and net total hospital charge was $1.9 billion. The mean LOS was 11.4 days (95% CI 10.87 to 12.015). On multivariate analysis LOS was longer with increased Charlson index (AMD 0.77, 95% CI 0.56 to 0.98, p

Description: Introduction: ITP is an autoimmune disease characterized by low platelet counts and variable bleeding. Ritux treatment of ITP patients (pts) receiving 375 mg/m2 once a week for 4 weeks results in 50-60% achieving complete responses (CR). However, most pts will relapse, usually around 1 year from initial treatment. In a previous study, 20 pts were retreated with a second round of 4 infusions of ritux and 16 (80%) had essentially the same response to retreatment with ritux with the second set of 4 infusions (Hasan A, AmJHem, 2009). Maintenance ritux infusions in Non-Hodgkin Lymphoma are now well-demonstrated to increase cure despite variable infusion schedules. This retrospective study explores ritux maintenance in pts with ITP or / and other autoimmune cytopenias who responded to but relapsed after a first induction with Ritux and who then received a 2nd to 4th induction with ritux. Methods: We enrolled 17 pts with ITP, Autoimmune hemolytic anemia (AIHA), Autoimmune Neutropenia (AIN) and/or Evans syndrome, who previously responded to but then relapsed following induction with 4 ritux infusions. Ritux was administered to relapsed pts at standard dose during weeks 1, 2, 3, and 4 of induction. During the maintenance phase, single infusions of ritux were given at 1 dose of 375 mg/m2 every 4 months for a total of 2 years or until relapse or development of unacceptable adverse effects or infections or withdrawal from the study (to become pregnant); 3 pts with shorter remission times following previous ritux were treated at 3 month intervals. 5 pts received 40mg/day of dexamethasone (Dex) with the ritux maintenance infusions: 3 4-day cycles of Dex at 2 weekly intervals (Chapin, AJH, 2016) with induction and single dose dex with each maintenance infusion. The primary endpoint was the duration of response. Secondary endpoints included safety. Statistical analysis was largely descriptive. Comparisons of first and second ritux treatments (without and with maintenance) were made using the Fisher Exact test. Results: Of the 17 pts who received ritux maintenance, 11 had ITP, 2 AIHA, and 4 had Evans syndrome. Three pts had AIN as part of their Evans syndrome. 7 had received more than 1 ritux induction (2-4) in the past. At initiation of maintenance, there were 10 males and 7 females and 13 adults and 4 children. Three had undergone splenectomy prior to starting ritux. The mean duration of response following the first cycle of 4 ritux standard infusions was 19 months, while the mean duration of response with maintenance schedule was 48 months. Fifteen of 17 patients achieved CR with ritux re-induction; of these 7 relapsed. 2 patients achieved PR, 1 relapsed. The mean duration of response with ritux maintenance was 36.8 months in adults and 63.8 months in children; it was 48 months each in males and females; it was 49 months in the 3 patients who had undergone splenectomy and also in those who had not undergone splenectomy. Fisher exact test did not show any statistical difference in clinical parameters including the type of autoimmune cytopenia. Pts with more previous ritux inductions did worse than those receiving their 2nd reinduction. Three patients developed hypogammaglobulinemia and needed IVIG prophylaxis against infections; one patient had bacteremia. One patient developed sepsis secondary to hypogammaglobulinemia requiring ICU admission. JC virus cultures were negative in all tested pts. No pts developed transaminitis or signs of renal failure. Discussion: The expectation for these 17 very difficult to treat pts was that they would have all relapsed in 1 year or less following a "routine" ritux re-induction based on past data and clinical experience. The number of pts reported who achieved lasting remission following a second or third course of ritux is very small. Dex was added to reinduction in 5 of these multiply-induced pts, but curative effects occur only in female pts treated within 1 year of diagnosis, and these were pts with years of disease so this would not explain the results. Being able to achieve lasting remission over many years in half this group appears to be a significant improvement on their expected outcomes. Hypogammaglobulinemia became clinically significant in 1 pt who stopped coming for checkups; it has been reported primarily with the combination of dex-ritux but even then in only 10% of patients. A randomized controlled trial is needed to test these exciting findings. Figure. Figure. Disclosures Bussel: Prophylix: Consultancy, Research Funding; Momenta: Consultancy; Rigel: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; Uptodate: Honoraria; Amgen Inc.: Consultancy, Research Funding; Protalex: Consultancy.

Description: Introduction: Cancer patients tend to have a higher incidence of venous thromboembolism (VTE) - pulmonary embolism (PE) and deep venous thrombosis (DVT). There is conflicting data in the literature about the incidence of VTE in solid tumors versus hematological cancers. The purpose of this study was to analyze the prevalence of PE, DVT, and VTE in hospitalized patients with solid and hematologic malignancies using the National Inpatient Sample database. Methods: We performed a retrospective cohort analysis of the National Inpatient Sample 2014 Database (HCUP-NIS). Patients were included in the study if they had a principal diagnosis of DVT, PE, or both (VTE); primary or secondary diagnosis of solid tumors or hematological malignancy; and age 18 years or older. We performed univariate and multivariate regression to analyze the association of PE, DVT, and VTE with solid versus hematologic cancers. We performed univariate and multivariate regression to determine their statistical significance. We also performed univariate analysis for tumor type and saddle PE and upper extremity DVT. All analyses applied the HCUP-NIS weights. Results: We identified 27,410 patients with isolated DVT; 41,645 with isolated PE; and 69,055 with both DVT and PE (VTE). On multivariate analysis, hematologic malignancy had lower odds of DVT (OR 0.82, 95% CI 0.75-0.89), isolated PE (OR 0.65, 95% CI 0.60 - 0.71) and VTE (OR 0.72, 95% CI 0.67-0.76). Female sex and Charlson index were associated with modest increased odds of DVT, PE and VTE (OR

Description: Introduction: Both acute lymphocytic leukemia (ALL) and acute myeloid leukemia (AML) require hospitalization for intensive chemotherapy, stem cell transplantation, and disease or treatment-related complications. There is a dearth of evidence in prediction of inpatient resource utilization and hospital outcomes among patients with these conditions. The goal of this study is to identify predictors of average length of stay in the hospital (ALOS) and inpatient mortality in adult ALL and AML patients. Methods: We performed a retrospective cohort analysis of the National Inpatient Sample 2014 Database (HCUP-NIS). Patients were included in the study if they had a principal diagnosis of ALL or AML and age 18 years or older. We used descriptive statistics to characterize the cohort in terms of personal demographic factors (age, race, sex, insurance type, community income level), hospital characteristics (size, geographical region, teaching status, and urban or rural location), and admission timing (weekend or weekday). We performed univariate and multivariate regression to analyze the association of these factors with mortality and ALOS. All analyses apply the HCUP-NIS weights. Results: The ALL cohort included 5,550 admissions. Most ALL patients were white (65%) males (60%), and approximately half were age 50 years or younger. The AML cohort included 18,930 admissions. Most AML patients were white (74%) males (54%), aged 60 years or older (59%). Nearly all (95%) of ALL patients had insurance coverage, either private (40%), Medicare (25.9%), Medicaid (25%), or another type (5%). In contrast, most AML patients had Medicare (46%), followed by private insurance (36%), Medicaid (11.0%), other insurance (3.8%) or no insurance (2.8%). Care for both cohorts occurred most often in large, urban, and teaching hospitals. While Charlson index was the only statistically significant predictor of mortality in the ALL cohort (AMD 1.34, 95% CI 1.11 to 1.63, p=0.002), age (OR 1.02; 95% CI 1.014 - 1.03), Charlson index (OR 1.24; 95% CI 1.16 - 1.34) and other type of insurance were associated with increased mortality for AML. ALOS was similar for both cohorts: ALL 18.5 days and AML 18.9 days. For ALL, multivariate analysis showed Charlson index (AMD 1.53, 95% CI 0.32 - 2.74, p=0.013), and hospital type (urban AMD 5.73; 95% CI 2.73 to 8.73, p