Approximately 20,000 hematopoietic cell transplantation (HCT) procedures
are performed in the United States annually. With advances in transplantation
technology and supportive care practices, HCT has become safer and patient
survival continues to improve over time. Indications for HCT continue to evolve
as research refines the role for HCT in established indications and identifies
emerging indications where HCT may be beneficial. The American Society for Blood
and Marrow Transplantation (ASBMT) established a multi-stakeholder task force
consisting of transplant experts, payer representatives and a patient advocate
to provide guidance on ‘routine’ indications for HCT. This white
paper presents the recommendations from the Task Force. Indications for HCT were
categorized as (1) Standard of care, where indication for HCT is well defined
and supported by evidence, (2) Standard of care, clinical evidence available,
where large clinical trials and observational studies are not available but HCT
has been shown to be effective therapy, (3) Standard of care, rare indication,
for rare diseases where HCT has demonstrated effectiveness but large clinical
trials and observational studies are not feasible, (4) Developmental, for
diseases where pre-clinical and/or early phase clinical studies show HCT to be a
promising treatment option, and (5) Not generally recommended, where available
evidence does not support the routine use of HCT. The ASBMT will periodically
review these guidelines and will update them as new evidence becomes
available.
Hematopoietic cell transplantation (HCT) is an expensive, resource-intensive, and medically complicated modality for treatment of many hematologic disorders. A well-defined care coordination model through the continuum can help improve health care delivery for this high-cost, high-risk medical technology. In addition to the patients and their families, key stakeholders include not only the transplantation physicians and care teams (including subspecialists), but also hematologists/oncologists in private and academic-affiliated practices. Initial diagnosis and care, education regarding treatment options including HCT, timely referral to the transplantation center, and management of relapse and late medical or psychosocial complications after HCT are areas where the referring hematologists/ oncologists play a significant role. Payers and advocacy and community organizations are additional stakeholders in this complex care continuum. In this article, we describe a care coordination framework for patients treated with HCT within the context of coordination issues in care delivery and stakeholders involved. We outline the challenges in implementing such a model and describe a simplified approach at the level of the individual practice or center. This article also highlights ongoing efforts from physicians, medical directors, payer representatives, and patient advocates to help raise awareness of and develop access to adequate tools and resources for the oncology community to deliver well-coordinated care to patients treated with HCT. Lastly, we set the stage for policy changes around appropriate reimbursement to cover all aspects of care coordination and generate successful buy-in from all stakeholders.
The use of high dose chemotherapy followed by autologous hematopoietic stem cell transplantation for remission consolidation after initial induction represents standard of care for patients with multiple myeloma. Patients with myeloma and Acquired von Willebrand Syndrome (AVWS) undergoing autologous stem cell transplant (ASCT) are at significant risk of bleeding due to the profound thrombocytopenia, low Factor VIII levels, fever, and toxicities associated with the preparative regimen. We report a patient with AVWS associated with multiple myeloma who underwent autologous stem cell transplants as consolidation after initial induction and again at relapse. He was successfully treated with high dose intravenous immunoglobulin (IVIG) prior to each transplant with rapid resolution of AVWS.
Bundled payments for hematopoietic cell transplantation (HCT) have long been accepted by both commercial health insurance providers and transplant centers, effectively outpacing the use of this payment model elsewhere in health care. As with the rest of health care, interest in payment and health delivery reform has created demand for transplant providers to address value by incorporating quality metrics and strategic changes in network design The complexity of evaluating performance in HCT complicates the goal of rewarding providers for better performance and penalizing poor results. We provide an introduction to value-based purchasing and address potential considerations in the adoption of incentives to improve quality of care in HCT.
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