Quality Process Improvement: The Impact of Recipient Selection & Evaluation

High dose chemotherapy followed by allogeneic hematopoietic cell transplantation (HCT) can achieve long-term remission and potentially cure patients with hematologic malignancies. Accurate quantification of risk for patients undergoing HCT is critical for medical decision-making. Recipient selection criteria vary from center to center but for the most part include age, disease status, Karnofsky Performance Status (KPS) and co-morbidity index (HCT-CI). Patient age has been studied relatively extensively in this framework and has previously been shown to have little association with treatment related mortality. Additionally, outcomes based on disease status at the time of transplant have been previously well defined. It is well established that overall functional status of a recipient as scored by the KPS tool alone can be subjective between providers. The HCT-CI has been shown to accurately capture the prevalence and level of severity of various organ impairments before HCT though the relationship is vague between psychosocial variables and patient outcomes after allogeneic hematopoietic stem cell transplantation. Whether patient-specific factors can contribute to prediction of outcomes after allogeneic HCT is not well characterized and there is currently no consensus for including these variables in HCT-CI risk-assessment stratification. As a process improvement project to improve one year survival a full scale audit of all allo transplants performed from 2013-2017 was conducted. Results of the audit revealed KPS range of 50-100% and a HCT-CI score mean of 2.7. Disease status at time of transplant was CR1 or CR2. As a result of these findings a deeper delve was completed. Upon reviewing medical histories of all recipients there was significant findings for history of psychiatric illness and illicit drug/alcohol abuse. All recipients were divided into 3 groups as depicted in the table below. NOTE: Per center guidelines: Psychiatric evaluations are completed on all allogeneic recipients, drug screens are completed on patients with a history of abuse and must be negative for 3 months prior to transplant. Conclusion: As a small program, each death greatly impacts a center's overall one year survival which in turn impacts accreditation and insurance Center of Excellence status. After completion of the internal audit, the findings have caused a change in practice to include a critical evaluation for substance abuse that is more restrictive than a three month history of non-use. Additionally a frailty index has been added along with a modification of the HCT-CI for increased scoring for dual history of psych and drug/alcohol abuse. Further studies are needed to evaluate the impact of a dual diagnosis history.