To Treat or Not to Treat: Factors Associated with Receipt of Allogeneic Hematopoietic Cell Transplant

Little is currently known about patient, physician and hospital factors that may play a role in the treatment older adults receive. Data linkages can be used to assess such factors. To examine the association of patient, physician, and hospital factors with alloHCT receipt within one year of diagnosis, comparing patients who received an alloHCT to those who received no chemotherapy (no treatment). Centers for Medicare and Medicaid (CMS) Medicare Administrative claims data from 2010 to 2018 were linked to publicly available CMS and National Provider Identifier (NPI) physician and hospital data. Eligible patients included those age 65-74 diagnosed with AML between 2010 and 2017, enrolled in fee-for-service Medicare for at least one year after diagnosis or until death; those missing physician and hospital characteristics were excluded. AlloHCT was identified using diagnosis and procedure codes; no treatment was identified by the absence of alloHCT or chemotherapy codes. Multivariable hierarchical logistic regression was conducted;. Fixed effects included patient (diagnosis year, sex, age, Elixhauser comorbidity index [ECI], race/ethnicity, United States census region), hospital (ownership, rurality, chemotherapy provision, medical school affiliation, hospital ranking) and physician (years since graduation, specialty, sex) characteristics at diagnosis; hospital was a random effect. A total of 868 patients were included: 486 (56%) received alloHCT; 382 (44%) received no treatment. The majority of patients in both groups were Non-Hispanic White; more patients in the alloHCT group were age 65-69. Characteristics significantly associated with decreased odds of receiving alloHCT were: ECI (≥3 compared to no comorbidities; odds ratio [OR]: 0.29; 95% confidence interval [CI]: 0.13-0.65), age (71-75 compared to 65-69 years: OR: 0.23, 95% CI: 0.16-0.34); medical school affiliation (no compared to yes: OR: 0.59; 95% CI: 0.40-0.87); and physician specialty (all other compared to hematologist-oncologist: OR: 0.60, 95% CI: 0.42-0.86). Living in an area with a higher population percentage with a college education was associated with an increased likelihood of receiving alloHCT (OR: 1.03, 95% CI: 1.02-1.04). Other factors were not statistically significant. This analysis used linked data to assess the association of patient, hospital, and physician characteristics at diagnosis with receiving alloHCT within one year of diagnosis among those who received alloHCT or no treatment. ECI, age, neighborhood education, medical school association, and physician specialty at diagnosis were associated with receipt of alloHCT. ECI and age may be proxies for disease severity. Using linked datasets can help identify factors that limit access to alloHCT, and can inform strategies to improve access and reduce barriers.