Risk Factors for 30-Day Hospital Readmission following

Myeloablative Allogeneic Hematopoietic Cell

Transplantation (allo-HCT)
Nelli Bejanyan,1 Brian J. Bolwell,1 Aleksandr Lazaryan,1 Lisa Rybicki,2 Shawnda Tench,1
Hien Duong,1 Steven Andresen,1 Ronald Sobecks,1 Robert Dean,1 Brad Pohlman,1
Matt Kalaycio,1 Edward A. Copelan1

Patient readmission within 30 days from discharge has been perceived by the Centers for Medicare and Med-
ical Services as an indicator of poor healthcare quality for specific high-cost medical conditions. Patients who
undergo allogeneic hematopoietic cell transplantation (allo-HCT) are often being readmitted. Our study
identified the risk factors for 30-day readmission among 618 adult recipients of myeloablative allo-HCT
from 1990 to 2009. Two hundred forty-two (39%) of 618 patients (median age 5 42 years [range: 18-66])
were readmitted a median of 10 days (range: 1-30) from their hospital discharge. Median duration of read-
mission was 8 days (range: 0-103). Infections (n 5 68), fever with or without identified source of infection
(n 5 63), gastrointestinal complications (n 5 44), graft-versus-host disease (GVHD) (n 5 38), and other
reasons (n 5 29) accounted for 28%, 26%, 18%, 16%, and 12% of readmissions, respectively. During their
index admission, patients who were subsequently readmitted had more documented infections (P \.001),
higher hematopoietic cell transplantation comorbidity index (HCT-CI) (P \ .01), total body irridiation
(TBI)-based conditioning (P \.001), unrelated donor (P \.001), and peripheral stem cell (P 5 .014) trans-
plantation. In multivariable analysis, HCT-CI (odds ratio [OR] 5 1.78; 95% confidence interval [CI], 1.25-
2.52), TBI-based preparative regimen (OR 5 2.63; 95% CI, 1.67-4.13), and infection during admission for
allo-HSCT (OR 5 2.00; 95% CI, 1.37-2.92) predicted 30-day readmission. Thirty-day readmission itself
was an independent predictor of all-cause mortality (hazard ratio [HR]Adj 5 1.66; 95% CI, 1.36-2.10).
Our data emphasize the importance of a risk-standardized approach to 30-day hospital readmission if it is
used as a quality-of-care metric for bone marrow transplantation.
Biol Blood Marrow Transplant 18: 874-880 (2012) Ó 2012 American Society for Blood and Marrow Transplantation

KEY WORDS: 30-Day readmission, Risk factors, Allogeneic stem cell transplantation, allo-HCT

INTRODUCTION by the Centers for Medicare and Medical Services

(www.qualitynet.org). Data on 30-day readmission
Hospital readmission shortly after index hospitali- rates for a number of leading causes of hospitalization
zation increases healthcare costs. Approximately 20% (eg, pneumonia, heart failure) reveal substantial het-
of Medicare beneficiaries are readmitted within erogeneity across the United States and are thought
30 days of hospital discharge, and about 90% of these to reflect differences in quality of care. These differ-
readmissions are unplanned [1-3]. The 30-day read- ences have led to calls for nationwide quality improve-
mission rate has been chosen as a quality care metric ment efforts [4,5]. Risk-standardized readmission and
mortality rates vary among older patients with
From the 1Taussig Hematologic Oncology and Blood Disorders, pneumonia from 14% to 27% and from 10% to
Taussig Cancer Institute, Cleveland Clinic, Ohio; and 2Quanti- 12%, respectively [6]. The nationwide rate of 30-day
tative Health Sciences, Lerner Research Institute, Cleveland readmission for patients with heart failure reaches
Clinic, Ohio.
Financial disclosure: See Acknowledgments on page 880.
29%, and the risk-standardized mortality rate is up
Correspondence and reprint requests: Nelli Bejanyan, MD, Taussig to 17% [3,7-9]. Risk factors predicting 30-day hospital
Hematologic Oncology and Blood Disorders, Taussig Cancer readmissions among patients above 65 years old in-
Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, clude demographic (such as age, male gender, African
OH 44195 (e-mail: [email protected]). American race), medical (comorbid conditions such as
Received June 13, 2011; accepted October 20, 2011
Ó 2012 American Society for Blood and Marrow Transplantation
heart failure, vasculopathies, diabetes, renal failure,
1083-8791/$36.00 end-stage liver disease, chronic lung disease, solid
doi:10.1016/j.bbmt.2011.10.032 organ malignancies, lymphomas, and leukemias), and

874
Biol Blood Marrow Transplant 18:874-880, 2012 Risk Factors for 30-Day Hospital Readmission 875

healthcare features (such as having Medicare insurance patient characteristics was collected retrospectively
and being discharged to a skilled nursing facility) [10]. from the Unified Transplant Database (UTD) at the
In a study conducted among adults admitted to a gen- Cleveland Clinic Taussig Cancer Institute.
eral medicine service, Charlson comorbidity index, Information on readmissions including the reasons
SF12 physical component score, insurance status, for readmissions were captured and collected prospec-
social support, previous admissions within a year, tively from patients’ individual transplant coordinators
and length of hospital stay during index admission and/or from on-call physician documentations in
were all found to be independent predictors for early either electronic or paper charts. In addition, further
readmissions [11]. Many readmissions might be pre- detailed information was also collected during daily in-
vented by the use of alternative nonhospital services, as patient rounds by our dedicated UTD data-collecting
most readmissions are because of chronic medical con- personnel. We collected and analyzed the following
ditions [7,12]. Transitional care programs have thus variables: patient age, gender, race, type of hematologic
been proposed to improve hospital discharge planning malignancy (myeloid, lymphoid, or other), pretrans-
for the patients at highest risk for readmissions, plantation disease status (remission or no remission),
including those requiring continuous complex medical number of prior chemotherapy regimens, prior radia-
care [13-15]. On the other hand, some studies have tion treatment, hematopoietic cell transplantation-
demonstrated a correlation between increased use of specific comorbidity index (HCT-CI), type of
hospital resources and lower patient mortality rate preparative regimen, source of hematopoietic cells,
[8,16]. Mortality was found to be lower among donor type, time until neutrophil count recovery, in-
patients with heart failure who were readmitted within fection and acute graft-versus-host disease (aGVHD)
30 days of discharge compared with those who were during hospital stay, and length of hospital stay.
not [5]. Successful inpatient care with low in-hospital Myeloid malignancies were acute myelogenous leuke-
mortality among patients with heart failure may mia, myelodysplastic syndromes, myeloproliferative
lead to a larger living patient population at risk for neoplasms, and chronic myelogenous leukemia. Lym-
readmission [5]. phoid malignancies included acute lymphoblastic
Patients treated with allogeneic hematopoetic cell leukemia, biphenotypic leukemia, lymphomas, multi-
transplantation (allo-HCT) have high rates of hospital ple myeloma, and plasma cell leukemia. Other condi-
readmission [17]. However, neither the factors pre- tions requiring allo-HCT included aplastic anemia
dicting 30-day readmission nor the impact of readmis- and paroxismal nocturnal hemoglobulinemia. Infec-
sion on overall survival (OS) has been examined in the tions were defined as any documented bacterial, viral,
context of allo-HCT. We designed this single-center or fungal infections with isolation of a specific microor-
retrospective study to identify the reasons and risk ganism. The diagnosis of pneumonia was made when
factors for 30-day readmission among the recipients both radiologic and clinical findings of pneumonia
of myeloablative allo-HCT. We also evaluated the were present. This study was approved by the
impact of those factors and of readmission on survival. Cleveland Clinic institutional review board.
Statistical Analysis
MATERIALS AND METHODS Study variables were compared between the pa-
tients who were readmitted and those who were not.
Patients and Setting Chi-square and Wilcoxon rank sum tests were used
A total of 748 adult patients underwent allo-HCT to compare categoric and continuous variables, respec-
between 1990 and 2009 at the Cleveland Clinic tively. Univariate and multivariable risk factors for
Taussig Cancer Institute. Of these, 121 died during readmission were assessed using logistic regression
the transplant admission and 9 died within 30 days of analysis. As multiple preparative regimens were
discharge without a readmission. These 130 patients employed, recursive partitioning analysis was used to
were excluded, and the analysis was based on the categorize these regimens. Recursive partitioning
remaining 618 patients. All patients received their allo- analysis indicated that the most important aspect of
grafts in an inpatient bone marrow transplant unit. The the preparative regimen associated with readmission
patients were kept hospitalized until they became free was whether or not it included total body irridiation
of fever, infections, or other serious complications, (TBI). Multivariable analysis was performed using
and their absolute neutrophil count recovered above a stepwise procedure with a variable entry criterion
500 cells/mL. All patients received discharge teaching of P \ .10 and a variable retention criterion of P \
instructions on common complications after allo- .05. Model-based probabilities of readmission were
HCT, and the appropriate follow-up appointments calculated for all combinations of variables in the final
were arranged by individually assigned transplant co- multivariable logistic model. The number of risk fac-
ordinators upon their hospital discharge. Information tors was calculated for each patient, and the percentage
on hospital readmissions, demographic, and clinical readmitted was compared relative to the number of
876 N. Bejanyan et al. Biol Blood Marrow Transplant 18:874-880, 2012

risk factors using the Cochran-Armitage trend test. Table 1. Patient Characteristics
Survival after the transplantation discharge was esti- Readmission Not Readmitted
mated using the Kaplan-Meier method and compared Variable (n 5 242) (n 5 376) P Value
between patients who were readmitted within 30 days
Age, median 42 (18-66) 40 (18-68) .32
of discharge and those who were not using the log-rank Male 130 (54) 325 (53) .65
test. Univariate and multivariable risk factors for mor- Race
Caucasian 215 (89) 342 (91) .27
tality were assessed using Cox proportional hazards
African American 23 (10) 24 (6)
analysis. Multivariable analysis was done using a step- Other 4 (2) 10 (3)
wise procedure as described earlier. Analyses were Malignancy type
Myeloid 161 (67) 275 (73) .06
done using SASÒ software (SAS Institute, Inc., Cary,
Lymphoid 73 (30) 83 (22)
NC). All statistical tests were 2 sided, and P \ .05 Other* 8 (3) 18 (5)
was used to indicate statistical significance. Disease status
Active disease 141 (58) 206 (55) .40
Remission 101 (42) 170 (45)
Prior chemoRx
RESULTS 0/hydrea§ 23 (9) 50 (13) .06
1-2 159 (66) 257 (69)
Patient Characteristics $3 60 (25) 66 (18)
Prior RT 28 (12) 34 (9) .31
A total of 242 of the 618 allograft patients (39%) HCT-CI‡
were readmitted within 30 days after hospital dis- High/intermediate 150 (64) 177 (49)
Low 84 (36) 187 (51)
charge following their index hospitalization for allo- TBI-containing prep 64 (26) 40 (11) <.001
HCT. Baseline characteristics of both the readmitted Stem cell source
and the not readmitted subsets are summarized in Bone marrow 203 (84) 344 (92) .014
Peripheral stem cell cord 31 (13) 24 (6)
Table 1. Compared with the group that was not read- Cord 8 (3) 8 (2)
mitted, the readmitted group was enriched for patients Donor, unrelated 112 (46) 113 (30) <.001
who had higher HCT-CI (64% versus 49%, P \ .01), Infection† 99 (41) 80 (21) <.001
aGVHD, grade II-IV† 40 (17) 52 (14) .36
TBI-containing preparative regimens (26% versus Length of stay, days† 32 (17-106) 31 (18-91) .96
11%, P \ .001), unrelated donors (46% versus 30%, Days to ANC >500 15 (6-66) 16 (7-75) .10
P \ .001), peripheral blood stem cell source (13% ver- Days to readmission 10 (1-30) —
sus 6%, P 5 .014), and documented infectious compli- ANC indicates absolute neutrophil count.
cations (41% versus 21%, P \ .001) during their index Note: Values in brackets correspond to percentage or range for median
admission for transplantation. Grade 2 or greater values.
*Other: aplastic anemia, peroxismal nocturnal hemoglobulinemia.
aGVHD developed in 15% of patients receiving allo- †During index admission for allo-HCT.
HCT. Median neutrophil count recovery was 16 ‡Twenty subjects had missing HCT-CI data.
days (range: 6-75) and median length of hospital stay §Fifty-three subjects had no prior chemotherapy: chronic myeloid leuke-
32 days (range: 17-106) for all patients. Median days mia (n 5 17), aplastic anemia (n 5 16), myelodysplastic syndromes/
chronic myelomonogotic leukemia (n 5 9), secondary acute myeloge-
from hospital discharge to readmission were 10 (range: nous leukemia (n 5 4), myelofibrosis (n 5 4), myeloproliferative disor-
1-30), and the median duration of the readmission ders (n 5 1), paroxismal nocturnal hemoglobulinemia (n 5 1), and Ph+
hospital stay was 8 days (range: 0-103). acute lymphoblastic leukemia (n 5 1).

Reasons for 30-Day Hospital Readmission

within 30 days of discharge compared with those with
Four major reasons for hospital readmission within myeloid malignancy (odds ratio [OR] 1.50; 95% confi-
30 days were identified following myeloablative allo- dence interval [CI], 1.04-2.17; P 5 .031). An increased
HCT, including 68 patients with identified infections number of prior chemotherapy regimens was associ-
(28%); 63 patients with fever (26%) without identifiable ated with a significantly higher readmission rate (OR
infection; 44 patients with gastrointenstinal complica- 1.20; 95% CI, 1.05-1.37; P 5 .007). In addition,
tions such as nausea, vomiting, or diarrhea (18%); and patients with higher HCT-CI (OR 1.89; 95% CI,
38 patients with GVHD (16%). Less common reasons 1.35-2.64; P \ .001) and those who received a TBI-
included cardiac (n 5 7), respiratory (5), neurologic containing preparative regimen (OR 3.02; 95% CI,
(n 5 5), and renal or electrolyte abnormalities (n 5 4). 1.96-4.66; P \ .001) during their allo-HCT were
Rare reasons for hospital readmission included throm- found to have a greater readmission risk. Use of an un-
boembolic events, disease relapse, and graft rejection. related donor (OR 2.0; 95% CI, 1.43-2.8; P \ .001)
Several patients were readmitted for 2 or more reasons, was also associated with higher risk of 30-day readmis-
accounting for 11% of all readmissions. sion. Patients with infectious complications during
their index admission were at higher risk for readmis-
Risk Factors for Readmission sion (OR 2.56; 95% CI, 1.79-3.66; P \ .001). In
In univariate analysis (Table 2), patients with lym- multivariable analysis, only 3 variables remained
phoid malignancies were more likely to be readmitted significant in their association with higher risk of
Biol Blood Marrow Transplant 18:874-880, 2012 Risk Factors for 30-Day Hospital Readmission 877

Table 2. Risk Factors for Readmission: Logistic Regression Analysis

Univariable Multivariable

Variable OR 95% CI P Value OR 95% CI P Value

Age
Per 10 year increase 1.06 0.92-1.22 .42 — — —
Gender
Male/female 1.08 0.78-1.49 .65 — — —
Race
African American/other 1.54 0.85-2.80 .16 — — —
Malignancy type
Lymphoid/myeloid 1.50 1.04-2.17 .031 — — —
Other/myeloid 0.76 0.32-1.78 .53
Disease status
Active/remission 1.15 0.83-1.60 .40 — — —
Number of prior chemoRx
Per 1 regimen increase 1.20 1.05-1.37 .007 — — —
Prior RT
Yes/No 1.32 0.78-2.23 .31 — — —
HCT-CI
High+Int/Low 1.89 1.35-2.64 <.001 1.78 1.25-2.52 .001
Prep regimen
TBI/No TBI 3.02 1.96-4.66 <.001 2.63 1.67-4.13 <.001
Donor type
Unrelated/related 2.00 1.43-2.80 <.001 — — —
Infection*
Yes/No 2.56 1.79-3.66 <.001 2.00 1.37-2.92 <.001
aGVHD*
Per 1 grade increase 1.13 0.94-1.35 .19 — — —
Days to ANC >500
Per 1 day increase 0.98 0.95-1.01 .16 — — —
Length of stay, days*
Per 1 week increase 1.05 0.96-1.15 .26 — — —

ANC indicates absolute neutrophil count.

*During index admission for allo-HCT.

30-day readmission: HCT-CI (OR 1.78; P 5 .001), sion was 10.0 months and 42.8 months, respectively
preparative regimen (OR 2.63; P\.001), and infection (P \ .001).
during index admission for allo-HCT (OR 2.0; P \ Univariate survival analysis identified 30-day read-
.001). mission (hazard ratio [HR] 1.81; 95% CI, 1.47-2.23;
Model-based probabilities for readmission were P \ .001), patient age at transplantation (HR 1.11;
calculated from 3 risk factors identified by multivari- 95% CI, 1.01-1.22; P 5 .035), disease status (HR
able logistic regression analysis (Table 3). The lowest 1.41; 95% CI, 1.15-1.74, P 5 .001), number of prior
risk for readmission (24%) was among the patients chemotherapy regimens (HR 1.14; 95% CI, 1.05-
with low HCT-CI who received non-TBI-based regi- 1.23; P 5 .002), HCT-CI (HR 1.77; 95% CI, 1.42-
mens and had no documented infection during index 2.20; P \ .001), unrelated donor types (HR 1.27;
transplantation admission. In contrast, the greatest 95% CI, 1.02-1.56; P 5 .029), infections (HR 1.32;
risk for readmission (75%) was observed in the pres- 95% CI, 1.06-1.65; P 5 .012), aGVHD (HR 1.20;
ence of all 3 risk factors; those patients with high 95% CI, 1.07-1.33; P 5 .001), and length of hospital
HCT-CI who received a TBI-based regimen and stay (HR 1.18; 95% CI, 1.12-1.24; P\.001) during in-
had infectious complications during their hospital dex admission for transplantation as significant risk
stay. Estimated readmission percentages in the pres- factors for all-cause mortality (Table 4). In the ad-
ence of 0, 1, 2, or all 3 risk factors demonstrated step- justed Cox analysis, however, only 5 of these factors
wise increments with 23.3%, 38.5%, 54.1%, and
76.7% rates of readmission, respectively (P \ .001).
Table 3. Predicted Risk of 30-Day Readmission

Patients’ Survival and Risk Factors for HCT-CI

Postdischarge Mortality Prep Infection Low Intermediate/High

OS was significantly worse among patients who No TBI No 24.0% 35.9%
were readmitted within 30 days after hospital dis- Yes 38.7% 52.9%
TBI No 45.3% 59.5%
charge following myeloablative allo-HCT (Figure 1). Yes 62.4% 74.7%
Median survival for patients with and without readmis-
878 N. Bejanyan et al. Biol Blood Marrow Transplant 18:874-880, 2012

risk increases with longer readmission (HR 1.07,

95% CI 1.01-1.13, P 5 .025, per 7 day increase in
length of readmission).

DISCUSSION

Myeloablative allo-HCT is potentially curative for

patients with various hematologic malignancies. How-
ever, it is associated with substantial posttransplanta-
tion morbidity and mortality [18]. Patients receiving
allo-HCT remain at risk for serious complications
such as infections, GVHD, and disease relapse for
a prolonged period following initial hospital discharge.
These complications may require hospital readmis-
Figure 1. Survival by readmission within 30 days of discharge. sions for further inpatient management. Investigators
from City of Hope evaluated the readmission pattern
in 100 adult patients following autologous or alloge-
remained predictive for all-cause mortality beyond 30 neic stem cell transplantation for various hematologic
days: 30-day readmission (HR 1.66; 95% CI, 1.36- malignancies and reported in every patient at least 1
2.10; P \ .001), pretransplantation disease status unscheduled readmission within 6 months of dis-
(HR 1.42; 95% CI, 1.14-1.78; P 5 .002), number of charge. They found significantly higher rates of read-
prior chemotherapy regimens (HR 1.13; 95% CI, mission and prolonged hospital stays in allogeneic
1.04-1.22; P 5 .004), higher HCT-CI (HR 1.54; transplant recipients compared with those undergoing
95% CI, 1.23-1.93; P \ .001), and length of index hos- autologous transplantation. The most common com-
pitalization (HR 1.16; 95% CI, 1.10-1.22; P \ .001) plications were fever/infections, followed by gastroin-
(Table 4). Additionally, among the subset of patients testinal problems and GVHD. Up to 80% of the
who were readmitted, we identified that mortality patients had infectious complications, which were

Table 4. Risk Factors for Postdischarge Mortality: Cox Regression Analysis

Univariable Multivariable

Variable HR 95% CI P Value HR 95% CI P Value

30-day readmission
Yes/No 1.81 1.47-2.23 <.001 1.66 1.36-2.10 <.001
Age
Per 10 year increase 1.11 1.01-1.22 .035 — — —
Gender
Male/female 1.22 0.99-1.50 .06 — — —
Race
African American/other 1.20 0.83-1.72 .33 — — —
Malignancy type
Lymphoid/myeloid 1.22 0.97-1.52 .09 — — —
Other/myeloid 0.35 0.16-0.78 .011
Disease status
Active/remission 1.41 1.15-1.74 .001 1.42 1.14-1.78 .002
Number of prior chemoRx
Per 1 regimen increase 1.14 1.05-1.23 .002 1.13 1.04-1.22 0.004
Prior RT
Yes/No 1.43 1.04-1.95 .025 — — —
HCT-CI
High + Int/Low 1.77 1.42-2.20 <.001 1.54 1.23-1.93 <.001
Prep regimen
TBI/no TBI 1.08 0.82-1.41 .58 — — —
Donor type
Unrelated/related 1.27 1.02-1.56 .029 — — —
Infection*
Yes/No 1.32 1.06-1.65 .012 — — —
aGVHD*
Per 1 grade increase 1.20 1.07-1.33 .001 — — —
Days to ANC >500
Per 1 day increase 1.01 0.99-1.02 .32 — — —
Length of stay, days*
Per 1 week increase 1.18 1.12-1.24 <.001 1.16 1.10-1.22 <.001

*During index admission for allo-HCT.

Biol Blood Marrow Transplant 18:874-880, 2012 Risk Factors for 30-Day Hospital Readmission 879

more prevalent among recipients of allo-HCT. We higher rates of 30-day readmissions. This hypothesis,
have found a similar pattern of readmission within however, will require further validation in independent
the 30 days of discharge. Uniformity of readmission dataset(s).
patterns across geographic regions favors the notion As was expected, HCT-CI was strongly associated
that the frequency of readmission is not specific for with both 30-day readmissions and postdischarge mor-
individual transplant centers but is rather related to tality. In this regard, our data corroborates the findings
the allo-HCT patient population. from other studies that consistently report increased
We identified 3 risk factors predictive for 30-day risks of readmissions in patients with underlying
hospital readmissions including HCT-CI, TBI-con- chronic medical conditions [7,10-12]. A reasonable
taining regimens, and infections during index trans- strategy to minimize hospital readmissions because
plant admission. Two of these risk factors (infections of underlying chronic medical conditions would
and use of TBI) are potentially modifiable, but preven- involve scheduling early postdischarge outpatient
tion of infections during index admission may be par- follow-ups with appropriate subspecialty physicians.
ticularly challenging for a number of reasons. First, the Model-based readmission probabilities calculated
increased rate of infectious complications in myeloa- based on the number of risk factors facilitate stratifica-
blative allo-HCT recipients is because of enhanced tion of patients according to their risk of 30-day post-
susceptibility to various pathogens up to a year follow- discharge readmission. According to our model, the
ing allo-HCT until full immune reconstitution is individuals at highest risk are those with high HCT-
achieved [19-21]. Second, discharging allo-HCT CI who received a TBI-based regimen and who devel-
recipients with indwelling central venous catheters re- oped infectious complications during their index
mains a common institutional policy across transplant admission. Identification of these patients before dis-
centers, including ours. Although this practice facili- charge may help improve the quality of their outpa-
tates frequent outpatient blood product transfusions tient care and prevent complications by scheduling
in the early posttransplantation period, it may increase closer follow-ups with their transplant physicians as
the risk for line infections. Third, in order to control well as other specialists.
GVHD, allograft recipients require prolonged immu- The study of heart failure patients across the U.S.
nosuppressive therapy, which itself leads to increased ranked and nonranked hospitals demonstrated that
susceptibility to infectious complications. Further- ranked hospitals had more patient readmissions, but
more, the rate of infections is particularly high in pa- less mortality, compared with nonranked hospitals,
tients who develop GVHD [22]. emphasizing that readmissions and OS possibly
Because the risk of developing life-threatening in- measure distinct quality metrics among heart failure
fections is higher for allo-HCT patients, our institu- patients [11]. In contrast to patients with heart failure,
tional approach has been to require these patients to the correlation between 30-day readmission and
reside within 1 hour of driving distance from the hos- all-cause patient mortality in our study appears to be
pital within first 100 days after allo-HCT. The pa- specific for patients with allo-HCT. Our findings
tients are also expected to have 24-hour caregivers support the notion that quality metrics are highly
and are instructed to notify their transplant nurse or disease-specific and therefore cannot be uniformly
overnight/weekend coverage physician for any fever generalized.
$100.4 F in order to facilitate direct hospital admis- Although the length of index hospital stay for allo-
sion to the bone marrow transplant unit. Such a low HCT was independently associated with overall
threshold for readmission has been used to maximize patient mortality, it was not found to be predictive
rapid detection and management of life-threatening for 30-day readmissions in our study. Prolonged hos-
complications of allo-HCT. Although this strategy pitalization during admission for allo-HCT is gener-
may lead to increased rates of hospital readmissions ally because of serious complications, which could
in patients with allo-HCT, it may also ensure the have possibly resulted in poor OS for the patients in
best quality of care. this study.
Although the type of preparative regimen had no One possible limitation of our study is its retro-
impact on patient survival, the use of TBI-containing spective design with its inherent potential to introduce
regimens was associated with higher rates of readmis- the ascertainment bias. However, our Bone Marrow
sion. A recent large meta-analysis involving over Transplant Database was created independently from
3000 patients from 18 trials compared the outcomes this study and continuous data quality checking has
of TBI/cyclophosphamide and busulfan/cyclophos- been set up to minimize potential bias.
phamide and demonstrated differences in types of In summary, 30-day hospital readmissions follow-
posttransplantation complications [23]. Because TBI- ing myeloablative allo-HCT was associated with poor
containing regimens were associated with 30-day OS. The risk-stratification approach to patient read-
readmission, but not the OS, it is possible that TBI- mission appears to be an essential component of the
induced complications manifested earlier leading to quality-of-care metric among patients with allo-HCT.
880 N. Bejanyan et al. Biol Blood Marrow Transplant 18:874-880, 2012

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