LAUSR

Introduction Stem cell transplant (SCT) is associated with deconditioning and variable need for assistance in instrumental activities of daily living at discharge. Discharge to a rehabilitation facility (RF, [e.g.: skilled nursing (SNF) or inpatient rehabilitation facility (IRF)]) is preferentially avoided due to immunocompromised state and lack of post-transplant expertise. Despite this risk, there are no published reports of poor patient outcomes in SCT recipients discharged to RF. We hypothesized that patients discharged to RF following SCT would experience increased non-relapse mortality (NRM) and decreased overall survival (OS) compared to those discharged to home. Methods A retrospective, matched case-control study was conducted using a case-control ratio of 1:4. The study period included 2007-2017 and cases included patients discharged to SNF or IRF following initial hospital admission for SCT. Controls were matched by autologous or allogeneic source and date of transplant. Pre- and during transplant risk factors for RF discharge were explored. NRM and OS were described via Kaplan-Meier method and compared by log-rank test. Results Over the 10 year period, 2245 transplants were performed with 56 cases identified (3% incidence; 2% allogeneic, 3% autologous). Increasing age, decreasing albumin, female sex, reduced-intensity conditioning regimen, and high risk hematopoietic cell transplant comorbidity index (HCT-CI) score were associated with increased risk of RF discharge (table 1). During transplant, culture-positive or serologically confirmed infection (odds ratio [OR]: 2.51, 95% confidence interval [CI]: 1.36 – 4.69, p=0.0027) and new or worsening arrhythmia (OR: 2.93, 95% CI: 1.39 – 6.16, p= 0.0058) were associated with increased risk of RF discharge. One-year OS and NRM were better for home compared to RF discharged patients (OS: 88.8% [95% CI: 83.6-92.4%] v. 70.5% [95% CI: 55.8% - 81.1%], p = 0.0055; NRM: 4.9% [95% CI: 2.6% - 8.9%] v. 14.6% [95% CI: 7.2% - 28.4%], p = 0.0237). OS for allogeneic RF discharges was 82.4% at 100 days (95% CI: 54.7% - 92.9%) and 38.8% at 1 year (95% CI: 16.3% - 61.1%). OS and NRM are shown in Figures 1 and 2. Discussion We have demonstrated greater odds of all-cause and non-relapse mortality associated with RF compared to home discharge. Early OS for autologous RF discharges is similar to allogeneic home discharges. The risk of RF discharge may be reduced by mitigating pre-transplant factors including nutritional status and HCT-CI. In cancer care, pre-habilitation is any intervention prior to cancer-directed therapy designed to increase tolerability. Our identification of pre-transplant risk factors for RF discharge warrants further prospective study of pre-habilitation, especially as it relates to nutritional status. Exploring the role of caregiver status for female gender transplant recipients requires further exploration.