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Current situation and development of hematopoietic cell transplantation centers: A nationwide survey in China

Year: 2024

Type: article

Abstract: To the Editor: Hematopoietic cell transplantation (HCT) is a vital modality to cure severe hematological disorders.[1] Global or regional summarized data of HCT are annually reported by the Chinese Blood and Marrow Transplantation Registry Group (CBMTRG), European Society for Blood and Marrow Transplantation (EBMT) and Center for International Blood and Marrow Transplant Research (CIBMTR). It is shown that the number of transplants is continuously increasing, particularly in China in recent years.[2] Since the donor accessibility is significantly addressed by the well-established protocol of haplo-identical HCT (haplo-HCT), the requirements of HCTs in China is expected to be sustained for decades.[3] However, the capacity of Chinese HCT centers is hardly investigated. A comprehensive description of the current status is beneficial for capacity construction adapted to the rapid development of HCT in the future. This survey was designed by the National Clinical Research Center for Hematologic Diseases at Suzhou. Survey information, definitions and demonstrations of the variables, as well as statistical details, are shown in Supplementary Materials, https://links.lww.com/CM9/B920. There were 83 HCT centers from 23 provincial regions enrolled in this study. Forty-five centers (54%) located in provincial capital cities, and 23 (28%) in prefecture-level cities. Sixty-one centers (74%) and 76 centers (92%) belonged to hospitals with over 2000 beds and grade 3A hospitals, separately [Supplementary Figure 1, https://links.lww.com/CM9/B920]. Sixty-six centers (80%) possessed HCT units independent of their hematological department, and 25 centers (30%) had independent post-HCT departments. Daytime wards were set in 26 centers (31%), and hematological intensive care units (HICUs) in 8 centers (10%). According to the quartile of annual transplant number, centers were divided into: level-1 (≤25 transplants annually): 24 centers, level-2 (26–50 transplants annually): 15 centers, level-3 (51–100 transplants annually): 23 centers, and level-4 (>100 transplants annually): 21 centers [Supplementary Table 1, https://links.lww.com/CM9/B920]. The top quartile centers (level-4) conducted 61.4% (4238/6904) of total transplants. The covariates related to the level of HCT centers were the located city, hospital bed number, and the independence of HCT departments [Supplementary Figure 2, https://links.lww.com/CM9/B920]. Seventy-four centers (89%) conducted both autologous HCT (auto-HCT) and allogeneic HCT (allo-HCT). Four centers (5%) conducted allo-HCT only, and five centers (6%) conducted auto-HCT only. The median experience of auto-HCT and allo-HCT were 20 years and 16 years, respectively. Notably, 74 centers could conduct haplo-HCT. All 83 enrolled centers possessed 1159 HCT units (median [Q1–Q3]: 10 [5–17]) and conducted 6904 transplants (53 [24–101]) in 2020. The total numbers of HCT physicians and nurses were 993 (8 [6–15]) and 1780 (15 [9–23]), respectively. The median number of HCTs per bed and per physician was 5.8 and 6.4, respectively [Supplementary Figure 3A,B, https://links.lww.com/CM9/B920), which increased along with the levels of the centers. The median number of nurses per bed was 1.5, but significantly decreased to 1.2 in level-4 centers (t = 2.234, P = 0.028) (Supplementary Figure 3C, https://links.lww.com/CM9/B920). The quantity of HCT units seemed insufficient that recipients had to wait. Forty-nine centers (63%, 49/78) reported a waiting time of more than 2 months for allo-HCT, and for auto-HCT the proportion was 65% (51/79) [Supplementary Figure 4A, https://links.lww.com/CM9/B920]. After auto-HCT, HCT centers usually recommended patients to go back home (36/79, 46%) or transfer to the normal hematological ward (35/79, 44%). While for allo-HCT recipients, more centers recommended to transfer to the normal hematological ward (43/78, 55%), or to post-HCT department (27/78, 35%). The difference between auto- and allo-HCT was significant (χ2 = 46.258, P <0.001) [Supplementary Figure 4B, https://links.lww.com/CM9/B920]. Although most centers recommended recipients to be followed up by their HCT physicians after either auto-HCT (56/79, 71%,) or allo-HCT (75/78, 96%), but 16 centers recommended auto-HCT recipients to be followed-up by previous hematologists [Supplementary Figure 4C, https://links.lww.com/CM9/B920], which was statistically higher than those after allo-HCT (χ2 = 24.310, P <0.001). Nineteen allo-HCT centers could perform human leukocyte antigen typing, and 61 centers could collect, process and store grafts. However, 81 of the 83 centers could conduct HCT-related tests (chimerism, etc.), and 72 centers had their own laboratories [Supplementary Figure 5A–C, https://links.lww.com/CM9/B920]. Although HCT databases (66/83, 80%) and biobanks (56/83, 68%) were widely established, prospective collection programs were not common (23/83, 28%). Among the 65 centers who set hematological subspecialties, 48 centers (74%) set a HCT subspecialty, and 34 centers (52%) set a post-HCT subspecialty [Supplementary Figure 5D,E, https://links.lww.com/CM9/B920]. The establishement of these subspecialties was generally in accordance with the level of HCT centers. Features of large HCT centers were analyzed by auto-HCT and allo-HCT separately due to the significant disparities between these two approaches. The results of univariate analyses are shown in Supplementary Tables 2,3, https://links.lww.com/CM9/B920. Multivariate analysis for large auto-HCT centers revealed that more beds in hematological department (>100) (odds ratio [OR] = 6.540, 95% confidence interval [CI] [1.142–37.456], P = 0.035) and more auto-HCT per bed (≥3) (OR = 6.457, 95% CI [1.329–31.356], P = 0.021) were independent factors for large auto-HCT centers [Supplementary Table 4, https://links.lww.com/CM9/B920]. For large allo-HCT centers, more beds in hematological department (>100) (OR = 19.838, 95% CI [1.315–299.308], P = 0.031), more allotransplants per bed (≥5) (OR = 18.610, 95% CI [1.694–204.454], P = 0.017), more allotransplants per physician (≥4) (OR = 132.747, 95% CI [1.842–9568.521], P = 0.025), location in large cities (OR = 115.532, 95% CI [1.525–8753.317], P = 0.031), and prospective bio-sample collecting programs (OR = 11.665, 95% CI [1.065–127.754], P = 0.044) had independent correlations with large allo-HCT centers [Supplementary Table 4, https://links.lww.com/CM9/B920]. Distinguished from previous HCT activity reports, this report was a nationwide survey aiming at outlining the current capacity of Chinese HCT centers. Collating with the 2020 report of CBMTRG, the transplants and participating centers in this survey accounted for 51.5% of total transplants and 47.6% of HCT centers, respectively, with a similar distribution on the transplant scale, indicating the representativeness of our survey. Owing to the complexity and difficulty of HCT procedure, the assembly effect was obvious when comparing different levels of HCT centers. Large HCT centers are usually located in large cities and large hospitals, where they can acquire more medical resources. Likewise, these large centers, which accounted for one-fourth of participating centers, conducted nearly two-thirds of both the transplants and allotransplants. Similarly, it was reported in the CIBMTR report that 15% of large HCT centers conducted approximately half of all transplants in the US, which suggests a similar assembly effect for HCT recipients. The management of allo-HCT is much more complicated than that of auto-HCT due to a series of posttransplant complications related to alloreactivity. Accordingly, 14% of centers reported by CIBMTR during 2015–2019 and 31% of centers reported by EBMT in 2020 underwent only auto-HCT, compared to 6% of the centers in our survey. Moreover, more than 90% of allo-HCT centers in our survey performed haplo-HCT, which requires more expertise on allo-HCT. These data hinted that Chinese HCT centers tended to develop a complete capacity of HCT to meet the regional requirements of local patients as a public hospital. However, efforts are still needed in existing HCT centers to improve HCT-related facilities, such as post-HCT departments, laboratories, HICUs, databases, and biobanks, even in large centers. Large HCT centers exerted high efficiency measured by transplants per physician and per HCT unit, which reflected a well-established HCT procedure in large centers. Compared with CIBMTR data[4] in centers of similar levels, transplants per physician seemed lower in our survey, which was partially ascribed to the lack of physician assistants in China. Another potential explanation for the gap in efficiency per physician was that the clinical practice of HCT physicians in China was not restricted to HCT only, and the full-time equivalent was not calculated in our survey. On the other hand, HCT efficiency per unit was higher than the CIBMTR data, which also indicated the lack of HCT units in China. A majority of enrolled centers reported a HCT waiting time of more than 2 months for recipients, and the lack of HCT nurses could be observed as well. An interesting difference between the US and China was the management after allo-HCT. Most allotransplant recipients stay in the hospital after leaving HCT units and are followed up by HCT physicians in China, while most of them in the US prefer to be discharged and followed by first-diagnosed physicians.[5] This evidence suggests that HCT is considered an intermediary procedure during the treatment course for hematological disorders in the US but is somehow an ultimate step in China. The HCT recipients in the US benefited from a better recognition of HCT by hematologists and the well-established patient referral system in the US, which facilitated the regular management of complications post-HCT. Recognizing the features of large HCT centers will provide clues for the development of smaller centers. Although large allo-HCT centers were related to the location of large cities, smaller centers may be dedicated to improving HCT efficiency and supporting facilities, which may accelerate the enhancement of HCT capacity. In conclusion, we outlined the landscape and challenges of HCT centers in China, which were supposed to be beneficial for an individual center as well as for policy-making. Nevertheless, our conclusion was limited by selective bias partially derived from the absence of pediatric centers and private hospitals in the sample and regional differences since there were gaps in economy and welfare among different parts of China; finally, the collected data were inadequate to exhibit the panorama of the HCT centers. The integrated planning of HCT centers aiming at differentiation development will further improve the capacity of HCT in China. Acknowledgments The authors gratefully acknowledge the contribution of Prof. Gorin of the EBMT Paris office for questionnaire design and thank all the respondents who participated in the survey. Conflicts of interest None.

Source: Chinese Medical Journal

DOI: 10.1097/cm9.0000000000002984