Preparing for Growth: Current Capacity and Challenges in Hematopoietic Stem Cell Transplantation Programs

Schriber, Jeffrey R.; Anasetti, Claudio; Heslop, Helen E.; Leahigh, Alan K.

doi:10.1016/j.bbmt.2010.02.010

« Previous Next »Biology of Blood and Marrow Transplantation
Volume 16, Issue 5 , Pages 595-597, May 2010

Preparing for Growth: Current Capacity and Challenges in Hematopoietic Stem Cell Transplantation Programs

Received 3 February 2010; accepted 5 February 2010. published online 17 February 2010.

During the past decade, the demand for hematopoietic stem cell transplantation has grown dramatically, and there are expectations that this will continue or even accelerate over the next decade. This prompts a variety of questions about the ability of the health care system to accommodate the increased demands on transplantation centers; for example, what is the current patient capacity of transplantation programs, and how much elasticity do they have to accept a larger volume of patients? An informal survey of a sample of medical directors of transplantation programs found that existing facilities might be able to increase their patient volume by about 7%. Expanding much beyond that limit will require an infusion of resources to enlarge current programs and/or establish new programs.

Key Words: HSCT, Facility, Growth

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Introduction

According to the Center for International Blood and Marrow Transplant Research (CIBMTR), an estimated 18,600 hematopoietic stem cell transplantations (HSCTs) were performed in the United States in 2006, including about 12,500 autologous, 3800 related allogeneic, and 2300 unrelated allogeneic HSCTs (Center for International Blood and Marrow Transplant Research, unpublished data, 2009). The number of HSCTs performed in the United States increased by 24% over the 5-year period from 2002 to 2006. The most dramatic growth occurred in adult allogeneic HSCT. The National Marrow Donor Program (NMDP) reported facilitating approximately 2160 adult unrelated allogeneic HSCTs in U.S. transplantation centers in 2007, compared with approximately 760 in 1997. The number of pediatric HSCTs also has increased significantly, from approximately 380 in 1997 to approximately 730 in 2007 (National Marrow Donor Program, unpublished data, 2009).

Reasons for Anticipated Growth

There are many reasons to expect continued increases in the number of HSCTs performed in the coming decade. Current tends include the following:

•HSCT is increasingly effective, with continual improvements in treatment outcome.

•HSCT is increasingly safer, with constantly favorable survival rates.

•The number of diseases for which HSCT is indicated continues to grow.

•The sources of donor cells and the number of suitable matches are expanding.

•An aging population is increasing the proportion of people who are susceptible to diseases for which HSCT is indicated.

•Modified transplantation regimens have facilitated safer procedures despite an increase in the median patient age.

•Proposed national health insurance reforms currently under debate in Congress may expand the number of insured patients and reduce economic barriers for more patients.

Anticipating an increasing need for hematopoietic stem cell donors, the NMDP has launched a campaign designed to increase the number of registered donors to accommodate 10,000 unrelated allogeneic HSCTs per year by 2015, more than double the 4300 facilitated in 2008.

Workforce Shortage

A significant concern related to the anticipated increase in HSCTs is whether sufficient hematologists and oncologists specifically trained and experienced in cellular therapies will be available to meet the demand. Gajewski et al. [1] explored this question in a recent commentary in which they estimated the need for an expanded transplantation physician workforce. They estimated the current number of adult and pediatric transplantation physicians at 959 and 156, respectively. Their projections indicated that even with nonaccelerated, straight-line growth, 1264 new adult transplantation physicians and 94 new pediatric transplantation physicians will be needed by the year 2020. These needs are particularly daunting considering the anticipated shortage of physicians across nearly all specialties and primary care, the 10-12 years of postundergraduate training required for subspecialization in HSCT, and the increasing barriers to immigration to the United States faced by foreign-trained physicians.

Exacerbating the transplantation workforce shortage is the fact that most of the growth is expected to be in allogeneic HSCT. Current trends are to perform allogeneic HSCT in older patients and those with comorbidities that once would have been contradictions to transplantation. The increased success in addressing some early causes of mortality has resulted in the welcome consequence of an increased need for post-HSCT management. These patients often have multiple medical issues related to HSCT that might preclude a return to the primary oncologist. These patients often are seen more frequently and require more complex routine and unexpected clinic visits, as well as more complicated late hospitalizations.

Transplantation Facility Expansion

In addition to concerns about workforce shortage, there is the question of how many additional patients can be absorbed by current transplantation programs. Expressed another way, to what degree are current transplantation programs able to accept larger numbers of patients?

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Methods

In an attempt to answer the foregoing question, an informal survey was conducted to quantify the current patient volume and capacity of transplantation programs. Information was gathered from 31 transplantation programs representing nearly 7,000 transplantation procedures in 2008. The survey was conducted at the behest of the American Society for Blood and Marrow Transplantation's (ASBMT) Board of Directors.

The survey sample included the 20 U.S. transplantation programs or centers with the highest volume of allogeneic HSCTs and the 20 U.S. programs or centers with the highest volume of autologous HSCTs in 2002-2006, as identified by the CIBMTR. Twelve centers were on both lists; thus, a total of 28 centers were initially identified. Added to the sample were 6 centers with smaller patient volumes, selected to add their dimension and representation to the sample. In all, 34 centers were invited to participate in the survey.

A questionnaire addressing current patient volume and expansion potential were sent by e-mail to the medical directors of the 34 centers in May 2008. The questions were brief, and the questionnaire was designed to be completed in about 10 minutes. Follow-up telephone calls helped to ensure a high response rate. Information solicited included the number of transplantation procedures performed annually, the number of physicians and “physician extenders” (eg, physician assistants, nurse practitioners), the nurse-to-patient ratio, and the number of additional transplantations that could be performed with current resources and staffing levels. Also included were questions about factors that might limit expansion, changes foreseen in the transplantation field, and how the ASBMT could help manage those changes.

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Results

Thirty-one of the 34 centers completed the survey, for an overall response rate of 91%. Included among the respondents were medical directors at 19 of the 20 largest allogeneic HSCT programs, 6 of the 8 largest autologous HSCT programs, and all 6 of the smaller programs. In total, the centers represented 6937 transplantations, 313 transplantation physicians, and 204 physician extenders.

One of the questions asked was whether the center would need additional resources to increase the number of patients served. The centers reporting no need for additional resources were then asked to project how many additional transplantations they could perform.

Eleven of the 19 large allogeneic HSCT programs reported that they were already operating at capacity and could not accept a larger patient volume without increased resources. The other 8 of these centers together estimated being able to perform 210 additional transplantations. One of the 6 large autologous HSCT centers reported operating at capacity. The other 5 centers together estimated that they could perform 274 additional transplantations. Two of these centers indicated that the additional patients would severely strain current staff and resources, however, so this number might be overly optimistic. Among the 6 smaller centers surveyed, 4 reported being at capacity, and the other 2 reported the ability to increase their annual patient volume by a total of 30 patients. Adding all of these figures, the centers representing a current volume of 6937 patients reported the capacity to perform 514 additional transplantations per year, an increase of about 7%.

Among the other survey findings were the following:

•The median ratio of annual transplantations per physician was 25:1.

•Every center reported using “physician extenders,” such as physician assistants and nurse practitioners. Combining these personnel with physicians, the median ratio of annual transplantations per health professional was 14:1.

•Thirteen of the 31 centers (42%) were actively looking for additional medical personnel, and most reported having difficulty filling current staffing needs.

•Transplantation physicians are the most difficult to find, although shortages of physician extenders, nurses, pharmacists, and stem cell laboratory staff were reported as well.

•Every center mentioned burdens in meeting the accreditation requirements of the Foundation for the Accreditation of Cellular Therapy (FACT) and the unfunded federal requirements for reporting outcomes to the Stem Cell Transplant Outcomes Database (SCTOD).

•Recruitment of new fellows is hindered by a lack of recognition for transplantation clinicians, a perceived lack of major clinical advances in the field, and a shortage of funding for clinical trials. Another repeatedly mentioned concern was that the lifestyle of transplantation physicians was not attracting many hematology and oncology fellows, who seem to favor outpatient specialties with fewer demands on personal time. There also was a concern that the expected growth in the number of patients per transplantation physician could aggravate the negative perceptions about lifestyle.

ASBMT Assistance

The survey respondents suggested the following ways in which the ASBMT could help address these issues:

•Seek increased funding from government and industry for clinical and basic research.

•Seek funding to support required reporting of treatment outcomes.

•Seek reimbursement from public and private third-party payers for donor acquisition and typing and for such diseases as myelodysplastic syndrome.

•Develop common transplantation guidelines and requirements for third-party payers.

To help alleviate the time and resource burdens imposed by FACT, some survey respondents suggested that the ASBMT could develop templates for standard operating procedures and quality assurance programs. The respondents also suggested that the ASBMT help recruit fellows and residents to the field of transplantation and encourage those currently practicing in the field to remain active. Suggested approaches included educational incentives, certification of the specialty, and increased interaction among clinicians and investigators to promote research advances. Respondents indicated that similar recruitment efforts are needed to bring physician extenders into the transplantation field as well.

Finally, respondents recommended that the ASBMT work to ensure that data collected by the SCTOD are interpreted correctly. There was a concern that third-party payers could use the data to preclude patients from transplantation, or that centers might turn away high-risk patients who might jeopardize their treatment outcomes scores.

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Conclusion

Although this survey of transplantation centers regarding their ability to absorb additional patients was neither comprehensive nor statistically representative, it did include most of the largest programs and a sample of smaller programs, sufficient to give a general indication of capacity. Among the 31 centers representing 6937 transplantations performed in 2008, the estimated potential for expansion was 7%. That degree of elasticity falls well short of the expected increased demand for transplantation. Recognition of this issue is a critical step for the field and should help justify the need for increased resources and incentives to recruit and retain transplantation personnel.

The power and scope of this survey are limited. There is a need for a formal census of transplantation facilities, workforce activities, and compensation to facilitate planning for anticipated growth and developing strategies for marshalling resources and recruiting transplantation personnel.

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Reference

Gajewski JL, LeMaistre CF, Silver SM, et al. Impending challenges in the hematopoietic stem cell transplantation physician workforce. Biol Blood Marrow Transplant. 2009;15:1493–1501