The role of cytotoxic therapy with hematopoietic stem cell transplantation in the treatment of diffuse large B cell lymphoma: update of the 2001 evidence-based review.

Clinical research published since the 2001 evidence-based review on the role of hematopoietic stem cell transplantation (SCT) in the treatment of diffuse large B cell lymphoma (DLBCL) in adults is presented and critically evaluated in this update. Treatment recommendations that remain unchanged from the original review include: (1) autologous SCT as salvage therapy is recommended for patients with chemosensitive relapsed DLBCL; and (2) autologous SCT is not recommended for patients who achieve a partial response to an abbreviated induction regimen. New treatment recommendations based on new published data include: (1) autologous SCT as first-line therapy is not recommended for any IPI group; (2) planned tandem or multiple sequential autologous SCT is not recommended; (3) peripheral blood is the standard stem cell source for autologous SCT; (4) age is not a contraindication for autologous SCT, although outcomes in older adults are not as good as in younger adults. There are insufficient data to make recommendations on the routine use of rituximab maintenance after autologous SCT, autologous versus allogeneic SCT, fewer versus more cycles of induction therapy prior to autologous SCT, or the use of reduced intensity versus myeloablative conditioning regimens. Areas of needed research in the treatment of DLBCL with SCT were identified and are presented in the review.

A commercial transplant network's perspective of value in solid organ transplantation: Strategizing for value in transplant care.

INTRODUCTION: Solid organ transplantation has been an area of great interest to commercial payers ever since it moved into mainstream medical care beginning in the 1980s. Over the years a system of evaluating transplant program performance based on volume and one year graft and patient survival has developed. While this system has served its purpose, there is an increasing realization from payers that a need exists for a more sophisticated way to evaluate quality and cost-effectiveness of these complex procedures. We report on the perspective of a large transplant network and its efforts to better understand the drivers of value over the entire continuum of care from referral through one year post-transplant. METHODS: We evaluated members of a large commercial health plan who were referred for solid organ transplantation between January 1, 2010 and April 30, 2014. A total of 18,453 cases were evaluated for both clinical and economic outcomes. RESULTS: We report on two areas that can impact value over the entire continuum of care. Large variation in clinical practice and cost was noted. The observed variation was independent of inclusion in the transplant network's preferred network. The average pre-transplant and post-transplant costs for kidney, liver and heart transplantation cases at center level showed a variation of between 18 and 250% of the network's average. Clinical outcomes of median days on the waitlist, waitlist mortality and readmission within thirty days after transplant also showed wide variation. There was similar wide variation in cardiac evaluation of transplant candidates despite the existence of published recommendations. We demonstrated that pre-emptive renal transplantation is a high value strategy for this membership independent of donor source. CONCLUSION: In the studied population the data show wide variation in both clinical and economic parameters related to the transplant process in programs with statistically similar one year patient and graft survival. These results require further examination. In this era of increased concern about delivering value in medical care we may need to reassess how we evaluate organ transplantation programs.