Hematopoietic stem cell transplantation in Europe. Differences between Eastern and Western countries

Abstract

Hemopoietic stem cell transplantation (HSCT) is increasingly used worldwide. The geographical distribution of this procedure is not homogenous within a particular continent. We have previously reviewed these differences in the use of bone marrow transplant in Europe, and in two reports we emphasized the economical reasons explaining these differences. The increasing demand for this high cost procedure represents a challenge for health care institutions. While patients need an optimal therapy, public health is confronted with limited resources. Information on changes in HSCT technology and on factors associated with its utilization might be of help. Insights into mechanisms of HSCT use are essential for rational decision making.

Keywords:

• Bone marrow transplantation
• Economics
• Developing countries

Introduction

Hemopoietic stem cell transplantation (HSCT) is increasingly used worldwide.1,2 Transplant numbers and transplant rates differ among European countries.3^–9 It is essential to get information on the reasons behind these differences. We have previously reported the association of these differences with economics, such as gross national per capita or health care expenditure per capita.10,11 However, they explain only part of the difference. In view of the current and previous political differences, and also in differences in available resources, we compared a few years ago the transplant activity between eastern and western European countries.12 For this purpose we used the European Group for Blood and Marrow Transplantation (EBMT) activity survey and looked at HSCT evolution in selected countries.

Methods

Data collection was based on the EBMT activity surveys introduced in 1990. All EBMT members and affiliated non members are requested annually to report on a survey sheet the number of new patients transplanted during the preceding year by indication, stem cell source, and donor type. In addition, the form collects generic information on the number of re- or multiple transplants, on the percentage of cord blood HSCT and, since 1999, on the percentage of transplants with reduced intensity conditioning. The EBMT survey, which was adopted by the General Assembly as a mandatory self-reporting system, forms an integral part of a prospective quality assurance program (http//www.EBMT.org). The latter includes revalidation of a computer printout of entered data by reporting teams, cross-checking with national transplant registries, and onsite visits.

For this particular analysis, 652 teams in 40 European countries were contacted. Of them, 578 reported their data and 39 reported being inactive. This corresponds to a 94% return rate for all participating teams, and includes 98% of the 461 transplanting EBMT team members reporting to the survey.

Results

Of the total of 578 teams, 334 (58%) performed both allogeneic and autologous transplants; 22 teams (38%) restricted their activity to autologous transplants, and 8 teams (1%) to allogeneic transplants only. Fourteen teams (3%) reported that they had not performed any transplants in that year. The restriction to the 8 eastern and 15 western European countries includes 41 teams in eastern Europe and 475 teams in western Europe. A total of 20 598 first transplants, 6901 (34%) allogeneic and 13,697 (66%) autologous, were carried out in Europe. The selected European countries performed a total of 18 732 first transplants: 6048 (32%) allogeneic and 12 684 (68%) autologous. There were differences between and within eastern and western European countries in all aspects analyzed. In western European countries transplant rates were higher with only slight differences in terms of donor type or indication. The total number of transplants increased from 4234 HSCT in 1990 to their current number and this increase was paralleled by an increase in transplant rates. Transplant rates started at a higher level in western European countries in 1990, increased earlier (and to a greater extent at the beginning of the 1990s), and were always about 33–50% higher than in eastern European countries.

Macroeconomic factors of the individual countries strongly influenced transplant rates. In general, countries with higher gross national income (GNI) per capita had higher transplant rates than countries with lower GNI per capita. There were marked differences between and within the eastern and western European countries in GNI per capita and transplant rates. In general, GNI per capita and transplant rates were lower in eastern European countries, with a few exceptions, such as in the Czech Republic, where transplant rates paralleled the transplant rates of some western European countries despite a lower GNI per capita. The regression analysis suggests a saturation effect of GNI per capita on transplant rates at about US$20 000 per capita with no further increase in transplant rates, which could be attributed to higher income of the countries at higher GNI per capita. There was a clear correlation between team density and transplant rates. Transplant rates were substantially higher in the countries with higher team density. In general, team density was markedly lower in eastern compared to western European countries. There was a clear but weak correlation between GNI per capita and team density, even though, team density had a higher impact on transplant rates than GNI per capita.

Discussion

The present analysis from the EBMT activity survey documents similarities and differences between eastern and western European countries and gives insight into the most recent developments. Transplant rates and team densities were in general lower in Eastern Europe. They were lower in Eastern Europe at the beginning of the EBMT activity survey in 1990 and, with a few exceptions, remained lower despite a continuing increase in HSTC in the majority of countries during the observation period. Transplant rates were lower in Eastern Europe for autologous, allogeneic, or unrelated HSTC and, for all indications alike, eastern European countries started at a lower level in 1990 and followed the massive increase which was observed in early 1990s in western European countries with a delay from a few to several years. Specifically, HSCT from unrelated donors has only begun to be an important part of HSCT activity in eastern Europe in the most recent years.

These data also provide some explanations for the differences. The correlation between transplant rates and certain macroeconomic factors, such as GNI per capita in low-income countries and the absence of such correlation in high-income countries, is easily understood. Below a certain level of economic power, no country can afford a substantial number of HSCT procedures. This has been presented earlier for HSTC and is in general considered to be the case for most of high cost medical procedures. Vice versa, there is no indication that the number of patients with the diseases which are considered as indications for HSTC increases with increasing GNI per capita. Hence, there should be a plateau. A note of caution is necessary. The risk of overuse of resources cannot be neglected in medicine. As such, part of the major increase of HSCT in Western Europe during the mid-1990s was due to a rapid increase in autologous HSCT for breast cancer. Despite thousands of HSCT procedures for breast cancer, the final role of HSCT in the disease remains unknown, and many of the HSCT procedues might, in retrospect, have been of little benefit. Eastern European countries at least made more judicious use of their resources during that time.

Conclusion

The data of the analysis point to an additional important macroeconomic factor–team density. More transplants were performed in countries with more transplants teams per number of inhabitants. There is a need to disseminate a given technology within a country for its optimal use. An access to the procedure is a prerequisite for obtaining a transplant. The question of what is the optimal number of transplant teams compared to the number of inhabitants is still unanswered. The present data at least indicate the need for more than one team per country. This report gives no information on the outcome differences between eastern and western European countries, but simply illustrates the current situation of HSCT in Europe, showing the similarities and differences between eastern and western European countries.