Health care utilization
Although payer source and median household income were not significantly different between the transplant and the non-transplant arms, the total charge for each admission was higher in the transplant arm.(Table 2) . ED visits were similar in both arms (p = 0.56). Elective admissions were more in the transplant arm compared to the non-transplant arm (p = 0.0244). Length of stay was prolonged in transplant arm (18 days) compared to non-transplant arm (6.8 days) and was statistically significant (p<0.001). When comparing the morbidities, lymphomas, ulcerative colitis and autoimmune complications of WAS were seen only in the non-transplant arm (Figure 2) . Of 85 centers, only 10% centers had 42% (2.8-9.1% each) of the hospitalizations and 90% of the centers had less than 2.5% of hospitalizations each (Table 3) .
DISCUSSION :
This study is one of the largest database reviews for patients with WAS, with data from all over the United States over a 6-year period. We found very interesting results with the review of the KIDS inpatient database made available through HCUP.
The study showed 7 female patients with WAS seeking medical care, and all of them were in the non-transplant arm. Females with WASP gene mutations are usually asymptomatic as their mature blood cells have nonrandom X chromosome inactivation, with the chromosome having normal WASP gene active in most cells. Prchal et al12 looked at X-chromosome expression in the mother of two siblings with WAS and suggested that there is selection against cells expressing the defective WASP gene in the hematopoietic system in carriers. Fearon13 et al studied eight carriers of WAS defect and identified skewed patterns of X chromosome inactivation in T-cells, granulocytes and B cells. Multiple other studies have been done to look at the carrier state in WAS14,15,16. A case report for a female presenting with mild WAS symptoms was found to have 60% of normal WASP levels in peripheral blood mononuclear cells, compared to actual cases of WAS where WASP levels were 0-20%.17She was noted to have heterozygosity with 2 distinct populations in her lymphocytes and monocytes. Many other case reports have been described with females with WAS symptoms.18-22 Hypothesis for disease expression in a female with heterozygosity to the WASP mutation are either : abnormality in transcriptional X chromosome silencing in the hematopoietic stem cells, or abnormality in the process that leads to preferential survival and expansion of cells that bear the active wild-type X chromosome.23
Post-transplant hospitalization is the largest contributor to health care utilization for transplant patients. We noted that the length of stay (LOS) was longer in transplant patients compared to the non-transplant patients, especially in admissions associated with transplant as a procedure code, with mean LOS of 8 days for non-transplant arm and 18 days in the transplant arm. In a study using national claims database of commercially insured population in the United States, Majhail et al24 showed that the median duration of hospitalization was 19 days for autologous HCT recipients and 31 days in allogenic HCT recipients. The median days of hospital stay after the transplant was 21 days in <20-year age group for autologous HCT and 42 days for allogenic HCT. In another multicenter cohort study25, LOS compared between different graft sources in the first 100 days after transplant for acute leukemias showed umbilical cord blood (UCB) and mismatched unrelated donor transplants (MMUD) to have a longer hospital stay compared to matched unrelated donors (MUD). The median value of LOS in the pediatric group were 50 days for single UCB, 54 days for double UCB and 60 days for MUD HCT. Our study suggests a much lesser LOS in WAS patients, but the graft source for our patients was not available in the database.
Due to restricted availability of HCT, concerns have been raised regarding disparities based on race, socioeconomic status, education and insurance status. Our study revealed more African Americans (18.3%) in the non-transplant arm compared to transplant arm (6.8%). This disparity could be explained by lack of donor sources, access to HCT and outcomes of HCT. Cancer facts and figures summarized by the American Cancer Society in 2019 show highest incidence of cancer and deaths in African Americans when compared to other races26. HCT is an expensive procedure, hence socioeconomic factors create a barrier to its easy access. Also, allogenic HCT needs appropriate HLA-matched donors, and the likelihood of matching between two random individuals increases if they are of the same race. The National Marrow Donor Program’s Registry27 has about 16 million potential donors, 7% of them are African Americans, 6% Asians and 1% American Indian/Alaskan Native, and they have ongoing initiatives to increase the diversity of the pool. Barker et al28 in a prospective study conducted between 2005–2017 found that increasing registry size has not resolved the racial disparity and suggested use of alternative graft sources such as cord blood transplant. However, unavailable matched donors continue to be a barrier to HCT in these populations.
WAS is a disease identified at a young age due to multiple infections or bleeding manifestations. Sullivan et al29 found that 36% patients with WAS experience non-HCT associated deaths at a mean age of 8 years, mostly due to infections (44%), bleeding (23%) and malignancy (26%). This study also found that the median survival was 20 years in patients with WAS with supportive care only. Our study showed most admissions were in the 0-5 year age group for both arms, which suggests early identification of the disease. Our hypothesis is due to increased awareness and ease of diagnosis, cases are more easily identified. Also, greater number of children > 5 years age required admission in the non-transplant arm, suggesting increased complications and medical needs with increased age. We were further able to consolidate this hypothesis by looking at the complications in both arms. We found that none of the patients in the transplant arm developed lymphoma, whereas 5.6% patients in the non-transplant arm developed lymphoma. Malignancies in untreated WAS has been reported as 13%29 and 22%30 in two different case series, including lymphomas, leukemias and myelodysplasia. Similarly, autoimmune manifestations are much more common in untreated WAS, ranging from 22% to 72% in various case series29,30,31,32. This was similarly reflected in our study where ulcerative colitis was noted only in the non-transplant arm compared to the transplant arm. Due to limitation of our database, we were unable to compare the course of WAS in the two arms beyond 20 years of age.
Our study did not show splenectomy done in either arm. There have been controversies regarding splenectomy if a potential donor is present, but this represents a shift in practice even in the non-transplant arm. Mullen et al33 had shown median survival of 25 years in splenectomized non HCT patients, compared to less than 5 years in unsplenectomized patients. Infectious complications related to splenectomy has been shown to be significant in WAS patients receiving HCT.34 Moratto et al35 observed the long term outcomes for WAS and HCT over a 30 year period and showed that splenectomy may normalize platelet counts after HCT, however, there are associated risks of potentially fatal infections that need to be considered. Imai et al30 had similar results of improvement in platelet counts after splenectomy, but with increased risk of life-threatening meningitis/sepsis. Our study shows a significant shift in practice away from splenectomy for management of thrombocytopenia.
Our study did not show significant difference in mortality between the two arms, but it is not reliable given that ours is an inpatient database. However, our study agrees with other studies that HCTs done at <5-year age group have better outcomes.34,35
STRENGTHS AND LIMITATIONS :
The KID inpatient database is one of the largest pediatric inpatient databases, with each data set providing 3-years data, with roughly 2 to 3 million discharges (unweighted), which corresponds to a national estimate of 6 to 7 million (weighted) discharges per data set. Our study has incorporated 2 datasets, which amounts to about 12-14 million (weighted) discharges and therefore, is a very powerful tool to study a rare disease like WAS.
There are several limitations to this study that need to be discussed. Since this is an administrative dataset, there are limitations to using it for secondary analysis of clinical outcomes. The data is based on each hospitalization and is patient specific, hence we are unable to provide exact rates based on patient numbers. This is an inpatient dataset, outpatient care and mortality in the outpatient setting cannot be assessed. There might be errors secondary to incorrect ICD-9 coding, which are not avoidable in a large dataset study like these. However, there have been several studies that have looked at the sensitivity of ICD-9 codes10,11. This dataset is a pediatric dataset for <21 years of age, and hence we were not able to analyze the course of the disease beyond that age.