- Email: [email protected]
Activity and Capacity Profile of Transplant Physicians and Centers in Australia and New Zealand
Accepted Manuscript Title: Activity and Capacity Profile of Transplant Physicians and Centers in Australia and New Zealand Author: Ian Nivison-Smith, Samuel Milliken, Anthony J. Dodds, David Gottlieb, John Kwan, David D.F. Ma, Peter J. Shaw, Steven Tran, Leonie Wilcox, Jeff Szer PII: DOI: Reference:
S1083-8791(17)30722-X https://doi.org/doi:10.1016/j.bbmt.2017.09.011 YBBMT 54803
To appear in:
Biology of Blood and Marrow Transplantation
Received date: Accepted date:
14-6-2017 18-9-2017
Please cite this article as: Ian Nivison-Smith, Samuel Milliken, Anthony J. Dodds, David Gottlieb, John Kwan, David D.F. Ma, Peter J. Shaw, Steven Tran, Leonie Wilcox, Jeff Szer, Activity and Capacity Profile of Transplant Physicians and Centers in Australia and New Zealand, Biology of Blood and Marrow Transplantation (2017), https://doi.org/doi:10.1016/j.bbmt.2017.09.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Activity and Capacity Profile of Transplant Physicians and Centers in Australia and New Zealand
Authors Ian Nivison-Smith, BSc MAppStat PhD1 Samuel Milliken, MB BS FRACP FRCPA2 Anthony J Dodds, MB BS (Hons) FRACP FRCPA2 David Gottlieb, MB BS FRACP FRCPA3 John Kwan, MB BS FRACP FRCPA3 David DF Ma, MB BS MD FRACP FRCPA2 Peter J Shaw, MA MB BS MRCP FRACP4 Steven Tran, BEng, MBiomed E1 Leonie Wilcox, BSc1 Jeff Szer, B Med Sc MB BS FRACP5 Affiliations 1 Australasian Bone Marrow Transplant Recipient Registry (ABMTRR), Darlinghurst NSW, Australia 2 St Vincent’s Hospital, Darlinghurst NSW, Australia 3 Westmead Hospital, Westmead NSW, Australia 4 The Children’s Hospital at Westmead, Westmead NSW, Australia 5 Royal Melbourne Hospital, Parkville Victoria, Australia Corresponding author Ian Nivison-Smith ABMTRR, Level 6 The Kinghorn Cancer Centre, 370 Victoria St DARLINGHURST NSW 2010 Australia Email address: [email protected] Phone number: 61 2 9355 5693 Short title: Capacity profile of HCT centers in Australia and New Zealand Keywords: Hematopoietic; Cell; Transplantation; Australia; New Zealand Conflict of Interest The authors declare no financial relationship with any organizations that have a direct financial interest in the subject matter discussed in the submitted manuscript. Financial disclosure statement The authors declare no financial relationship with any organizations that have a direct financial interest in the subject matter discussed in the submitted manuscript.
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Highlights
This study reports on the profiles of HCT physicians in A&NZ.
The median age of HCT physicians was 48 and 31% were female.
HCT physicians spent an average of 31.7% of their time on HCT related tasks.
Physicians perform an annual average of 10.6 allogeneic and autologous HCT.
Physician HCT workloads are projected to increase in future years.
Abstract
We conducted a study to analyze and report on indicators of hematopoietic cell transplant (HCT) physician time use and HCT center output measures. HCT centers in Australia and New Zealand (A&NZ) were invited to provide demographic and time use details for physicians participating in HCT patient care (HCT physicians). Resource details for adult and pediatric centers were included. From a total of 46 centers that were invited to participate, completed data were received from 37 (80%) representing 185 HCT physicians, with a median age of 48 (range 33-72), of whom 31% were female. Just over half of HCT physicians cited prior work experience in large overseas HCT centers (97, 52%) and over one-third (79, 43%) possessed postgraduate qualifications other than specialist training. Total annual mean HCT per HCT physician FTE was 14.2 for centers performing both allogeneic and autologous HCT, 6.6 for autologous only centers and 10.6 for all centers. For all HCT physicians surveyed, the mean proportion of time spent on HCT related tasks was 31.7%. In A&NZ, for centers that perform both allografts and autografts, there was a mean of 4.0 allogeneic HCT annually per HCT bed, compared to 2.6 for the USA, and 7.1 allogeneic HCT annually per HCT physician FTE (USA 6.3). Projections of the
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A&NZ HCT physician workforce indicated that the numbers of HCT physicians are likely to stay within the region of 170 to 190 for the next 10 years, while HCT activity will likely continue to climb steadily. Healthcare and government authorities should be prepared to enable and support greater HCT activity in A&NZ in the future.
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Introduction
The numbers of HCT performed worldwide is reported to have risen steadily in recent years [1,2,3,4]. In addition, numbers of HCT survivors continue to increase [5]. In Australia and New Zealand (A&NZ), total annual numbers of autologous and allogeneic HCT increased from 1,359 in 2005 to 1,736 in 2013 [6] and 1,966 in 2015 (unpublished), a 2005-15 increase of 45%.
A study carried out in the USA in 2008 indicated that most large HCT centers were working to their full capacity and would not be able to increase numbers of HCT performed without an increase in staff and resources [4]. The study also predicted an increased need for HCT physicians and a possible shortage in future years. A detailed study by Majhail et al published in 2011 analysed data on transplant center capacity and allogeneic HCT activity in the USA in the period 2005 to 2009 [7]. The study reported that numbers of allogeneic HCT had increased by 29.9% in this 5-year period. The study also found that in 2009, there were means of 2.6 allogeneic HCT per HCT dedicated bed, 6.3 allogeneic HCT per HCT physician Full-Time Equivalents (FTE) and 2.4 HCT dedicated beds per HCT physician FTE [7]. In 2014, the National Marrow Donor Program (NMDP) published a report from their System Capacity Initiative Physician Workforce Group indicating that the number of unrelated donor HCT was likely to double in the USA between 2010 and 2020 and a future shortage of HCT physicians was possible [8].
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It would be advantageous for management and planning purposes to understand the current capacity of HCT centers in regard to staffing resources and bed numbers compared to HCT performed. The current study aimed to collect and analyse details on transplant physicians and centers in A&NZ, report on relevant indicators of capacity and output measures and compare results with international experience.
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Materials and Methods
All centers that perform allogeneic and/or autologous HCT and report to the Australasian Bone Marrow Transplant Recipient Registry (ABMTRR) were invited to participate in this study (n=46). All HCT centers in A&NZ are associated with academic institutions. Every center that consented to participate was sent a data entry spreadsheet asking for demographic and workforce details of physicians who participate in the primary care of HCT patients at the center (regardless of the percentage of time they spent on this practice), plus questions on bed capacity and numbers of junior medical staff. Physicians were identified by a code (i.e. Physician 1, Physician 2 and so on), and physician names were not requested (see Supplementary Figure 1, ABMTRR Study Questions Template). All physicians included in this study are termed as “HCT physicians” regardless of hours worked.
Comment [RE1]: AU: Please confirm it is appropriate to add this document as a supplementary file.
Responses to the questionnaire were collected from participating centers between October 2015 and August 2016. HCT activity for each center for the calendar year of 2015 was used as baseline data.
HCT physicians were asked to provide details on their position title, sex, year of birth, postgraduate qualifications, prior experience in overseas transplant centers and hours worked in an average week. Postgraduate qualifications were defined here as postBachelor level tertiary qualifications other than specialist training (i.e. other than FRACP FRCPA or equivalent in A&NZ). In A&NZ, until approximately 2016 the basic medical degree was MBBS (Bachelor of Medicine / Bachelor of Science) or similar, and an MD was a postgraduate degree completed through scientific / medical
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research. Recently the majority of Australian universities have offered a basic medical qualification as an MD. However, the results of the current study refer to the situation in place at the time when the MBBS was the standard basic medical degree. The hematologist training path is a basic medical degree followed by specialist training, accompanied in individual cases, by choice, by a postgraduate degree. Transplant fellowships are available on application to augment clinical hematology training but are not necessary for practice in HCT haematology. Physicians were further asked to provide estimates of average (mean) time spent on different activities by allocating a percentage of time to each task. The following tasks were nominated: Autologous HCT - inpatient care, Autologous HCT - outpatient care, Allogeneic HCT - inpatient care, Allogeneic HCT - outpatient care, Administration - HCT related, Administration - other than HCT related, Research including clinical trials - HCT related, Research including clinical trials - other than HCT related, General Hematology and Other Tasks, which respondents were asked to specify.
Physicians were allocated an FTE value according to the number of hours they were paid for, with 40 hours or more considered to be 1 FTE and amounts less than this given a proportion based on actual hours paid. The term “HCT physician FTE” refers to the fraction of full-time work represented by that HCT physician’s stated hours worked and in this study is a number ranging from 0.125 to one. This is the same definition as used by a US study that the current study has been compared to [7]. A special measure of “HCT dedicated physician FTE” was also calculated, as HCT physician FTE multiplied by the self-stated average percentage of time spent on HCTrelated tasks by that HCT physician. This measure has not been compared to overseas studies.
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Centers were classified as performing either “Autologous only” or “Autologous and allogeneic” HCT - there were no “Allogeneic only” centers. A classification of “Adult” or “Paediatric” was also applied according to the center type. In 2015, the median number of HCT performed by “Autologous” centers was 24, while for “Autologous plus allogeneic” centers the median activity was 64. On this basis, centers were further classified as “large allo + auto” with a combined allogeneic and autologous activity of 64 or more in the calendar year of 2015, “small allo + auto” with a combined allogeneic and autologous activity of less than 64, “large auto” with an autograft activity of 24 or more, or “small auto” with an activity of less than 24.
Centers were asked how many beds were reserved exclusively for HCT patients, and if there were none, how many beds were occupied by HCT patients on a typical day. Number of HCT beds for the centre was calculated as the number nominated by the institution as either number reserved for HCT patients or, if none, average (mean) number of beds occupied by HCT patients.
A number of indicators were calculated to describe physician and center activity, including annual HCT activity per HCT bed, annual HCT activity per HCT physician FTE and annual HCT activity per HCT dedicated physician FTE. These measures were compared among centers according to nature of activity (auto + allo vs auto only), size (small vs large), center type (adult / paediatric) and country (Australia vs New Zealand).
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Ten-year projections of numbers of HCT physicians in the A&NZ workforce were constructed by adding a year of age to each of the surveyed physicians for every year from 2015 to 2025, and counting the number each year whose projected ages fell between 33 and 68. The lower limit of 33 was chosen because no HCT physician in the study was younger than this, and the upper limit of 68 was chosen as only 3 physicians in the study were older. On the basis of numbers of 33 to 39 year old physicians in the surveyed group, it was estimated that the average entry of new transplant physicians to the population was around four per year, and this number of physicians was added each year and given an age of 33. Projections of the numbers of HCT performed each year were constructed by taking the average annual per cent change in numbers over the years 2006 to 2015 for centers that participated in the study (4.2% annual increase) and applying this to the figure for 2016 and following.
All analyses were carried out using Statistical Package for the Social Sciences (SPSS) software Version 21 (IBM, Armonk NY USA, 2012). Cross-tabulations of physician characteristics were tested for statistical significance using Fisher’s Exact Test.
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Results
From a total of 46 centers that were invited to participate, completed data were received from 37 (80% - Table 1). These responding centers represented 88% of the total HCT activity of A&NZ centers in calendar year 2015. Of the responding centers, 19 performed both allografts and autografts, representing a total of 633 allografts and 607 autografts in 2015. A further 18 centers performed autografts only, representing a total of 512 autografts in 2015.
Large allo + auto centers (those with 2015 activity of 64 or more – the median for allo + auto centres) performed 903 HCT and employed 49.0 HCT physician FTEs in 2015 while small auto + allo centers performed 333 HCT and employed 37.8 HCT physician FTEs. Large auto only centers (those with 2015 activity of 24 or more – the median for auto only centres) performed 385 HCT and employed 47.8 HCT physician FTEs while small auto only centers performed 131 HCT and employed 30.4 HCT physician FTEs (Table 1). Among the 37 responding centers, 13 (35%) maintained beds that were exclusively allocated to HCT patients while 24 (65%) did not. The responding centers employed a total of 165.0 HCT physician FTEs, 107.0 hematology trainee FTEs, 10.0 BMT fellow FTEs and 108.1 other junior medical staff FTEs.
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A total of 185 HCT physicians were counted (responses, not FTEs), comprising 95 from allo + auto centers and 90 from auto only centers. The median age of HCT physicians is shown in Table 2. Among HCT physicians surveyed in A&NZ aged 3349yr, 37% were female, while the corresponding percentage for physicians aged 50yr and above was 24% (P = 0.08). Just over half of HCT physicians cited prior work experience in large overseas transplant centers (97, 52%) and more than one-third (79, 43%) possessed postgraduate qualifications other than specialist training (Table 2). The proportion of HCT physicians with prior experience in major overseas transplant centers was 45% for the <50yr group and 62% for the 50yr+ group (P = 0.02). For the <50yr group, 44% had a postgraduate qualification, while for the 50yr+ group this proportion was 41% (P = 0.8).
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Across all centers, the median number of hours worked per week for full-time HCT physicians was 54, while median hours paid was 40. For allo + auto centers, the median hours were 55 worked and 40 paid, while for auto only centers the median hours were 48 worked and 40 paid. For adult centers, the median hours were 55 worked and 40 paid, while for paediatric centers the median hours were 50 worked and 40 paid. For all HCT physicians surveyed in A&NZ (full-time and part-time), the median number of hours worked per week was 50.
The
proportion of time spent on HCT related tasks was 31.7% for all HCT
physicians. HCT physicians at allo + auto centers spent 43.9% of their available time on HCT related tasks while for those at auto only centers this figure was 18.9% (Figure 2). The overall proportion of HCT physician time spent on HCT related tasks was 50.8% in large allo + auto centers, 34.1% in small allo + auto centers, 23.3% in large auto centers, and 11.5% in small auto centers.
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Table 3 shows a set of capacity and activity indicators for transplant centers. The measure of total annual HCT per HCT physician FTE was 14.2 for allo+auto centers, 6.6 for auto only centers and 10.6 for all centers. HCT activity per HCT physician FTE was higher for large (13.3) compared to smaller (6.8) centers, New Zealand (13.2) compared to Australian (10.3) centers and adult (11.4) compared to pediatric (6.5) centers.
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“HCT dedicated physician FTE” is the physician’s FTE multiplied by the percentage of time spent on HCT-related tasks. While a total of 185 HCT physicians were counted, representing 165.0 HCT physician FTEs, the sum of HCT dedicated physician FTEs was 50.9 (Table 1). Total annual HCT activity per HCT dedicated physician FTE was 33.6 for allo + auto, 36.7 for autos only and 34.4 for all centers.
Comparisons between A&NZ and US activity indicators can be seen in Figure 3. In A&NZ, it was calculated, for centers that perform allografts and autografts, that there were
means
of 4.0 allogeneic HCT annually per HCT bed, compared to 2.6
calculated for the USA [7]. Additionally, in A&NZ there were 7.1 allogeneic HCT annually per HCT physician FTE, compared to 6.3 calculated for the USA [7]. A survey distributed to American Society for Blood and Marrow Transplantation (ASBMT) members in 2010 showed that 75% of US respondents were male (compared to 69% of A&NZ respondents), 46% were aged 50 or over (A&NZ 44%) and 87% worked more than 50 hours per week (A&NZ 41%) [8].
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Projections of the transplant physician workforce indicated that if current trends continue, the numbers of HCT physicians in A&NZ, in the centers that responded to this study, are likely to stay within the region of 165 to 180 FTEs for the next 10 years. Adjusting for non-response, this yields an estimate of between 188 and 205 HCT physician FTEs for all A&NZ centers in the next 10 years, including those that did not respond to this study. However, projections of the number of HCT performed in A&NZ at centers that participated in the study show that if the recent mean annual increase of 4.2% is sustained, the number of HCT would increase by 51% between 2015 and 2025. Using these figures, the mean number of HCT per HCT physician FTE per year was 10.6 in 2015 and projected to be 14.4 in 2025 – an increase of 36% (Figure 4). The corresponding projections for adult centres were 11.1 in 2015 and 14.9 in 2025 (increase of 34%), while for paediatric centres they were 5.3 in 2015 and 7.3 in 2025 (increase of 38%).
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Discussion
This study is the first investigation of workplace activity in the medical discipline of HCT in A&NZ, and aims to provide characteristics of the HCT workforce and the tasks that are carried out, to assist in evaluation and planning.
The total of 37 centers that responded to this study represents a large proportion (80%) of all centers (n=46) currently engaged in performing HCT in A&NZ, representing 88% of total HCT activity in 2015. Representation was high in each of the categories of “Large allo + auto” (10 responded from a total of 11), Small allo + auto” (9/10), “Large auto” (10/13), and “Small auto” (8/12). There was good response from both adult (31/38) and paediatric (6/8) centers, and also a good level of response from both Australian (33/40) and New Zealand (4/6) centers. Broadly, although not a complete enumeration, the centers that responded to this study can be considered to be representative of all centers across A&NZ.
The classification of centers into “Large allo + auto”, “Small allo + auto”, “Large auto” and “Small auto” was made on the basis of activity in the years 2015. Analysis on the basis of size / activity category indicates that large allo + auto centers have a relatively large share of transplant activity (52%) with a lower share of HCT physician FTEs (30%) but a higher share of HCT dedicated physician FTEs (46%), confirming that transplant physicians in these centers are spending on average more of their time on HCT-related activities (50.8%) than is the case in other center types (23.5%).
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In a recent US survey of allogeneic HCT units, 93% of both adult and paediatric centers reported that they had inpatient beds exclusively dedicated to the care of HCT recipients [9]. In contrast, among A&NZ centers, 13 or 35% had dedicated inpatient HCT beds indicating a differing model of care in A&NZ compared to the USA. Thus, comparisons with the USA involving bed numbers should be interpreted with some caution. Comparisons of other key indicators show that HCT practice in A&NZ differs from the USA with higher numbers of allogeneic HCT per bed and per HCT physician FTE, however these comparisons should be interpreted with caution due to differing practices between the two countries.
Additional comparisons with US surveys indicate that the Australian HCT physician workforce is demographically similar to the comparable US workforce but with a lower proportion of physicians working full-time in HCT [8].
The mean figures of 4.0 allogeneic HCT per HCT bed per year among A&NZ Auto + Allo centers, 5.4 autologous HCT per HCT bed per year among all centres and 8.5 total HCT per year among all centres may appear to be surprisingly low, however these beds are frequently occupied by HCT patients undergoing re-admission posttransplant for treatment of infections, GVHD or other HCT-related complications. Comparative figures from a USA study showed a lower figure of 2.6 allogeneic HCT per HCT bed [7], possibly indicating a more intensive use of HCT beds, which could be linked to the high proportion of centers in the USA with dedicated HCT beds [9].
In A&NZ, the representation of female HCT physicians was non-significantly (P=0.08) higher among 33-49 year olds (37%) than for the 50+ age group (24%). This
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trend may signal an increasing presence of female HCT physicians in the near future, which does seem likely, given that in 2015, 52% of medical students in A&NZ were female [10]. However, this can only be taken as an indication, as medical students may progress to any one of many specialities.
The relatively even distribution of physicians across age categories indicates that there appears to be a fairly ordered progression from entry into this speciality to retirement. A smaller proportion of physicians aged less than 50 had overseas experience (45%) compared to older physicians (62%); this difference was statistically significant (P=0.02), which may reflect a higher level of difficulty in organising overseas postings in recent years, or a decreasing desire to do so. The proportion of physicians with overseas experience was also lower for women (43%) than for men (57%).
Overseas training via appointments in large established
transplant centers provides additional experience, often of a more intensive nature and with access to international leaders in transplantation. It is to be hoped that overseas experience will continue to be a viable choice for aspiring HCT physicians.
HCT physicians reported spending time on a variety of tasks, including HCT-related activities, non-HCT related activities and general hematology. The overall mean time spent on HCT-related tasks was less than one-third of all time spent (31.7%), and only 2 of the 185 surveyed HCT physicians spent 100% of their time on HCT-related tasks. The largest mean amount of time spent on any single task was for “general hematology” (38.2%). Physicians in “allo + auto” centers spent more time on HCTrelated tasks (43.9%) than physicians in autos only centers (18.9%), and physicians in larger centers spent more time on HCT-related tasks (37.0%) than those in smaller
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centers (23.6%). This finding highlights the diversity of demands put on the time and expertise of transplant physicians, especially in smaller centers. Most HCT centers in A&NZ employ advanced practice professionals who are qualified Clinical Nurse Consultants (CNCs). Only a small number of nurse practitioners are currently employed in A&NZ HCT centers. These professionals are referred to as “physician extenders” in the USA. CNC duties comprise HCT co-ordination and support. Details on numbers and characteristics of CNCs were not collected in the current study. While playing a major role in HCT physician support, the contribution of these medical professionals is unlikely to impact the current or projected numbers of HCT physicians as their role is supportive, and not directly involved with the management of the transplant procedure or clinical follow-up of HCT patients.
HCT is an expensive procedure [11] but its utility has been proven in many medical contexts [1]. The steady increase in HCT activity in A&NZ in recent years can be attributed to a greater availability of potential allogeneic donors [12,13], improved HCT techniques enabling HCT physicians to transplant older and more extensively pre-treated patients [1], a widening of diseases which may be treated by HCT (e.g. autoimmune diseases) [1] and an ageing population which mediates an increase in the incidence of diseases where HCT is recommended as treatment [1]. Projections indicate that if numbers of HCT increase steadily while numbers of HCT physicians stay largely static, the number of HCT per HCT physician FTE will increase steadily over the next ten years 2015-2025 (Figure 4). The complexity of HCT practice can also be expected to increase with patterns such as the strong increase in numbers of allogeneic HCT with unrelated or mismatched related donors, compared to the lower rate of increase of allogeneic HCT with matched related donors [6]. Management
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policies and recruitment practices should ensure that numbers of transplant physicians will be adequate to support greater transplant activity either at existing or new centers to cater for greater numbers of this procedure in the future. Care of an increased number of transplant patients could also be improved through the use of advanced practice professionals, such as nurse practitioners. Currently, A&NZ has very few nurse practitioners in HCT; it is hoped that increasing numbers will be attracted to and trained in HCT, to assist in this increased patient load.
Several US studies have warned of a need for greater resources to enable larger capacity as numbers of HCT expand in the near future [4,5,8,9]. There is strong reason to believe that in A&NZ, increases in HCT will continue as they have in recent years (Figure 4). Current projections indicate that the transplant physician workforce in A&NZ may stay in the region of 170 to 190 in the next 10 years. To maintain the 2015 estimated number of 10.6 HCTs per physician FTE per year, it is calculated that an additional 8 transplant physician FTEs would need to enter the workforce in A&NZ annually, additional to current projected workforce growth.
This study provides baseline estimates of HCT activity and physician time use for HCT-related activities in A&NZ and should provide guidance for planning in this area. It is clear from this study that HCT physicians need to balance HCT-related activities with many other duties in their working life. Healthcare authorities and governments of all jurisdictions should be prepared to enable and support greater transplant activity either at existing or new centers to cater for greater numbers of this procedure in the future, and this will require additional staffing resources.
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Acknowledgments
The ABMTRR sincerely thanks clinical and data management staff at all centers that correspond with the ABMTRR for their continuing and invaluable support. Sincere thanks are also due to Donna Aarons of the ABMTRR for her tireless work on the ASTRO database, and Annabel Horne of St Vincent’s Hospital Darlinghurst for advice on inpatient flows. The ABMTRR is grateful to the following organizations for their support: The Bone Marrow Transplant Society of Australia and New Zealand, the Arrow Bone Marrow Transplant Foundation, St Vincent’s Hospital Sydney, the Australian Bone Marrow Donor Registry and state and federal governments of Australia.
Conflict of interest statement
The authors report no conflicts of interest.
References
1. Passweg JR, Baldomero H, Bader P et al. Hematopoietic SCT in Europe 2013: recent trends in the use of alternative donors showing more haploidentical donors but fewer cord blood transplants. Bone Marrow Transplant 2015;50:476-82.
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2. Gratwohl A, Baldomero H, Aljurf M et al. Hematopoietic stem cell transplantation: a global perspective. JAMA 2010;303:1617-1624.
3. Niederwieser D, Baldomero H, Szer J, et al. Hematopoietic stem cell transplantation activity worldwide in 2012 and a SWOT analysis of the Worldwide Network for Blood and Marrow Transplantation Group including the global survey. Bone Marrow Transplant 2016;51:778-785.
4. Schriber JR, Anasetti C, Heslop HE, Leahigh AK. Preparing for growth: current capacity and challenges in hematopoietic stem cell transplantation programs. Biol Blood Marrow Transplant 2010;16:595-597.
5. Majhail NS, Tao L, Bredeson C et al. Prevalence of hematopoietic cell transplant survivors in the United States. Biol Blood Marrow Transplant 2013; 19:1498-1501.
6. Nivison-Smith I, Bardy P, Dodds AJ et al. A Review of Hematopoietic Cell Transplantation in Australia and New Zealand, 2005-2013. Biol Blood Marrow Transplant. 2015;22:284-291.
7. Majhail NS, Murphy EA, Omondi NA et al. Allogeneic transplant physician and center capacity in the United States. Biol Blood Marrow Transplant 2011;17:956-961.
8. Burns LJ, Gajewski JL, Majhail NS et al. Challenges and potential solutions for recruitment and retention of hematopoietic cell transplantation physicians: the
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National Marrow Donor Program’s System Capacity Initiative Physician Workforce Group Report. Biol Blood Marrow Transplant 2014;20:617-621.
9. Majhail NS, Mau L-W, Chitphakdithai P et al. National Survey of Hematopoietic Cell Transplantation Center Personnel, Infrastructure, and Models of Care Delivery. Biol Blood Marrow Transplant. 2015;21:1308-14.
10. Medical Deans Australia and New Zealand. Statistical Tables 2015. Website www.medicaldeans.org.au/statistics/annualtables.
11. Majhail NS, Mau LW, Denzen EM, Arneson TJ. Costs of autologous and allogeneic hematopoietic cell transplantation in the United States: a study using a large national private claims database. Bone Marrow Transplant 2013;48:294-300.
12. Passweg JR1, Baldomero H, Gratwohl A et al. The EBMT activity survey: 19902010. Bone Marrow Transplant 2012; 47:906-23.
13. Passweg JR, Baldomero H, Bader P et al. Hematopoietic SCT in Europe 2013: recent trends in the use of alternative donors showing more haploidentical donors but fewer cord blood transplants. Bone Marrow Transplant 2015;50:476-82.
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Figure 1. Age and sex distribution of HCT physicians 60
Number
50
Female
40
Male
30 20
10
65+
60-64
55-59
50-54
45-49
40-44
35-39
33-34
0
Figure 2. Proportion of HCT physician time spent on grouped tasks, by center type 100% 80%
10.7%
5.6%
Other tasks General hematology
26.5% 50.5%
60%
10.1%
40%
8.8% 5.4% 5.3%
20%
33.2%
Research - not HCT Admin - not HCT
12.3% 12.7% 1.2% 2.7% 14.9%
0%
Allo + auto
Research - HCT Admin - HCT HCT patient care
Auto only
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Figure 3. Indicators of allogeneic HCT activity: comparison of A&NZ allo + auto centers (2015) and US allo centers (2009) 8 7
Aust / NZ
6
USA
5 4
7.1
3 2
6.3
4.0
2.6
1 0
Allogeneic HCT / HCT bed
Allogeneic HCT / physician FTE
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
16 14 12 10 8 6 4 2 0
2015
Projected transplants / physician
Figure 4. Projected annual numbers of HCT per physician FTE, A&NZ, 2015 2025
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Table 1. Characteristics of transplant centers that responded to this study Characteristic N Center type Adult Pediatric Country Australia New Zealand Provided exclusive HCT beds Yes No Size / activity type Large allo+auto centers (annual activity 64+) Small allo+auto centers (annual activity <64) Large auto centers (annual activity 26+) Small auto centers (annual activity <26) Number of HCT performed in centers in 2015 Large allo+auto centers Small allo+auto centers Large auto centers Small auto centers Total HCT physician FTEs represented Large allo+auto centers Small allo+auto centers Large auto centers Small auto centers Total HCT dedicated physician FTEs represented Large allo+auto centers Small allo+auto centers Large auto centers Small auto centers Total
n (%) 37 31 6 33 4 13 (35%) 24 (65%) 10 9 10 8 903 (52%) 333 (19%) 385 (22%) 131 (7%) 1752 (100%) 49.0 (30%) 37.8 (23%) 47.8 (29%) 30.4 (18%) 165.0 (100%) 23.6 (46%) 13.2 (26%) 10.6 (21%) 3.5 (7%) 50.9 (100%)
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Table 2. Characteristics of HCT physicians counted in this study Characteristic N Sex Male Female Age group 30 – 39 40 – 49 50 – 59 60 + Median age (range) Prior experience in overseas centers Yes No Postgraduate qualifications (other than specialist training) PhD MD (Doctorate of Medicine) Master's degree Other postgraduate qualification No postgraduate qualification (other than specialist training) Center type Adult Pediatric Country Australia New Zealand
n (%) 185 127 (69%) 58 (31%) 27 (15%) 76 (41%) 59 (32%) 23 (12%) 48 (33 - 72) 97 (52%) 88 (48%)
38 (21%) 17 (9%) 20 (11%) 4 (2%) 106 (57%) 157 (85%) 28 (15%) 168 (91%) 17 (9%)
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Table 3. Indicators of annual center activity and performance by center type Indicator Allogeneic HCT / HCT bed Allogeneic HCT / physician FTE Autologous HCT / HCT bed Autologous HCT / physician FTE Total HCT / HCT bed Total HCT / physician FTE Total HCT / Total staff FTE
Allo + auto 4.0 7.2 3.9 7.0 7.9 14.2 5.8
Auto only 10.2 6.6 10.3 6.6 2.9
All centres 5.4 6.8 8.5 10.6 4.5
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S1083-8791(17)30722-X https://doi.org/doi:10.1016/j.bbmt.2017.09.011 YBBMT 54803
To appear in:
Biology of Blood and Marrow Transplantation
Received date: Accepted date:
14-6-2017 18-9-2017
Please cite this article as: Ian Nivison-Smith, Samuel Milliken, Anthony J. Dodds, David Gottlieb, John Kwan, David D.F. Ma, Peter J. Shaw, Steven Tran, Leonie Wilcox, Jeff Szer, Activity and Capacity Profile of Transplant Physicians and Centers in Australia and New Zealand, Biology of Blood and Marrow Transplantation (2017), https://doi.org/doi:10.1016/j.bbmt.2017.09.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Activity and Capacity Profile of Transplant Physicians and Centers in Australia and New Zealand
Authors Ian Nivison-Smith, BSc MAppStat PhD1 Samuel Milliken, MB BS FRACP FRCPA2 Anthony J Dodds, MB BS (Hons) FRACP FRCPA2 David Gottlieb, MB BS FRACP FRCPA3 John Kwan, MB BS FRACP FRCPA3 David DF Ma, MB BS MD FRACP FRCPA2 Peter J Shaw, MA MB BS MRCP FRACP4 Steven Tran, BEng, MBiomed E1 Leonie Wilcox, BSc1 Jeff Szer, B Med Sc MB BS FRACP5 Affiliations 1 Australasian Bone Marrow Transplant Recipient Registry (ABMTRR), Darlinghurst NSW, Australia 2 St Vincent’s Hospital, Darlinghurst NSW, Australia 3 Westmead Hospital, Westmead NSW, Australia 4 The Children’s Hospital at Westmead, Westmead NSW, Australia 5 Royal Melbourne Hospital, Parkville Victoria, Australia Corresponding author Ian Nivison-Smith ABMTRR, Level 6 The Kinghorn Cancer Centre, 370 Victoria St DARLINGHURST NSW 2010 Australia Email address: [email protected] Phone number: 61 2 9355 5693 Short title: Capacity profile of HCT centers in Australia and New Zealand Keywords: Hematopoietic; Cell; Transplantation; Australia; New Zealand Conflict of Interest The authors declare no financial relationship with any organizations that have a direct financial interest in the subject matter discussed in the submitted manuscript. Financial disclosure statement The authors declare no financial relationship with any organizations that have a direct financial interest in the subject matter discussed in the submitted manuscript.
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Highlights
This study reports on the profiles of HCT physicians in A&NZ.
The median age of HCT physicians was 48 and 31% were female.
HCT physicians spent an average of 31.7% of their time on HCT related tasks.
Physicians perform an annual average of 10.6 allogeneic and autologous HCT.
Physician HCT workloads are projected to increase in future years.
Abstract
We conducted a study to analyze and report on indicators of hematopoietic cell transplant (HCT) physician time use and HCT center output measures. HCT centers in Australia and New Zealand (A&NZ) were invited to provide demographic and time use details for physicians participating in HCT patient care (HCT physicians). Resource details for adult and pediatric centers were included. From a total of 46 centers that were invited to participate, completed data were received from 37 (80%) representing 185 HCT physicians, with a median age of 48 (range 33-72), of whom 31% were female. Just over half of HCT physicians cited prior work experience in large overseas HCT centers (97, 52%) and over one-third (79, 43%) possessed postgraduate qualifications other than specialist training. Total annual mean HCT per HCT physician FTE was 14.2 for centers performing both allogeneic and autologous HCT, 6.6 for autologous only centers and 10.6 for all centers. For all HCT physicians surveyed, the mean proportion of time spent on HCT related tasks was 31.7%. In A&NZ, for centers that perform both allografts and autografts, there was a mean of 4.0 allogeneic HCT annually per HCT bed, compared to 2.6 for the USA, and 7.1 allogeneic HCT annually per HCT physician FTE (USA 6.3). Projections of the
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A&NZ HCT physician workforce indicated that the numbers of HCT physicians are likely to stay within the region of 170 to 190 for the next 10 years, while HCT activity will likely continue to climb steadily. Healthcare and government authorities should be prepared to enable and support greater HCT activity in A&NZ in the future.
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Introduction
The numbers of HCT performed worldwide is reported to have risen steadily in recent years [1,2,3,4]. In addition, numbers of HCT survivors continue to increase [5]. In Australia and New Zealand (A&NZ), total annual numbers of autologous and allogeneic HCT increased from 1,359 in 2005 to 1,736 in 2013 [6] and 1,966 in 2015 (unpublished), a 2005-15 increase of 45%.
A study carried out in the USA in 2008 indicated that most large HCT centers were working to their full capacity and would not be able to increase numbers of HCT performed without an increase in staff and resources [4]. The study also predicted an increased need for HCT physicians and a possible shortage in future years. A detailed study by Majhail et al published in 2011 analysed data on transplant center capacity and allogeneic HCT activity in the USA in the period 2005 to 2009 [7]. The study reported that numbers of allogeneic HCT had increased by 29.9% in this 5-year period. The study also found that in 2009, there were means of 2.6 allogeneic HCT per HCT dedicated bed, 6.3 allogeneic HCT per HCT physician Full-Time Equivalents (FTE) and 2.4 HCT dedicated beds per HCT physician FTE [7]. In 2014, the National Marrow Donor Program (NMDP) published a report from their System Capacity Initiative Physician Workforce Group indicating that the number of unrelated donor HCT was likely to double in the USA between 2010 and 2020 and a future shortage of HCT physicians was possible [8].
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It would be advantageous for management and planning purposes to understand the current capacity of HCT centers in regard to staffing resources and bed numbers compared to HCT performed. The current study aimed to collect and analyse details on transplant physicians and centers in A&NZ, report on relevant indicators of capacity and output measures and compare results with international experience.
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Materials and Methods
All centers that perform allogeneic and/or autologous HCT and report to the Australasian Bone Marrow Transplant Recipient Registry (ABMTRR) were invited to participate in this study (n=46). All HCT centers in A&NZ are associated with academic institutions. Every center that consented to participate was sent a data entry spreadsheet asking for demographic and workforce details of physicians who participate in the primary care of HCT patients at the center (regardless of the percentage of time they spent on this practice), plus questions on bed capacity and numbers of junior medical staff. Physicians were identified by a code (i.e. Physician 1, Physician 2 and so on), and physician names were not requested (see Supplementary Figure 1, ABMTRR Study Questions Template). All physicians included in this study are termed as “HCT physicians” regardless of hours worked.
Comment [RE1]: AU: Please confirm it is appropriate to add this document as a supplementary file.
Responses to the questionnaire were collected from participating centers between October 2015 and August 2016. HCT activity for each center for the calendar year of 2015 was used as baseline data.
HCT physicians were asked to provide details on their position title, sex, year of birth, postgraduate qualifications, prior experience in overseas transplant centers and hours worked in an average week. Postgraduate qualifications were defined here as postBachelor level tertiary qualifications other than specialist training (i.e. other than FRACP FRCPA or equivalent in A&NZ). In A&NZ, until approximately 2016 the basic medical degree was MBBS (Bachelor of Medicine / Bachelor of Science) or similar, and an MD was a postgraduate degree completed through scientific / medical
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research. Recently the majority of Australian universities have offered a basic medical qualification as an MD. However, the results of the current study refer to the situation in place at the time when the MBBS was the standard basic medical degree. The hematologist training path is a basic medical degree followed by specialist training, accompanied in individual cases, by choice, by a postgraduate degree. Transplant fellowships are available on application to augment clinical hematology training but are not necessary for practice in HCT haematology. Physicians were further asked to provide estimates of average (mean) time spent on different activities by allocating a percentage of time to each task. The following tasks were nominated: Autologous HCT - inpatient care, Autologous HCT - outpatient care, Allogeneic HCT - inpatient care, Allogeneic HCT - outpatient care, Administration - HCT related, Administration - other than HCT related, Research including clinical trials - HCT related, Research including clinical trials - other than HCT related, General Hematology and Other Tasks, which respondents were asked to specify.
Physicians were allocated an FTE value according to the number of hours they were paid for, with 40 hours or more considered to be 1 FTE and amounts less than this given a proportion based on actual hours paid. The term “HCT physician FTE” refers to the fraction of full-time work represented by that HCT physician’s stated hours worked and in this study is a number ranging from 0.125 to one. This is the same definition as used by a US study that the current study has been compared to [7]. A special measure of “HCT dedicated physician FTE” was also calculated, as HCT physician FTE multiplied by the self-stated average percentage of time spent on HCTrelated tasks by that HCT physician. This measure has not been compared to overseas studies.
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Centers were classified as performing either “Autologous only” or “Autologous and allogeneic” HCT - there were no “Allogeneic only” centers. A classification of “Adult” or “Paediatric” was also applied according to the center type. In 2015, the median number of HCT performed by “Autologous” centers was 24, while for “Autologous plus allogeneic” centers the median activity was 64. On this basis, centers were further classified as “large allo + auto” with a combined allogeneic and autologous activity of 64 or more in the calendar year of 2015, “small allo + auto” with a combined allogeneic and autologous activity of less than 64, “large auto” with an autograft activity of 24 or more, or “small auto” with an activity of less than 24.
Centers were asked how many beds were reserved exclusively for HCT patients, and if there were none, how many beds were occupied by HCT patients on a typical day. Number of HCT beds for the centre was calculated as the number nominated by the institution as either number reserved for HCT patients or, if none, average (mean) number of beds occupied by HCT patients.
A number of indicators were calculated to describe physician and center activity, including annual HCT activity per HCT bed, annual HCT activity per HCT physician FTE and annual HCT activity per HCT dedicated physician FTE. These measures were compared among centers according to nature of activity (auto + allo vs auto only), size (small vs large), center type (adult / paediatric) and country (Australia vs New Zealand).
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Ten-year projections of numbers of HCT physicians in the A&NZ workforce were constructed by adding a year of age to each of the surveyed physicians for every year from 2015 to 2025, and counting the number each year whose projected ages fell between 33 and 68. The lower limit of 33 was chosen because no HCT physician in the study was younger than this, and the upper limit of 68 was chosen as only 3 physicians in the study were older. On the basis of numbers of 33 to 39 year old physicians in the surveyed group, it was estimated that the average entry of new transplant physicians to the population was around four per year, and this number of physicians was added each year and given an age of 33. Projections of the numbers of HCT performed each year were constructed by taking the average annual per cent change in numbers over the years 2006 to 2015 for centers that participated in the study (4.2% annual increase) and applying this to the figure for 2016 and following.
All analyses were carried out using Statistical Package for the Social Sciences (SPSS) software Version 21 (IBM, Armonk NY USA, 2012). Cross-tabulations of physician characteristics were tested for statistical significance using Fisher’s Exact Test.
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Results
From a total of 46 centers that were invited to participate, completed data were received from 37 (80% - Table 1). These responding centers represented 88% of the total HCT activity of A&NZ centers in calendar year 2015. Of the responding centers, 19 performed both allografts and autografts, representing a total of 633 allografts and 607 autografts in 2015. A further 18 centers performed autografts only, representing a total of 512 autografts in 2015.
Large allo + auto centers (those with 2015 activity of 64 or more – the median for allo + auto centres) performed 903 HCT and employed 49.0 HCT physician FTEs in 2015 while small auto + allo centers performed 333 HCT and employed 37.8 HCT physician FTEs. Large auto only centers (those with 2015 activity of 24 or more – the median for auto only centres) performed 385 HCT and employed 47.8 HCT physician FTEs while small auto only centers performed 131 HCT and employed 30.4 HCT physician FTEs (Table 1). Among the 37 responding centers, 13 (35%) maintained beds that were exclusively allocated to HCT patients while 24 (65%) did not. The responding centers employed a total of 165.0 HCT physician FTEs, 107.0 hematology trainee FTEs, 10.0 BMT fellow FTEs and 108.1 other junior medical staff FTEs.
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A total of 185 HCT physicians were counted (responses, not FTEs), comprising 95 from allo + auto centers and 90 from auto only centers. The median age of HCT physicians is shown in Table 2. Among HCT physicians surveyed in A&NZ aged 3349yr, 37% were female, while the corresponding percentage for physicians aged 50yr and above was 24% (P = 0.08). Just over half of HCT physicians cited prior work experience in large overseas transplant centers (97, 52%) and more than one-third (79, 43%) possessed postgraduate qualifications other than specialist training (Table 2). The proportion of HCT physicians with prior experience in major overseas transplant centers was 45% for the <50yr group and 62% for the 50yr+ group (P = 0.02). For the <50yr group, 44% had a postgraduate qualification, while for the 50yr+ group this proportion was 41% (P = 0.8).
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Across all centers, the median number of hours worked per week for full-time HCT physicians was 54, while median hours paid was 40. For allo + auto centers, the median hours were 55 worked and 40 paid, while for auto only centers the median hours were 48 worked and 40 paid. For adult centers, the median hours were 55 worked and 40 paid, while for paediatric centers the median hours were 50 worked and 40 paid. For all HCT physicians surveyed in A&NZ (full-time and part-time), the median number of hours worked per week was 50.
The
proportion of time spent on HCT related tasks was 31.7% for all HCT
physicians. HCT physicians at allo + auto centers spent 43.9% of their available time on HCT related tasks while for those at auto only centers this figure was 18.9% (Figure 2). The overall proportion of HCT physician time spent on HCT related tasks was 50.8% in large allo + auto centers, 34.1% in small allo + auto centers, 23.3% in large auto centers, and 11.5% in small auto centers.
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Table 3 shows a set of capacity and activity indicators for transplant centers. The measure of total annual HCT per HCT physician FTE was 14.2 for allo+auto centers, 6.6 for auto only centers and 10.6 for all centers. HCT activity per HCT physician FTE was higher for large (13.3) compared to smaller (6.8) centers, New Zealand (13.2) compared to Australian (10.3) centers and adult (11.4) compared to pediatric (6.5) centers.
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“HCT dedicated physician FTE” is the physician’s FTE multiplied by the percentage of time spent on HCT-related tasks. While a total of 185 HCT physicians were counted, representing 165.0 HCT physician FTEs, the sum of HCT dedicated physician FTEs was 50.9 (Table 1). Total annual HCT activity per HCT dedicated physician FTE was 33.6 for allo + auto, 36.7 for autos only and 34.4 for all centers.
Comparisons between A&NZ and US activity indicators can be seen in Figure 3. In A&NZ, it was calculated, for centers that perform allografts and autografts, that there were
means
of 4.0 allogeneic HCT annually per HCT bed, compared to 2.6
calculated for the USA [7]. Additionally, in A&NZ there were 7.1 allogeneic HCT annually per HCT physician FTE, compared to 6.3 calculated for the USA [7]. A survey distributed to American Society for Blood and Marrow Transplantation (ASBMT) members in 2010 showed that 75% of US respondents were male (compared to 69% of A&NZ respondents), 46% were aged 50 or over (A&NZ 44%) and 87% worked more than 50 hours per week (A&NZ 41%) [8].
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Projections of the transplant physician workforce indicated that if current trends continue, the numbers of HCT physicians in A&NZ, in the centers that responded to this study, are likely to stay within the region of 165 to 180 FTEs for the next 10 years. Adjusting for non-response, this yields an estimate of between 188 and 205 HCT physician FTEs for all A&NZ centers in the next 10 years, including those that did not respond to this study. However, projections of the number of HCT performed in A&NZ at centers that participated in the study show that if the recent mean annual increase of 4.2% is sustained, the number of HCT would increase by 51% between 2015 and 2025. Using these figures, the mean number of HCT per HCT physician FTE per year was 10.6 in 2015 and projected to be 14.4 in 2025 – an increase of 36% (Figure 4). The corresponding projections for adult centres were 11.1 in 2015 and 14.9 in 2025 (increase of 34%), while for paediatric centres they were 5.3 in 2015 and 7.3 in 2025 (increase of 38%).
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Discussion
This study is the first investigation of workplace activity in the medical discipline of HCT in A&NZ, and aims to provide characteristics of the HCT workforce and the tasks that are carried out, to assist in evaluation and planning.
The total of 37 centers that responded to this study represents a large proportion (80%) of all centers (n=46) currently engaged in performing HCT in A&NZ, representing 88% of total HCT activity in 2015. Representation was high in each of the categories of “Large allo + auto” (10 responded from a total of 11), Small allo + auto” (9/10), “Large auto” (10/13), and “Small auto” (8/12). There was good response from both adult (31/38) and paediatric (6/8) centers, and also a good level of response from both Australian (33/40) and New Zealand (4/6) centers. Broadly, although not a complete enumeration, the centers that responded to this study can be considered to be representative of all centers across A&NZ.
The classification of centers into “Large allo + auto”, “Small allo + auto”, “Large auto” and “Small auto” was made on the basis of activity in the years 2015. Analysis on the basis of size / activity category indicates that large allo + auto centers have a relatively large share of transplant activity (52%) with a lower share of HCT physician FTEs (30%) but a higher share of HCT dedicated physician FTEs (46%), confirming that transplant physicians in these centers are spending on average more of their time on HCT-related activities (50.8%) than is the case in other center types (23.5%).
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In a recent US survey of allogeneic HCT units, 93% of both adult and paediatric centers reported that they had inpatient beds exclusively dedicated to the care of HCT recipients [9]. In contrast, among A&NZ centers, 13 or 35% had dedicated inpatient HCT beds indicating a differing model of care in A&NZ compared to the USA. Thus, comparisons with the USA involving bed numbers should be interpreted with some caution. Comparisons of other key indicators show that HCT practice in A&NZ differs from the USA with higher numbers of allogeneic HCT per bed and per HCT physician FTE, however these comparisons should be interpreted with caution due to differing practices between the two countries.
Additional comparisons with US surveys indicate that the Australian HCT physician workforce is demographically similar to the comparable US workforce but with a lower proportion of physicians working full-time in HCT [8].
The mean figures of 4.0 allogeneic HCT per HCT bed per year among A&NZ Auto + Allo centers, 5.4 autologous HCT per HCT bed per year among all centres and 8.5 total HCT per year among all centres may appear to be surprisingly low, however these beds are frequently occupied by HCT patients undergoing re-admission posttransplant for treatment of infections, GVHD or other HCT-related complications. Comparative figures from a USA study showed a lower figure of 2.6 allogeneic HCT per HCT bed [7], possibly indicating a more intensive use of HCT beds, which could be linked to the high proportion of centers in the USA with dedicated HCT beds [9].
In A&NZ, the representation of female HCT physicians was non-significantly (P=0.08) higher among 33-49 year olds (37%) than for the 50+ age group (24%). This
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trend may signal an increasing presence of female HCT physicians in the near future, which does seem likely, given that in 2015, 52% of medical students in A&NZ were female [10]. However, this can only be taken as an indication, as medical students may progress to any one of many specialities.
The relatively even distribution of physicians across age categories indicates that there appears to be a fairly ordered progression from entry into this speciality to retirement. A smaller proportion of physicians aged less than 50 had overseas experience (45%) compared to older physicians (62%); this difference was statistically significant (P=0.02), which may reflect a higher level of difficulty in organising overseas postings in recent years, or a decreasing desire to do so. The proportion of physicians with overseas experience was also lower for women (43%) than for men (57%).
Overseas training via appointments in large established
transplant centers provides additional experience, often of a more intensive nature and with access to international leaders in transplantation. It is to be hoped that overseas experience will continue to be a viable choice for aspiring HCT physicians.
HCT physicians reported spending time on a variety of tasks, including HCT-related activities, non-HCT related activities and general hematology. The overall mean time spent on HCT-related tasks was less than one-third of all time spent (31.7%), and only 2 of the 185 surveyed HCT physicians spent 100% of their time on HCT-related tasks. The largest mean amount of time spent on any single task was for “general hematology” (38.2%). Physicians in “allo + auto” centers spent more time on HCTrelated tasks (43.9%) than physicians in autos only centers (18.9%), and physicians in larger centers spent more time on HCT-related tasks (37.0%) than those in smaller
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centers (23.6%). This finding highlights the diversity of demands put on the time and expertise of transplant physicians, especially in smaller centers. Most HCT centers in A&NZ employ advanced practice professionals who are qualified Clinical Nurse Consultants (CNCs). Only a small number of nurse practitioners are currently employed in A&NZ HCT centers. These professionals are referred to as “physician extenders” in the USA. CNC duties comprise HCT co-ordination and support. Details on numbers and characteristics of CNCs were not collected in the current study. While playing a major role in HCT physician support, the contribution of these medical professionals is unlikely to impact the current or projected numbers of HCT physicians as their role is supportive, and not directly involved with the management of the transplant procedure or clinical follow-up of HCT patients.
HCT is an expensive procedure [11] but its utility has been proven in many medical contexts [1]. The steady increase in HCT activity in A&NZ in recent years can be attributed to a greater availability of potential allogeneic donors [12,13], improved HCT techniques enabling HCT physicians to transplant older and more extensively pre-treated patients [1], a widening of diseases which may be treated by HCT (e.g. autoimmune diseases) [1] and an ageing population which mediates an increase in the incidence of diseases where HCT is recommended as treatment [1]. Projections indicate that if numbers of HCT increase steadily while numbers of HCT physicians stay largely static, the number of HCT per HCT physician FTE will increase steadily over the next ten years 2015-2025 (Figure 4). The complexity of HCT practice can also be expected to increase with patterns such as the strong increase in numbers of allogeneic HCT with unrelated or mismatched related donors, compared to the lower rate of increase of allogeneic HCT with matched related donors [6]. Management
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policies and recruitment practices should ensure that numbers of transplant physicians will be adequate to support greater transplant activity either at existing or new centers to cater for greater numbers of this procedure in the future. Care of an increased number of transplant patients could also be improved through the use of advanced practice professionals, such as nurse practitioners. Currently, A&NZ has very few nurse practitioners in HCT; it is hoped that increasing numbers will be attracted to and trained in HCT, to assist in this increased patient load.
Several US studies have warned of a need for greater resources to enable larger capacity as numbers of HCT expand in the near future [4,5,8,9]. There is strong reason to believe that in A&NZ, increases in HCT will continue as they have in recent years (Figure 4). Current projections indicate that the transplant physician workforce in A&NZ may stay in the region of 170 to 190 in the next 10 years. To maintain the 2015 estimated number of 10.6 HCTs per physician FTE per year, it is calculated that an additional 8 transplant physician FTEs would need to enter the workforce in A&NZ annually, additional to current projected workforce growth.
This study provides baseline estimates of HCT activity and physician time use for HCT-related activities in A&NZ and should provide guidance for planning in this area. It is clear from this study that HCT physicians need to balance HCT-related activities with many other duties in their working life. Healthcare authorities and governments of all jurisdictions should be prepared to enable and support greater transplant activity either at existing or new centers to cater for greater numbers of this procedure in the future, and this will require additional staffing resources.
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Acknowledgments
The ABMTRR sincerely thanks clinical and data management staff at all centers that correspond with the ABMTRR for their continuing and invaluable support. Sincere thanks are also due to Donna Aarons of the ABMTRR for her tireless work on the ASTRO database, and Annabel Horne of St Vincent’s Hospital Darlinghurst for advice on inpatient flows. The ABMTRR is grateful to the following organizations for their support: The Bone Marrow Transplant Society of Australia and New Zealand, the Arrow Bone Marrow Transplant Foundation, St Vincent’s Hospital Sydney, the Australian Bone Marrow Donor Registry and state and federal governments of Australia.
Conflict of interest statement
The authors report no conflicts of interest.
References
1. Passweg JR, Baldomero H, Bader P et al. Hematopoietic SCT in Europe 2013: recent trends in the use of alternative donors showing more haploidentical donors but fewer cord blood transplants. Bone Marrow Transplant 2015;50:476-82.
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2. Gratwohl A, Baldomero H, Aljurf M et al. Hematopoietic stem cell transplantation: a global perspective. JAMA 2010;303:1617-1624.
3. Niederwieser D, Baldomero H, Szer J, et al. Hematopoietic stem cell transplantation activity worldwide in 2012 and a SWOT analysis of the Worldwide Network for Blood and Marrow Transplantation Group including the global survey. Bone Marrow Transplant 2016;51:778-785.
4. Schriber JR, Anasetti C, Heslop HE, Leahigh AK. Preparing for growth: current capacity and challenges in hematopoietic stem cell transplantation programs. Biol Blood Marrow Transplant 2010;16:595-597.
5. Majhail NS, Tao L, Bredeson C et al. Prevalence of hematopoietic cell transplant survivors in the United States. Biol Blood Marrow Transplant 2013; 19:1498-1501.
6. Nivison-Smith I, Bardy P, Dodds AJ et al. A Review of Hematopoietic Cell Transplantation in Australia and New Zealand, 2005-2013. Biol Blood Marrow Transplant. 2015;22:284-291.
7. Majhail NS, Murphy EA, Omondi NA et al. Allogeneic transplant physician and center capacity in the United States. Biol Blood Marrow Transplant 2011;17:956-961.
8. Burns LJ, Gajewski JL, Majhail NS et al. Challenges and potential solutions for recruitment and retention of hematopoietic cell transplantation physicians: the
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National Marrow Donor Program’s System Capacity Initiative Physician Workforce Group Report. Biol Blood Marrow Transplant 2014;20:617-621.
9. Majhail NS, Mau L-W, Chitphakdithai P et al. National Survey of Hematopoietic Cell Transplantation Center Personnel, Infrastructure, and Models of Care Delivery. Biol Blood Marrow Transplant. 2015;21:1308-14.
10. Medical Deans Australia and New Zealand. Statistical Tables 2015. Website www.medicaldeans.org.au/statistics/annualtables.
11. Majhail NS, Mau LW, Denzen EM, Arneson TJ. Costs of autologous and allogeneic hematopoietic cell transplantation in the United States: a study using a large national private claims database. Bone Marrow Transplant 2013;48:294-300.
12. Passweg JR1, Baldomero H, Gratwohl A et al. The EBMT activity survey: 19902010. Bone Marrow Transplant 2012; 47:906-23.
13. Passweg JR, Baldomero H, Bader P et al. Hematopoietic SCT in Europe 2013: recent trends in the use of alternative donors showing more haploidentical donors but fewer cord blood transplants. Bone Marrow Transplant 2015;50:476-82.
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Figure 1. Age and sex distribution of HCT physicians 60
Number
50
Female
40
Male
30 20
10
65+
60-64
55-59
50-54
45-49
40-44
35-39
33-34
0
Figure 2. Proportion of HCT physician time spent on grouped tasks, by center type 100% 80%
10.7%
5.6%
Other tasks General hematology
26.5% 50.5%
60%
10.1%
40%
8.8% 5.4% 5.3%
20%
33.2%
Research - not HCT Admin - not HCT
12.3% 12.7% 1.2% 2.7% 14.9%
0%
Allo + auto
Research - HCT Admin - HCT HCT patient care
Auto only
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Figure 3. Indicators of allogeneic HCT activity: comparison of A&NZ allo + auto centers (2015) and US allo centers (2009) 8 7
Aust / NZ
6
USA
5 4
7.1
3 2
6.3
4.0
2.6
1 0
Allogeneic HCT / HCT bed
Allogeneic HCT / physician FTE
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
16 14 12 10 8 6 4 2 0
2015
Projected transplants / physician
Figure 4. Projected annual numbers of HCT per physician FTE, A&NZ, 2015 2025
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Table 1. Characteristics of transplant centers that responded to this study Characteristic N Center type Adult Pediatric Country Australia New Zealand Provided exclusive HCT beds Yes No Size / activity type Large allo+auto centers (annual activity 64+) Small allo+auto centers (annual activity <64) Large auto centers (annual activity 26+) Small auto centers (annual activity <26) Number of HCT performed in centers in 2015 Large allo+auto centers Small allo+auto centers Large auto centers Small auto centers Total HCT physician FTEs represented Large allo+auto centers Small allo+auto centers Large auto centers Small auto centers Total HCT dedicated physician FTEs represented Large allo+auto centers Small allo+auto centers Large auto centers Small auto centers Total
n (%) 37 31 6 33 4 13 (35%) 24 (65%) 10 9 10 8 903 (52%) 333 (19%) 385 (22%) 131 (7%) 1752 (100%) 49.0 (30%) 37.8 (23%) 47.8 (29%) 30.4 (18%) 165.0 (100%) 23.6 (46%) 13.2 (26%) 10.6 (21%) 3.5 (7%) 50.9 (100%)
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Table 2. Characteristics of HCT physicians counted in this study Characteristic N Sex Male Female Age group 30 – 39 40 – 49 50 – 59 60 + Median age (range) Prior experience in overseas centers Yes No Postgraduate qualifications (other than specialist training) PhD MD (Doctorate of Medicine) Master's degree Other postgraduate qualification No postgraduate qualification (other than specialist training) Center type Adult Pediatric Country Australia New Zealand
n (%) 185 127 (69%) 58 (31%) 27 (15%) 76 (41%) 59 (32%) 23 (12%) 48 (33 - 72) 97 (52%) 88 (48%)
38 (21%) 17 (9%) 20 (11%) 4 (2%) 106 (57%) 157 (85%) 28 (15%) 168 (91%) 17 (9%)
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Table 3. Indicators of annual center activity and performance by center type Indicator Allogeneic HCT / HCT bed Allogeneic HCT / physician FTE Autologous HCT / HCT bed Autologous HCT / physician FTE Total HCT / HCT bed Total HCT / physician FTE Total HCT / Total staff FTE
Allo + auto 4.0 7.2 3.9 7.0 7.9 14.2 5.8
Auto only 10.2 6.6 10.3 6.6 2.9
All centres 5.4 6.8 8.5 10.6 4.5
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