Journal of Bone Oncology 17 (2019) 100243 Contents lists available at ScienceDirect Journal of Bone Oncology journal homepage: www.elsevier.com/locate/jbo Research Paper Unplanned admissions for patients with myeloma in the UK: Low frequency T but high costs Spyros Kolovosa, Guido Nadorb, Bhuvan Kishorec, Matthew Streetlyd, Neil K. Rabine, Andrew D Chantryf,g, Kwee Yonge,h, John Ashcrofti, Stella Bowcockj, Mark T. Draysonk, ⁎ Karthik Ramasamyb, Daniel Prieto-Alhambral,m, Cyrus Coopern,o,p, M. Kassim Javaida, , Rafael Pinedo-Villanuevaa a Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Old Rd, Oxford OX3 7LD, UK b Oxford University Hospitals NHS Trust, Oxford, UK c Heart of England NHS Foundation Trust, Birmingham, UK d Guy's and St. Thomas’ NHS Foundation Trust and King's College London, London, UK e Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK f Department of Oncology and Metabolism, Medical School, University of Sheffield, Sheffield, UK g Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK h UCL Cancer Institute, London, UK i Department of Haematology, Mid Yorkshire NHS Trust, Wakefield, UK j King's College Hospital NHS Trust, London, UK k Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK l Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK m Grup de Recerca en Malalties Prevalents de l'Aparell Locomotor Research Group and CIBERFes, University Institute for Primary CareResearch Jordi Gol, Universitat Autonoma de Barcelona and Instituto de Salud Carlos III, Barcelona, Spain n MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK o NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK p NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK A R T I C LE I N FO A B S T R A C T Keywords: Background: Multiple myeloma (MM) is associated with high healthcare resource utilisation and increasing Multiple myeloma hospitalisation rates. The aim of this study was to characterise the hospital use by patients with MM in the Unplanned admissions English National Health Service (NHS). Elective admissions Methods: Routinely-collected aggregate data about all NHS-funded hospital admissions of patients with MM Costs were analysed. Data were obtained from the English Hospital Episodes Statistics on admissions between 1 April 2014 and 31 March 2018. Results: A total of 754,345 admissions were reported over four years, equivalent to a mean of 188,586 admis- sions per year. Of the 41,845 patients admitted during this period, 42% were women and 58% men. From the total admissions, 90% were elective and 10% unplanned. Mean annual estimated costs over the period were £46 million for elective and £56 million for unplanned admissions. The number of elective admissions increased by 4.5% with costs increasing 1.5% per year; for unplanned admissions, these figures were 4.1% and 9.0%, re- spectively. Conclusions: MM is associated with a significant number of hospital admissions and NHS costs. The majority of the hospital admissions are elective, but the highest burden in terms of costs relates to unplanned admissions, with numbers increasing over time. 1. Introduction associated with considerable morbidity and mortality. The incidence of MM has increased globally by 126% between 1990 and 2016 [1]. Po- Multiple myeloma (MM) is a malignant plasma cell neoplasm pulation growth, the aging world population, and rising age-specific ⁎ Corresponding author. E-mail address: kassim.javaid@ndorms.ox.ac.uk (M.K. Javaid). https://doi.org/10.1016/j.jbo.2019.100243 Received 15 March 2019; Received in revised form 31 May 2019; Accepted 4 June 2019 Available online 07 June 2019 2212-1374/ © 2019 The Authors. Published by Elsevier GmbH. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/). S. Kolovos, et al. Journal of Bone Oncology 17 (2019) 100243 incidence rates contributed to the increased global incidence. The and it is defined as an uninterrupted inpatient stay at one hospital. A highest incidence and death rates for MM are reported in Western spell may include several finished consultant episodes if a patient is Europe, North America, and Australasia [1]. MM is more prevalent in seen by various consultants during the same stay. However, a spell does men compared to women, with a global incidence rate of 2.4 per not include transfers between different hospitals. In a case where the 100,000 for men and 1.8 per 100,000 for women [1,2]. MM is asso- patient is transferred to another hospital, a new spell begins [11]. For ciated with impairments in quality-of-life (QoL) of patients and was our analysis, we used APC data organised by spell covering the period responsible for 2.1 million disability-adjusted life-years (DALYs) at a between 1 April 2014 and 31 March 2018, corresponding to four full global level in 2016 [1,3,4]. financial years. MM is also related to increased healthcare utilisation and high healthcare costs [5,6]. A recent study found that 42% of MM patients 2.2. Study populations reported at least one disease-driven hospital visit during the previous six months, 71% declared at least one specialty visit during the three Inclusion criteria were based on recorded primary or secondary months prior, and 9% received emergency care in the previous three diagnosis of multiple myeloma in the admissions record. International months [6]. Healthcare costs per MM patient have increased steadily Classification of Diseases-10 (ICD-10) codes of either Multiple myeloma between 2000 and 2014 for all healthcare services including treatment- (MM, code C90.00) or osteoporosis in multiple myelomatosis (OMM, related drug costs, the main contributor being outpatient visits [7]. code M82.00) were applied for the study period. With data available Hospitalisation costs account for an important proportion of healthcare only in aggregate form, no individual patient follow-up or character- cost. These were found to make up for 22% of the total healthcare costs isation beyond extracted tables by financial year, gender and age group in 2000 and for 33% in 2014, whilst during this same period hospita- was possible. To ensure confidentiality, small number suppression and lisation rates per patient per month increased from 0.05 to 0.11 [7]. rounding of patient and admission counts were applied to all outputs, in Both healthcare utilisation and hospitalisation rates appear to be accordance with NHS Digital guidelines. driving the rising healthcare costs associated with MM patients. Data for all NHS hospital admissions in the period of analysis were Although MM is currently not curable, several treatment options also extracted to investigate what percentage of the total NHS admis- have been introduced in this century [8]. Advances in treatment have sions and costs were related to myeloma. In addition, we collected data changed the natural history of MM, and as a result the clinical man- on admissions and costs by patients with colon cancer diagnosis to agement of the disease [9]. Novel therapies including proteasome in- compare our findings about myeloma against those of a more prevalent hibitors (PI) and immunomodulatory drugs (IMiDs) have resulted in cancer. Colon cancer was chosen as a comparator as it also affects both substantial extension of the survival time of MM patients [5,10]. A dual- women and men, its economic burden has been extensively investigated cohort study at the Mayo Clinic showed that the mean survival from the [14,15] and its ICD-10 codes have been validated in previous studies time of relapse increased from 11.8 months for patients relapsing before using HES APC [16,17]. ICD-10 codes used to extract data on colon 2000 to 23.9 months for those relapsing after that year [10]. cancer admissions were “Malignant neoplasms of the colon” (C18), of In the context of rising MM incidence, increasing hospitalisation the rectosigmoid junction (C19), and of the rectum (C20). rates and improved survival of patients, efficient planning of healthcare services requires detailed understanding of contemporary hospital use 2.3. Variables by patients with MM. The aim of this study was to characterise and identify the drivers of hospital admissions and costs associated with the Data were extracted by gender, age groups, admission method (i.e. treatment of patients with MM in the English National Health Service elective or unplanned), procedure codes, and patient classification. (NHS). To that end, we: (1) describe the total number and costs of Procedures are reported using the OPCS-4 classification system for in- admissions by patients with MM; (2) identify the procedures driving the terventions and procedures used by healthcare providers in England, number and costs of both elective and unplanned admissions; and (3) either by the main four-character code recorded for a hospitalization place the above findings into context by comparing the number and spell, or by corresponding OPCS-4 chapters. Description of specific costs of admissions by patients with MM to the number and costs of procedure codes clearly identify which intervention was performed, but admissions by patients with a more prevalent cancer, as well as to those in some cases the main code extracted characterizes the intervention of the NHS as a whole. without making clear which procedure it was (e.g. ‘Z94.2 Right sided operation’). Because there are thousands of procedure codes in the 2. Methods classification system and these are grouped into chapters, we use the latter to describe procedures at a higher level of aggregation [18]. 2.1. Study design and setting Patient classification is reported as day-case, ordinary, or regular. ‘Day- case’ is defined as an inpatient elective admission for treatment during We used routinely-collected aggregate hospital admission data from the course of the day without overnight stay; ‘ordinary’ is further individuals with MM from across all 451 hospitals trusts in the English classified into inpatient elective or unplanned admission for treatment NHS [11]. Data were sourced from the Vantage platform, by Health iQ, and staying in hospital for at least one night; and ‘regular’ was defined which aggregated data taken from the English Hospital Episodes Sta- as an inpatient elective admission that is part of a planned series of tistics (HES) database produced by the Health and Social Care In- admissions for an on-going regime of broadly similar treatment and the formation [12]. Hospital trusts manage NHS hospital care in England, patient is discharged within 24 h [19]. For each variable level, ag- including community care and mental health services. The data ex- gregate data on number of admissions, number of patients, and costs tracted reflected inpatient hospital records provided by HES Admitted were obtained. Patient Care (HES APC). HES APC contains data on all hospital ad- Costs were directly extracted from the platform as calculated by the missions, including elective and unplanned admissions to the NHS and data provider. They are treated as estimates, as they were calculated at admissions to independent sector providers paid for by the NHS [11]. spell-level but extracted in aggregate form. Reported cost estimates are Elective admissions are those that occur when the decision to admit and based on the NHS national tariff according to core Healthcare Resource the actual hospital admission happen at different times, such as with Group (HRG) codes assigned to each spell, plus any additional costs planned admissions or those originating from a waiting list and include associated with excess bed days (for spells with lengths of stay beyond both day case admissions and those requiring an overnight stay. An the trim point of the respective HRG code). Unbundled HRG codes unplanned admission is defined by admission that was not arranged in (specific elements of costs separated from core HRGs) [20] were not advance [13]. A hospital admission in HES APC is referred to as a ‘spell’ reported or accounted for in the calculation of costs. Reported figures 2 S. Kolovos, et al. Journal of Bone Oncology 17 (2019) 100243 hence represent an estimate of what it costs the NHS to reimburse analysis. Fig. 2 shows the average number of patients per year for the hospitals for the core care they provided patients admitted as per the different age groups of patients admitted with MM. The age groups inclusion criteria. contributing most to the number of admissions for MM were those between 65 and 84 years or age (median age group= 70 - 74 years of 2.4. Data analysis age), accounting for 62% of admitted patients. Descriptive statistics and figures were used to summarize findings 3.2. Main procedures driving admissions and costs and characterise the hospital admissions and total costs by patients with MM. The count of patients are reported for different age groups. Total The most common procedure for elective admissions was che- numbers or means are reported, but given the lack of patient-level data, motherapy, accounting for 69% of the total elective admissions. The inter-quartile ranges or standard deviations could not be provided. costs from chemotherapy contributed 32% of all elective costs. The To identify the main drivers of admissions and costs for patients classification of all primary procedures driving the number of admis- with MM, we categorised admissions according to the 25 clinically-re- sions is described in Fig. 3a and the classification of procedures driving levant procedure and intervention OPCS chapters used by the NHS (e.g. the cost of elective admissions in Fig. 3b. “Nervous System”, “Diagnostic Imaging, Testing and Rehabilitation”, Of all unplanned admissions, the most common primary procedure “Bones and Joints of Skull and Spine”, etc.) [18]. In addition, primary code used was diagnostic radiology, accounting for 34% of the total procedures related to chemotherapy were identified via a series of number of such admissions and 33% of the costs. The classification of OPCS procedure codes either exclusively used for chemotherapy (e.g. all primary procedures driving the number of unplanned admissions is X35.2 “Intravenous chemotherapy”) or used mainly though not ex- described in Fig. 3c and the classification of procedures driving the cost clusively for it (e.g. X28.1 “Intermittent intravenous infusion of ther- of unplanned admissions in Fig. 3d. apeutic substance”). Similarly, OPCS procedure codes were also used to identify those admissions whose primary procedure was radiology, such 3.3. Comparison with colon cancer and total NHS as U05.1 “Computed tomography of head”. Finally, the number of pa- tients admitted, number of admissions, and total costs for patients with Table 1 shows the number of admissions, number of patients and MM were compared to those with colon cancer as well as all NHS pa- total costs comparing MM with all NHS admissions for the entire period tients. of analysis. Of all patients admitted to hospital in the NHS, 0.2% had a diagnosis of MM, yet they accounted for 1% of all admissions and 0.5% 3. Results of all inpatient NHS costs in the period of analysis. Whereas the average NHS patient reports 0.7 hospital admission per year, a mean cost per 3.1. Total number and costs of admissions admission of £1,205 and average costs of £870 per patient per year, for those admitted with a diagnosis of MM the mean number of yearly For patients with MM as primary or secondary diagnosis (ICD-10 admissions was 4.5, each admission costing the NHS an average of code C90.00), there were a total of 754,345 admissions reported be- £544, and a mean yearly cost per patient of £2,455. This compares with tween 1 April 2014 and 31 March 2018, equivalent to a mean of 166,100 patients with diagnosis of colon cancer with 956,615 admis- 188,586 admissions per year. Of the 41,845 patients admitted during sions reported and estimated total costs of £1,246,139,188 during the the period, 17,555 (42%) were women and 24,290 (58%) men. For period of analysis. On average, patients with colon cancer had 1.4 patients with OMM as primary or secondary diagnosis (ICD-10 code hospital admissions per year, a hospital admission costed on average M82.00), only 205 admissions were reported during the four years, £1,302, and the mean cost per patient per year was £1,876. involving 45 patients, 25 of whom were women and 20 men. Based on these admission figures, we focused our analyses exclusively on patients 4. Discussion with a diagnosis of MM. There was a significant difference between the number of admis- This study has identified that patients with MM have accounted for sions for elective and unplanned procedures. Of the total number re- an average of 188,586 hospital admissions per year to the NHS between ported during the period of analysis, 675,400 (90%) were elective and 1 April 2014 and 31 March 2018 and that 90% of those were elective 78,945 (10%) unplanned admissions. Some procedures, such as admissions. We found that the mean annual core (excluding unbundled) “Autologous peripheral blood stem cell transplant”, reported both cost of those admissions was £45,847,286 for elective admissions and elective (4,360) and unplanned (245) admissions during the period of £56,912,522 for unplanned admissions, indicating that despite un- analysis. For all elective admissions, 41% of the admitted patients were planned admissions making up only 10% of all admissions, they ac- women and 59% men, and for unplanned admissions proportions were counted for over half (55%) of total hospitalisation costs. 43% and 57%, respectively. On average during the four years of ana- We observed an increase in the number of admissions and costs for lysis, each patient had 18 admissions recorded. patients with MM over time. Elective and unplanned admissions are Total estimated core costs during the full period analysis were increasing at a similar rate but costs for unplanned admissions are in- £183,389,143 (mean of £45,847,286 per year) for elective and creasing much more rapidly. This increase in the number of admissions £227,650,088 (mean of £56,912,522 per year) for unplanned admis- for patients with MM is in line with published reports of the respective sions. From all elective admission costs, 43% corresponded to admis- increase for the NHS as a whole (4.3% per year for both elective and sions of women and 57% to those of men, a nearly identical split as that unplanned admissions) [21]. The annual increase in costs for MM pa- of unplanned admissions (42% and 58%, respectively). From the total tients, especially for unplanned admissions, is also consistent with estimated core costs from all admissions, 65% were from day-cases, previous findings indicating that costs related to MM are increasing 20% from ordinary cases, and 15% from regular attenders. Despite steadily since 2000 [5,7]. The increase in hospitalisation costs for MM unplanned admissions making up only 10% of all admissions, they patients is of particular relevance considering the shrinking of NHS accounted for 55% of the total estimated hospitalisation costs. Over the funding (1.1% per year between 2015 and 2021) [21]. period of analysis, elective admissions increased in average by 4.5% per The number of admitted patients with MM was highest for the group year whilst the average yearly increase in costs was 1.5%; for un- aged between 65 and 84, which accounted for 62% of admitted pa- planned admissions, these figures were 4.1% and 9.0%, respectively. tients. Due to the lack of patient-level data we were unable to calculate Fig. 1 shows the number of admissions and total estimated costs sepa- the mean age of the patients, but we identified that the median age was rately for elective and unplanned admissions by month for the period of contained in the group of 70 to 74 years of age. Most of the admitted 3 S. Kolovos, et al. Journal of Bone Oncology 17 (2019) 100243 Fig. 1. Total estimated costs and number of admissions for elective and unplanned admissions of patients with MM in the NHS (April 2014–March 2018). Fig. 2. Average number of patients per year for different age groups of patients admitted with MM. 4 S. Kolovos, et al. Journal of Bone Oncology 17 (2019) 100243 Fig. 3. Admitted patient care admissions for patients with MM, April 2014 through March 2018 - Main procedures classification by NHS OPCS code chapter for: (a) number of elective admissions, (b) costs of elective admissions, c) number of unplanned admissions, (d) costs of unplanned admissions. patients were men (58%), and this gender difference remained the same under the chapter ‘X – Miscellaneous Operations’, and of unplanned for the number of admissions and costs. These characteristics are con- admissions under chapter ‘Z - Subsidiary Classification of Sites of sistent with the findings of a study reporting incidence cases of MM in Operation’. It appears that this classification is not very detailed and the the UK based on patients identified via a primary care dataset, which included OPCS procedures are often not specific enough, for instance found men to account for 55% of the sample with median age being 73 procedures were recorded as “Unspecified” or “Not elsewhere classi- years, which falls within the median age group identified in our analysis fied”. Since the treatment and course of MM include many complica- [22]. A clinical trial currently assessing the benefit of antibiotic pro- tions, such as bone pain, infections, peripheral neuropathy, asthenia phylaxis and its effect on associated infection has recruited nearly 1000 and renal inefficiency, it would be useful to examine the association of patients with MM with median age of 67 in both arms [23]. these pathologies with the number and costs of elective and unplanned The commonest procedures of the number of admissions and costs admissions [24,25]. We were not able to conduct this analysis with the were the same: for elective admissions the main driver was che- available data, but this should be explored from future studies. motherapy, whilst for unplanned admissions it was diagnostic radi- MM-related admissions are only a small part of the total inpatient ology. Most of the procedures of elective admissions were classified stays treated in NHS (1%). However, the average cost per patient per 5 S. Kolovos, et al. Journal of Bone Oncology 17 (2019) 100243 Fig. 3. (continued) year for MM-related admissions is nearly three times that of the average into context accounting for this, we compared our findings about MM patient in the NHS (£2,455 vs £870). This is driven by the significantly with those of colon cancer. Colon cancer admissions were found to be higher average number of admissions per year for MM patients com- more costly, in average, than MM-related admissions (£1,302 vs £544), pared to the average NHS patient. Considering that cost estimates ex- which can be expected to be equally affected by the exclusion of un- clude unbundled HRGs (which add to the cost of chemotherapy) as they bundled HRGs if chemotherapy accounts for similar shares of admis- were not available from the data provider, costs of MM-related ad- sions. The difference in mean cost of admission may be explained by the missions are more than likely higher than estimated in this analysis. As different therapeutic strategy more focused on surgery. However, the a result, the relative cost of the inpatient care of patients with MM average number of MM-related admissions per patient was much higher compared to the average patient in the NHS can be expected to be than those of colon cancer (4.5 vs 1.4, respectively), thus leading to a higher than three-fold. higher economic burden per patient for those being admitted to hos- Admission rates and costs per patient can reasonably be expected to pital with MM (£2,455 compared to £1,876 for colon cancer). be higher for patients with cancer than for all patients admitted to Therefore, even though MM is not prevalent, it is related to high hospital, as confirmed in our analysis in the case of patients with MM. healthcare costs. Further investigation of clinical and cost-effective To place the characterisation of hospital admission of patients with MM treatments that can reduce the economic burden related to the disease 6 S. Kolovos, et al. Journal of Bone Oncology 17 (2019) 100243 Table 1 Author contributions Number of admissions, number of patients, and total costs for multiple mye- loma (MM) and all the NHS for the entire period of analysis (four years). All authors made substantial contributions to the conception or NHS1 MM % MM design of the work. SK, RPV, and MKJ performed the data analysis and wrote the manuscript. All authors have contributed to the drafting and Patients Women 13,914,785 17,555 0.13 revising critically the manuscript for important intellectual content. All Men 11,157,950 24,290 0.22 authors approved the submitted version of the manuscript. Total 25,083,320 41,845 0.17 Admissions Women 39,719,370 319,770 0.81 Men 32,646,475 434,575 1.33 Conflict of interest Total 72,376,430 754,345 1.04 Costs (£) Women 45,120,504 778 174,452,366 0.39 Guido Nador has received research support form Amgen. Bhuvan Men 42,131,019 046 223,418,395 0.53 Total 87,256,644 580 410,974,873 0.47 Kishore has received travel grants and honorarium from Takeda, Celgene and Jazz. Neil K. Rabin has received consultancy, travel sup- 1 The small discrepancy between the sum of female and male values and the port and/or speakers bureau from Janssen Cilaf, Takeda, Celgene, and total for NHS is due to some values labelled as unknown gender. Novartis. Kwee Yong received honoraria, unrestricted research grants, travel and/or subsistence expenses from Amgen, Janssen, Celgene, is warranted. Takeda, Sanofi. Her research has been funded from National Institute of Our analysis benefited from using routinely-collected real world Health Research Oxford Biomedical Research Centre supports funding data from the most recent four financial years from HES, which group for Amgen: unrestricted educational grant with no input on study de- all NHS funded hospital admissions in England. However, we only had sign, collection, analysis, interpretation of data, writing of manuscript access to data on admitted patient care. Hospital outpatient and and decision to submit. John Ashcroft has received honoraria, unrest- emergency contacts are also an important part of the clinical pathway ricted research grants, travel and /or substinence expenses from of patients with MM and of the associated costs to the healthcare system Amgen, Celgene, Janssen-Cilag, and Takeda. Karthik Ramasamy has [8,9]. This is particularly relevant for patients with MM because out- received research grants, speaker fees, honoraria, and is in the advisory patient appointments can be used for oral chemotherapy. Furthermore board of Amgen. Daniel Prieto-Alhambra's institution has received re- without access to individual level data or clinical information, we were search grants from UCB Biopharma, Amgen and Les Laboratoires unable to ascertain the date of diagnosis and so unable to distinguish Servier; speaker fees from AMGEN; and consultancy fees from UCB admissions that were the presentation of myeloma vs. admissions fol- Biopharma. Janssen, on behalf of IMI-funded EHDEN and EMIF con- lowing diagnosis. We did not have access to age breakdown within sortiums, and Synapse Management Partners have supported training elective and unplanned admissions. This would have been important to programmes organised by Daniel Prieto-Alhambra's department and identify their hospitalisation reason, such as possibly non-intensive open for external participants. Cyrus Cooper has received lecture fees treatment for the older, frail patients, or intensive therapy with trans- and honoraria from Amgen, Danone, Eli Lilly, GSK, Kyowa Kirin, plant for younger ones. Finally, we could only access the primary OPCS Medtronic, Merck, Nestlé, Novartis, Pfizer, Roche, Servier, Shire, procedure, and not additional procedures that may be related to each Takeda and UCB outside of the submitted work. M. Kassim Javaid re- admission. ceived honoraria, unrestricted research grants, travel and/or sub- Costs were estimated based only on ‘core’ HRGs and excess length of sistence expenses from Amgen, Lilly UK, Shire, Internis, Consilient stay. Although these normally capture the bulk of regular hospital ad- Health, Mereo Biopharma, Optasia Medical, Zebra Medical Vision, mission costs in England, the exclusion of ‘unbundled’ HRGs is un- Kyowa Kirin Hakin, and UCB. His research has been funded from questionably relevant for cancer admissions. Whereas the medical and National Institute of Health Research Oxford Biomedical Research surgical care provided during hospitalisation are included in ‘core’ Centre. Amgen Ltd provided an unrestricted educational grant. Andrew HRGs, the procurement (regimen) and delivery of chemotherapy and D Chantry, Mark T. Drayson, Matthew Streetly, Rafael Pinedo- radiotherapy are placed into ‘unbundled’ HRGs, as are pharmacy costs Villanueva, Stella Bowcock, and Spyros Kolovos declare no conflict of [20,26]. This means that the total inpatient cost of MM-related ad- interest for this work. missions will be more accurately represented by the sum of the costs identified in this study plus those regularly grouped into unbundled Acknowledgements HRGs but such analysis requires patient-level data. Given the high admission frequency and the considerable burden of The research was supported by the National Institute for Health unplanned admissions, further work is needed to explore the reasons for Research (NIHR) Oxford Biomedical Research Centre (BRC). The views these admissions, and to assess the cost-effectiveness of those inter- expressed are those of the author(s) and not necessarily those of the ventions to inform planning of health services. Using patient-level data NHS, the NIHR or the Department of Health. The research was co- from hospital admissions including outpatient visits and considering funded by an investigator initiated study award by Amgen Ltd. The unbundled HRGs is necessary to provide a more accurate character- funder had no input in the analysis plan, analyses, reporting or decision isation of the economic burden of MM in the UK. to submit for this publication. References 5. Conclusion [1] A.J. Cowan, C. Allen, A. 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