ORIGINAL ARTICLE
Utility of the psychosocial assessment of candidates for transplantation
(PACT) scale in allogeneic BMT
LW Foster
1
, L McLellan
2
, L Rybicki
3
, J Dabney
2
, M Visnosky
2
and B Bolwell
2
1
School of Social Work, Cleveland State University, Cleveland, OH, USA;
2
Department of Hematology and Medical Oncology,
Taussig Cancer Center, Cleveland, OH, USA and
3
Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland,
OH, USA
The psychosocial assessment of candidates for transplan-
tation (PACT) scale was completed before the transplant
on 120 patients who underwent allogeneic transplant from
November 2003 to June 2007. The PACT has eight
subscales, each rated on a 5-point scale, and an initial and
final rating independently based on the rater’s overall
impressions of the candidate’s acceptability for transplant.
This exploratory study assessed the clinical utility of the
PACT scale for psychosocial screening in allogeneic
BMT. Associations of the PACT subscales and the final
rating with sixteen post transplant medical outcomes were
examined using the Jonchkheere–Terpstra test, the
Cochran–Armitage test or the Cox proportional hazards
analysis. Significant relationships (Pp0.05) between
PACT subscales and medical outcomes are as follows:
better compliance with medications and medical advice
associates with lower in-hospital mortality, shorter length
of stay and readmission duration, and faster neutrophil
and platelet engraftment; better scores on drug/alcohol
use associates with faster platelet engraftment; better
scores on family/support system availability and on
relevant knowledge and receptiveness to education associ-
ates with decreased risk of mortality. The final rating
score and medical outcomes are not significantly related;
however, study findings underscore the prognostic value of
the PACT subscales and the potential utility for screening
of BMT candidates.
Bone Marrow Transplantation advance online publication,
16March 2009; doi:10.1038/bmt.2009.37
Keywords: allogeneic BMT; psychosocial criteria; PACT
Scale
Introduction
Psychosocial risk factors have been reported to be
associated with or predictive of treatment-related vulner-
ability
1–4
and survival
5–17
in allogeneic BMT. Recent survey
research shows that BMT clinicians consider psychosocial
risk factors when making a decision whether or not to
proceed with allogeneic BMT;
18
75% of the responding
oncologists indicated that they have recommended not to
proceed with BMT based on a psychosocial risk factor.
Two psychosocial rating scales designed for use in solid
organ transplant (SOT), the psychosocial assessment of
candidates for transplantation (PACT) scale and the
transplant evaluation rating scale (TERS), have been
used
19–22
and compared
23
in BMT. Researchers have found
the PACT and TERS scales comparable in inter-rater
reliability, with similar conceptual items correlating fairly
highly with each other; however, the PACT scale offers
more flexibility than the TERS in using clinical judgment.
23
Although the PACT was designed to study clinical
decision making in psychosocial screening of SOT candi-
dates, there is no research on the relationship of the PACT
scores to medical outcomes post transplant, either in SOT
or BMT. Authors of the PACT scale recommend that
research should be conducted on ‘how well do ratings
on the PACT scale predict patient recovery, compliance,
and physical health outcomes.’
19
Therefore, this research
explores the clinical utility of the PACT scale for
psychosocial screening in BMT. Specifically, medical out-
comes post transplant are examined in relation to the
PACT subscale scores and the final rating or the rater’s
overall impression of the candidate’s quality for allogeneic
BMT. Will patients with better PACT subscale scores and
final rating score have better medical outcomes post
transplant? Which of the PACT subscales will contribute
most and least heavily to the final rating of allogeneic BMT
candidates?
Materials and methods
As the utility of psychosocial assessment of BMT patients
has been under debate,
8
the study is explorative and not
hypothesis testing. From November 2003 to June 2007, the
Received 31 July 2008; revised 16January 2009; accepted 22 January
2009
Correspondence: Dr LW Foster, School of Social Work, Cleveland State
University, 2121 Euclid Avenue, CB 202, Cleveland, OH 44115-2214,
USA.
E-mail: l.w.foster@csuohio.edu
Bone Marrow Transplantation (2009), 1–6
& 2009 Macmillan Publishers Limited All rights reserved 0268-3369/09 $32.00
www.nature.com/bmt

demographic and medical data were collected on 120 adult
allogeneic patients at a major tertiary hospital in the US.
All patients were treated on protocols that were reviewed
and approved by the hospital’s institutional review board
(IRB), with informed consent obtained from all patients.
These patients were seen pre-transplant for psychosocial
assessment by an oncology social worker, selected from a
pool of three oncology social workers assigned to the BMT
program. The duration of the assessment process was 1.5 to
2 h, after which the social worker took approximately 5 min
to complete a PACT scale for each patient. The PACT is a
helpful and easy-to-use scale that any mental health
professional (psychologist, psychiatrist or oncology social
worker) completing the pre-transplant psychosocial assess-
ment can use. Use of the PACT scale with allogeneic
patients in the present exploratory study is part of a larger
IRB-approved prospective study designed to verify the
effect of lay care partners on medical outcomes; each
patient consenting to this study has a PACT scale
completed at baseline.
The PACT scale is a single page 10-item rating scale with
high inter-rater reliability (intraclass correlation¼ 0.85) in
SOT.
19
Two of the 10 items, the initial and the final rating,
are based on the clinician’s judgment of candidate quality
for transplant and graded from 0¼ poor to 4¼ excellent
transplant candidate; the initial rating is just an impression
that is formed before assessing each subscale and it was not
used in this study. The PACT scale has four rating sections:
Social Support, Psychological Health, Lifestyle Factors,
and Understanding of Transplant and Follow-up. Under
these sections, there are eight subscales that represent
aspects of psychosocial importance: (1) Family/Support
System Stability; (2) Family/Support System Availability;
(3) Psychopathology, Stable Personality Factors; (4) Risk
for Psychopathology; (5) Healthy Lifestyle, Ability to
Sustain Change in Lifestyle, (6) Drug/Alcohol Use; (7)
Compliance with Medications and Medical Advice; and (8)
Relevant Knowledge/ Receptiveness to Education. Each
subscale is scored from 1 (poor score) to 5 (excellent score);
better or higher scores mean lower risk.
Statistical analysis
Categorical variables are summarized as frequency counts
and percentages; continuous variables are summarized as
the mean, s.d., median, minimum and maximum. Sixteen
outcomes were assessed: three were binary (in-hospital
mortality, 100-day mortality, any hospital readmission),
five were continuous (length of stay, days until neutrophil
engraftment, days until platelet engraftment, number of
readmissions, and average number of readmission days),
and eight were time-to-event (any acute graft-versus-host
disease (GVHD), grades II-IV acute GVHD, grades III–IV
acute GVHD, any chronic GVHD, extensive chronic
GVHD, relapse, overall survival, and relapse-free survival).
Analyses were performed to determine whether any of the
eight PACT subscales or the final PACT rating was
associated with these outcomes. Binary variables were
analyzed using the Cochran–Armitage trend test to
determine whether there is a trend in these outcomes as
the PACT score increases (less psychosocial risk); results
are summarized as frequency counts and percentages.
Continuous variables were analyzed using the Jonc-
kheere–Terpstra test to determine whether there is a trend
in these outcomes as the PACT score increases: results are
summarized as the median and range. Time-to-event
outcomes were analyzed using the Cox proportional
hazards analysis: results are summarized as the hazard
ratio per one point increase in PACT score, the 95%
confidence interval and the corresponding P-value.
Results
Patient characteristics are described in Table 1. The median
age of patients is 41; 87% are Caucasian and 52% are
female. Patients are nearly equally divided by having a
related or unrelated donor, and most patients have an acute
leukemia diagnosis (51% have acute myeloid leukemia
(AML) and 22% have acute lymphocytic leukemia (ALL)).
The median length of inpatient hospital transplant stay is
30 days, and most patients survive the inpatient hospital
transplant stay, with a 92% survival rate; 85% of patients
survive 100 days post transplant. Most patients (85%)
require an inpatient hospital readmission; 62% of patients
have an episode of acute GVHD, 36% chronic GVHD, and
a majority of patients (81%) remained relapse-free. The
median follow-up of living patients is 14.6months, with a
range of 1.6to 42.1 months.
Ratings for each PACT subscale and the final PACT
rating are shown in Table 2. As depicted, 70% to 89% of
patients were rated with better scores (4 or 5) on all eight
subscales. Noteworthy is the subscale Drug and Alcohol
Use; 79% of patients were rated with a score of 5,
indicating a large majority practice abstinence or rare
substance use. In addition, compared with the other
subscales, patients were more frequently rated with a score
of 3 on Family and Support System Stability; Family and
Support System Availability; Psychopathology, Stable
Personality Factors; and Relevant Knowledge and Recep-
tiveness to Education, indicating moderate concern about
these aspects of psychosocial importance. Regarding the
final rating scores of candidate quality for transplant, a
majority (68%) were rated as good or excellent candidates.
Significant relationships between PACT ratings and
binary or continuous outcomes are shown in Table 3. The
percentage of patients who die in the hospital decreases as
compliance with medications/medical advice improves
(P¼ 0.047). In addition, better compliance is significantly
associated with shorter length of stay (P¼ 0.037), faster
neutrophil engraftment (P¼ 0.015), faster platelet engraft-
ment (P¼ 0.029) and shorter average readmission duration
(P¼ 0.038). Better or higher scores on the drug and alcohol
use subscale, or less substance use, are associated with
faster platelet engraftment (P¼ 0.020). In addition, the
percentage of patients who require readmission decreases as
the risk for psychopathology lessens (P¼ 0.044), as
indicated by better or higher scores. Significant relation-
ships between PACT ratings and time-to-event outcomes
are shown in Table 4. Decreased risk of mortality is
significantly associated with better or higher scores on
family or support system availability (P¼ 0.042) and with
Utility of PACT Scale in Allo BMT
LW Foster et al
2
Bone Marrow Transplantation