Impact of transitioning inpatient chemotherapy regimens to the outpatient setting

Abstract

Background Chemotherapy regimens historically have required admission of the patient to the hospital for extended infusions running over multiple days to complete each cycle of therapy. With the evolution of monitoring strategies readily available, a renaissance in patient care and healthcare cost utilization is necessary as transitioning the administration of these agents to the outpatient setting is seemingly achievable and is potentially more cost-effective. Purpose This evaluation sought to primarily measure cost-savings for an institution by transitioning inpatient chemotherapy regimens to the outpatient setting. Secondary outcomes evaluated the effect of this transition on overall patient length of stay, prevalence of adverse effects, and overall chemotherapy schedule adherence as a result of implementing transitions in sites of care. Barriers to receiving care in the outpatient setting were assessed by evaluating the acuity of performance status as well as distance from the hospital. Methods This single-center retrospective, quantitative chart and expense analysis evaluated patients receiving rituximab, etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin (R-EPOCH) or rituximab, ifosfamide, carboplatin, and etoposide (R-ICE) chemotherapy regimens based on treatment setting at a single institution. Included patients were treated at the University of Chicago Medical Center. Those receiving inpatient-only management as compared with patients who received therapy in outpatient settings were compared in a matched cohort analysis. The control group was matched from the period before transition of therapy was instituted between November 2014 and November 2015, with those patients transitioned to outpatient therapy (December 2015 to November 2016), using demographic, diagnostic, treatment, and clinical status data to assure group similarity. Mean cost of therapy was compared between inpatient and outpatient regimens. Descriptive and demographic categorical data were compared using the Fisher’s exact test. Continuous data were evaluated using the Student’s t test. A significance level of alpha <0.05 was used for all analysis. Results The cost of R-EPOCH therapy represented a significant difference across groups. R-ICE therapy similarly saw significant cost differences between inpatient and outpatient groups. If this was made standard of care for qualifying patients a retrospective annualized estimation of $466,507.85 with R-EPOCH therapy and $205,977.60 for R-ICE therapy could have been saved if this was utilized for patients who previously received their therapy as an inpatient. Conclusion The population of patients cared for at the University of Chicago Medicine during this time-period qualified for outpatient treatment for those treated with R-EPOCH and R-ICE regimens with no significantly identifiable prohibitive barriers between groups. As no significant complications manifested, it is reasonable to continue transitioning patients receiving these regimens to the outpatient setting where appropriate. R-EPOCH and R-ICE therapies were shown to be reasonable outpatient therapy while providing significant cost-savings for the institution.

Utilization of an Outpatient Integrated Infusion Suite to Decrease Length of Stay, Increase Revenue, and Improve Patient Experience for Elective Chemotherapy Admissions

“…Although the use of R-EPOCH has declined in recent years, it is still considered for double-hit diffuse large B-cell lymphoma and Burkitt's lymphoma. 11,12 Additionally, transferring the entire R-EPOCH regimen to be infused in the outpatient setting, as done in other centers, 1,13,14 is not always clinically appropriate or feasible.…”

“…There are many advantages to administering chemotherapy in the outpatient setting. 1,2 Eliminating hospital admissions, or shortening length of stay (LOS), increases the availability of beds for acutely ill patients and respects patients' wishes to spend less time in the hospital. 3,4 However, some regimens, particularly in newly diagnosed hematologic malignancies, require inpatient admission.…”

“…This provided a financial incentive to transfer specific chemotherapy regimens from entirely inpatient to entirely outpatient when clinically appropriate. 1 There is also a well-established link between reductions of LOS with increase in revenue, 7 or rather cost avoidance, as the revenue is stable on the basis of the Diagnosis-Related Group (DRG) reimbursement. One study established that delays in chemotherapy initiation (particularly in infusions of EPOCH) had a mean cost of about $10,000 US dollars (USD) in the first day alone.…”

Expanding oncology pharmacist teams: Justifying the return on investment

“…13 A second study estimated an annualized savings of over $460,000 with R-EPOCH therapy and over $200,000 for R-ICE therapy. 14 TUKHS recently published a transition of BMT preparative regimens to the outpatient setting and estimated an approximate cost savings of $155,000 per transplant. 15 These cost savings can be translated to position justifications to support the increase in monitoring needs and patient and caregiver education in the ambulatory setting that can be provided by a pharmacist Additional valuable data that can be utilized to justify acute care positions includes the impact of pharmacist clinical interventions on medication errors.…”

Predictors of Central Vascular Access Device Bloodstream Infections in Patients With Acute Leukemia and Neutropenia

“…Historically, chemotherapy regimens required admission of patients to the hospital for extended infusions running over multiple days to complete each cycle of therapy 21. With the evolution of enhanced monitoring capabilities in the outpatient setting and readily available home infusion pump options, the transition of many of these regimens to the outpatient setting has demonstrated significant cost savings and has become the norm for many patients receiving chemotherapy 22,23. The shift of treatment options from inpatient hospitalization to the outpatient setting has occurred in many facilities that provide oncology care.…”