Lack of caregivers limits use of outpatient hematopoietic stem cell transplant program

Abstract

Summary:Our goal was to compare direct and indirect medical costs and quality of life associated with inpatient vs outpatient autologous hematopoietic stem cell transplantation (AuHSCT). Twenty-one sequential outpatients and 26 inpatients were enrolled on this prospective trial. All candidates for AuHSCT were screened for eligibility for outpatient transplantation. Patients with either breast cancer or hematologic malignancy, insurance coverage for the outpatient procedure, one to three caregivers available to provide 24 h coverage, and no significant comorbidities were eligible to participate. Patients without caregivers or insurance coverage for outpatient transplant were accrued to the study in a consecutive manner as inpatient controls, based on willingness to participate in the quality of life portion of the study and to permit review of their hospital and billing records. Approximately half of all 139 prospective outpatient candidates were ineligible because they lacked a caregiver. Most commonly, the patient without a caregiver was single or widowed or their family and friends were needed to provide childcare. Most caregivers were college educated from families with incomes greater than $80 000. Indirect costs to the caregivers totaled a median of $2520 (range $684-$4508), with the majority attributed to lost 'opportunity costs'. Overall, there were significant differences in the total costs of treatment for inpatient vs outpatient AuHSCT ($40 985 vs $29 210, P Ͻ 0.01)). In general, no significant differences were detected between inpatient and outpatient scores on quality of life measures. Although significant cost savings were associated with outpatient transplantation, this approach was applicable to only half of our otherwise eligible candidates because of a lack of caregivers. The financial burden associated with the caretaking role may underlie this finding.

Randomized study of early hospital discharge following autologous blood SCT: medical outcomes and hospital costs

“…This confirms previous studies, which already highlighted that a lack of caregivers may limit the use of outpatient HSCT programs. 7,9,13 As no previous study included the patients not discharged in the outpatient arm in their analysis, we could not discuss the comparability of our results. Moreover, the control groups used in previous studies' comparisons were often subject to the following factors: patient's refusal of outpatient follow-up, insurancecompany refusal, the absence of a caregiver, living too far from the hospital and physicians' decisions that their patient should not join the program.…”

“…Although it is difficult to compare costs' analyses between countries, to date all studies agree that outpatient programs lead to cost savings-from 7 to 47%. 6,9,11,14 In our study, shifting from inpatient to early discharge programs created cost savings of 19% when considering the patients actually discharged early. Considering all the patients randomized in the early discharge program, our early discharge program showed a mean cost per patient only 6% inferior to that for the conventional inpatient group, reflecting less attractive savings than those found in other studies.…”

“…antibiotics between the group A and group B were observed, which is in-line with other studies. 6,9,23 Antibiotics prophylaxis has been used in most other outpatient and early discharge programs. Our results suggest that the lack of prophylaxis did not result in an unacceptable increase in infectious complications for outpatients.…”

“…In several of the other studies outpatients were housed in residential facilities located close to the hospital. 9,11,16 Instead, in our program, patients were intentionally followed only 1-3 days a week in the outpatient clinics far from hospitals, so as to give them and their caregivers some 'resting' days. A total of 39% of the routine clinical practice patients with an indication for HDCT were not discharged early for social or psychological reasons (no caregiver, living too far or patient desire to stay as an inpatient).…”

“…Over the past decade, a number of studies have investigated the efficacy, safety and cost advantages of reduced hospitalization for auto-SCT. [5][6][7][8][9][10][11][12][13][14][15][16][17] During this time several models of outpatient (home-and clinic-based or daily clinic-based) and early discharge care (with or without planned readmission) have emerged. 18 Studies usually conclude that HDCT is feasible and safe in the outpatient setting, thanks to the use of hematopoietic growth factors and antimicrobial prophylaxis, which lower aplasia related complications.…”