Neutropenic infections in 100 patients with non-Hodgkin’s lymphoma or Hodgkin’s disease treated with high-dose BEAM chemotherapy and peripheral blood progenitor cell transplant: out-patient treatment is a viable option

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.

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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

Frey

Stinson

Siston

et al. 2002

“…These results are in line with previously reported data on infections in bone marrow transplant recipients. 16,17 Multivariate analysis identified a group of patients conditioned with a single alkylating agent-containing regimen and with no or mild mucositis, that had a lower probability of developing fever. The number of alkylating agents did not influence the duration of profound neutropenia.…”

Section: Discussionmentioning

confidence: 99%

Infectious complications in breast cancer patients undergoing peripheral blood stem cell transplantation: a single center retrospective analysis towards outpatient strategy

Morabito

Irrera

Olíva

et al. 2001

Summary:Infectious complications were retrospectively analyzed in 129 transplants, performed in 90 patients, to identify characteristics that qualify breast cancer patients for outpatient-based PBSCT. Thirty-one cases (24%) did not develop fever. Of the remaining 98 cases, 84.7% developed fever during severe neutropenia. On univariate analysis, disease stages II-III, first PBSCT, mucositis grades II-IV and the use of two alkylators were associated with a higher risk of fever development. The latter two factors also affected fever occurrence on multivariate analysis. A longer median time to fever onset was observed in patients conditioned with single as compared to double alkylating agent-containing regimens (respectively 8th vs 6th day, P Ͻ 0.00001). As compared with metastatic breast cancer (MBC), high risk breast cancer showed a 2.3-fold increased risk of developing early fever during neutropenia (CI 2.3-3.8), remaining the only variable still significant on multivariate analysis (P = 0.0039). Combination antibiotic therapy was equivalent to single agent therapy. Patients suffering from microbiologically documented fever were at higher risk of undergoing second-line antibiotic therapy. In conclusion, MBC patients treated with a conditioning regimen containing only one alkylating agent and adequate prophylaxis for mucositis may qualify for outpatientbased PBSCT on the basis of a lower risk of infection. Bone Marrow Transplantation (2001) 28, 883-888. Keywords: breast cancer; stem cell transplant; infection; outpatient High-dose chemotherapy (HDC) followed by peripheral blood stem cell transplantation (PBSCT) is increasingly being used

“…The same is true in very select instances for patients undergoing allogeneic transplants. [2][3][4][5][6][7][8] This shift of care has also occurred owing to improvements in supportive care, as well as cost and quality of life (QOL) issues. The main drivers of this change were the use of peripheral blood rather than bone marrow stem cells, and improvements in supportive care (i.e., antibiotic algorithms, antiemetic regimens and transfusion protocols).…”

Section: Introductionmentioning

confidence: 99%

“…With the development of less mucotoxic preparative regimens, approximately 10 years ago several groups began to explore the feasibility of performing HSCT at least partially on an outpatient basis. [1][2][3][4][5][6][7][8] The initial strategy was to administer the preparative regimen in the outpatient setting with subsequent admission for follow-up care for patients diagnosed with breast cancer. More recently, select patients diagnosed with lymphoma and multiple myeloma have been successfully autotransplanted completely in the outpatient setting, utilizing non-total body irradiation (TBI)-based regimens.…”

Section: Introductionmentioning

confidence: 99%

Autologous hematopoietic stem cell transplants that utilize total body irradiation can safely be carried out entirely on an outpatient basis

Stiff

Mumby

Miler

et al. 2006

Outpatient hematopoietic stem cell transplants (HSCT) are usually performed in patients receiving minimally mucotoxic preparative regimens; total body irradiation (TBI)-based regimens typically are excluded. To improve resource utilization and patient satisfaction, we developed a totally outpatient HSCT program for TBI regimens and compared outcomes for our first 100 such transplants to 32 performed as in-patients during the same interval, for caregiver or financial reasons. Symptoms were managed predominately with oral agents; pain management consisted of transdermal fentanyl and oral morphine solution. Except for more unmarried in-patients, the two groups were matched. Time to engraftment, severity of mucositis and transplant duration were identical for the two groups. Twenty-seven of the outpatients were admitted (median-6 days), primarily for progressing infection. Thus 92% of all transplant days were outpatient. There were no septic episodes or hospital admissions for pain management. There were no deaths to day 30 in either group and 100-day survival was identical. There was a mean cost savings of $16 000 per outpatient transplant and outpatient patient/caregiver quality of life was similar to that reported for in-patients. Patients undergoing severely mucotoxic regimens can be safely transplanted in an outpatient setting with a significant cost saving, with no increase in morbidity or mortality.