The Impact of Outpatient versus Inpatient Administration of CAR-T Therapies on Clinical, Economic, and Humanistic Outcomes in Patients with Hematological Cancer: A Systematic Literature Review

Abstract

Although chimeric antigen receptor (CAR)-T cell therapies are typically administered in the inpatient setting, outpatient administration is rapidly expanding. However, there is limited summarized evidence comparing outcomes between outpatient and inpatient administration. This systematic literature review aims to compare the safety, efficacy, quality of life (QoL), costs, and healthcare resource utilization (HCRU) outcomes in patients with hematological cancer who are administered CAR-T therapy in an outpatient versus an inpatient setting. Publications (2016 or later) that reported the outcomes of interest in patients treated with a CAR-T therapy in both outpatient and inpatient settings, or only the outpatient setting, were reviewed. In total, 38 publications based on 21 studies were included. Safety findings suggested the comparable frequency of adverse events in the two settings. Eleven studies that reported data in both settings showed comparable response rates (80–82% in outpatient and 72–80% in inpatient). Improvements in the QoL were observed in both settings while costs associated with CAR-T therapy were lower in the outpatient setting. Although unplanned hospitalizations were higher in the outpatient cohort, overall HCRU was lower. Outpatient administration of CAR-T therapy appears to have comparable outcomes in safety, efficacy, and QoL to inpatient administration while reducing the economic burden.

Clinician and administrator perspectives on outpatient administration of ciltacabtagene autoleucel in relapsed or refractory multiple myeloma

“…The findings of our study highlight key challenges faced by outpatient CAR T centers, notably: limited institutional capacity, the need for multidisciplinary teams, and the need for protocols for CAR T complications. This is supported by 2 recent articles that have highlighted similar findings to the current study with regard to key drivers of outpatient administration of CAR T for hematologic cancers (predictability of AEs, reduced healthcare burden, and patient quality of life), limiting factors (financial and caregiver support), and best practices (dedicated infrastructure, close monitoring of patients, and patient and caregiver education) ( 24 , 42 ). An expert roundtable also described the importance (in all administration settings) of close patient monitoring, financial and caregiver support considerations, and collaboration across multidisciplinary teams in the administration of CAR Ts for patients with RRMM ( 44 ).…”

“…The current study also highlighted the critical logistical challenges faced by some patients in securing lodging during the 30-day period following outpatient CAR T administration. This aligns with findings from a systematic literature review that identified logistical considerations (e.g., caregiver support, lodging in close proximity to the treatment center) as an important element to consider when administering CAR Ts in an outpatient setting ( 24 ).…”

“…By shifting CAR T administration to an outpatient setting, there is a potential for substantial cost savings and lower healthcare resource utilization, as shown in a systematic review by Hansen et al. reporting 2–4 times higher post-infusion costs and 2–3 times longer length of stays for inpatient relative to outpatient CAR T administration ( 24 ). Also, in relapsed/refractory large B-cell lymphoma, a retrospective study by Palomba et al.…”

“…As real-world experience with CAR T increases, administration in the outpatient setting is expanding ( 14 – 16 , 24 ), particularly for CAR Ts that are associated with AEs that potentially occur several days after infusion, such as cilta-cel. The objective of this mixed methods qualitative study was to evaluate clinical and administrative perspectives on outpatient administration of commercial cilta-cel to understand best practices from certified CAR T centers in the US.…”