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Gray TF, Do KM, Amonoo HL, Sullivan L, Kelkar AH, Pirl WF, Hammer MJ, Tulsky JA, El-Jawahri A, Cutler CS, Partridge AH. Family Caregiver Experiences in the Inpatient and Outpatient Reduced-Intensity Conditioning Allogeneic Hematopoietic Cell Transplantation Settings: A Qualitative Study. Transplant Cell Ther 2024; 30:610.e1-610.e16. [PMID: 37783339 DOI: 10.1016/j.jtct.2023.09.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/21/2023] [Accepted: 09/24/2023] [Indexed: 10/04/2023]
Abstract
Caregivers (ie, family and friends) are essential in providing care and support for patients undergoing hematopoietic cell transplantation (HCT) and throughout their recovery. Traditionally delivered in the hospital, HCT is being increasingly provided in the outpatient setting, potentially heightening the burden on caregivers. Extensive work has examined the inpatient HCT caregiving experience, yet little is known about how caregiver experiences may differ based on whether the HCT was delivered on an inpatient or outpatient basis, particularly during the acute recovery period post-HCT. This study explored the similarities and differences in caregiver experiences in the inpatient and outpatient settings during the early recovery from reduced-intensity conditioning (RIC) allogeneic HCT. We conducted semistructured interviews (n = 15) with caregivers of adults undergoing RIC allogeneic HCT as either an inpatient (n = 7) or an outpatient (n = 8). We recruited caregivers using purposeful criterion sampling, based on the HCT setting, until thematic saturation occurred. Interview recordings were transcribed and coded through thematic analysis using Dedoose v.9.0. The study analysis was guided by the transactional model of stress and coping and the model of adaptation of family caregivers during the acute phase of BMT. Three themes emerged to describe similar experiences for HCT caregivers regardless of setting: (1) caregivers reported feeling like they were a necessary yet invisible part of the care team; (2) caregivers described learning to adapt to changing situations and varying patient needs; and (3) caregivers recounted how the uncertainty following HCT felt like existing between life and death while also maintaining a sense of gratitude and hope for the future. Caregivers also reported distinct experiences based on the transplantation setting and 4 themes emerged: (1) disrupted routines: inpatient caregivers reported disrupted routines when caring for the HCT recipient while simultaneously trying to manage non-caregiving responsibilities at home and work, and outpatient caregivers reported having to establish new routines that included frequent clinic visits with the patient while altering or pausing home and work responsibilities; (2) timing of caregiver involvement: inpatient caregivers felt more involved in care after the patient was discharged from the HCT hospitalization, whereas outpatient caregivers were already providing the majority of care earlier in the post-transplantation period; (3) fear of missing vital information: inpatient caregivers worried about missing vital information about the patient's care and progress if not physically present in the hospital, whereas outpatient caregivers feared overlooking vital information that may warrant contacting the care team as they monitored the patient at home; and (4) perceived adequacy of resources to meet psychosocial and practical needs: inpatient caregivers reported having adequate access to resources (ie, hospital-based services), whereas outpatient caregivers felt they had more limited access and needed to be resourceful in seeking out assistance. Inpatient and outpatient HCT caregivers described both similar and distinct experiences during the acute recovery period post-HCT. Specific interventions should address caregiver psychosocial needs (ie, distress, illness uncertainty, communication, and coping) and practical needs (ie, community resource referral, preparedness for home-based caregiving, and transplantation education) of HCT caregivers based on setting.
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Affiliation(s)
- Tamryn F Gray
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts; Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; Division of Stem Cell Transplantation and Cellular Therapies, Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer, Boston, Massachusetts; Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Cancer Outcomes Research and Education Program, Massachusetts General Hospital Cancer Center, Boston, Massachusetts.
| | - Khuyen M Do
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hermioni L Amonoo
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Cancer Outcomes Research and Education Program, Massachusetts General Hospital Cancer Center, Boston, Massachusetts; Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lauren Sullivan
- Division of Stem Cell Transplantation and Cellular Therapies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Amar H Kelkar
- Division of Stem Cell Transplantation and Cellular Therapies, Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - William F Pirl
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
| | - Marilyn J Hammer
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer, Boston, Massachusetts
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Areej El-Jawahri
- Harvard Medical School, Boston, Massachusetts; Cancer Outcomes Research and Education Program, Massachusetts General Hospital Cancer Center, Boston, Massachusetts; Divison of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Corey S Cutler
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; Division of Stem Cell Transplantation and Cellular Therapies, Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Ann H Partridge
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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Romon I, Gonzalez-Barrera S, Coello de Portugal C, Ocio E, Sampedro I. Brave new world: expanding home care in stem cell transplantation and advanced therapies with new technologies. Front Immunol 2024; 15:1366962. [PMID: 38736880 PMCID: PMC11082320 DOI: 10.3389/fimmu.2024.1366962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 04/12/2024] [Indexed: 05/14/2024] Open
Abstract
Hematopoietic stem cell transplantation and cell therapies like CAR-T are costly, complex therapeutic procedures. Outpatient models, including at-home transplantation, have been developed, resulting in similar survival results, reduced costs, and increased patient satisfaction. The complexity and safety of the process can be addressed with various emerging technologies (artificial intelligence, wearable sensors, point-of-care analytical devices, drones, virtual assistants) that allow continuous patient monitoring and improved decision-making processes. Patients, caregivers, and staff can also benefit from improved training with simulation or virtual reality. However, many technical, operational, and above all, ethical concerns need to be addressed. Finally, outpatient or at-home hematopoietic transplantation or CAR-T therapy creates a different, integrated operative system that must be planned, designed, and carefully adapted to the patient's characteristics and distance from the hospital. Patients, clinicians, and their clinical environments can benefit from technically improved at-home transplantation.
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Affiliation(s)
- Iñigo Romon
- Transfusion Section, Hematology Department, University Hospital “Marques de Valdecilla”, Santander, Spain
| | - Soledad Gonzalez-Barrera
- Home Hospitalization Department, University Hospital “Marques de Valdecilla” - Instituto de Investigación Valdecilla (IDIVAL), Santander, Spain
| | | | - Enrique Ocio
- Hematology Department, University Hospital “Marques de Valdecilla” - IDIVAL, Santander, Spain
| | - Isabel Sampedro
- Home Hospitalization Department, University Hospital “Marques de Valdecilla” - Instituto de Investigación Valdecilla (IDIVAL), Santander, Spain
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Applebaum AJ, Sannes T, Mitchell HR, McAndrew NS, Wiener L, Knight JM, Nelson AJ, Gray TF, Fank PM, Lahijani SC, Pozo-Kaderman C, Rueda-Lara M, Miran DM, Landau H, Amonoo HL. Fit for Duty: Lessons Learned from Outpatient and Homebound Hematopoietic Cell Transplantation to Prepare Family Caregivers for Home-Based Care. Transplant Cell Ther 2023; 29:143-150. [PMID: 36572386 PMCID: PMC9780643 DOI: 10.1016/j.jtct.2022.12.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/15/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
In the past decade, the demand for home-based care has been amplified by the Coronavirus disease 2019 pandemic. Home-based care has significant benefits for patients, their families, and healthcare systems, but it relies on the often-invisible workforce of family and friend caregivers who shoulder essential health care responsibilities, frequently with inadequate training and support. Hematopoietic cell transplantation (HCT), a potentially curative but intensive treatment for many patients with blood disorders, is being increasingly offered in home-based care settings and necessitates the involvement of family caregivers for significant patient care responsibilities. However, guidelines for supporting and preparing HCT caregivers to effectively care for their loved ones at home have not yet been established. Here, informed by the literature and our collective experience as clinicians and researchers who care for diverse patients with hematologic malignancies undergoing HCT, we provide considerations and recommendations to better support and prepare family caregivers in home-based HCT and, by extension, family caregivers supporting patients with other serious illnesses at home. We suggest tangible ways to screen family caregivers for distress and care delivery challenges, educate and train them to prepare for their caregiving role, and create an infrastructure of support for family caregivers within this emerging care delivery model.
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Affiliation(s)
- A J Applebaum
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - T Sannes
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - H R Mitchell
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, New York
| | - N S McAndrew
- College of Nursing, University of Wisconsin-Milwaukee, Milwaukee, WI, USA; Froedtert & the Medical College of Wisconsin, Froedtert Hospital, Patient Care Research, Milwaukee, Wisconsin
| | - L Wiener
- Pediatric Oncology Branch, National Cancer Institute, Center for Cancer Research, National Institutes of Health, Bethesda, MD
| | - J M Knight
- Departments of Psychiatry, Medicine, and Microbiology & Immunology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - A J Nelson
- Department of Psychiatry, Harvard Medical School/Massachusetts General Hospital, Boston, Massachusetts
| | - T F Gray
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - P M Fank
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, Illinois
| | - S C Lahijani
- Department of Psychiatry & Behavioral Sciences, Division of Medical Psychiatry, Stanford University School of Medicine, Palo Alto, California
| | - C Pozo-Kaderman
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - M Rueda-Lara
- University of Miami/Leonard Miller School of Medicine, Department of Psychiatry and Behavioral Sciences, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - D M Miran
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - H Landau
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - H L Amonoo
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Feasibility of a Hospital-at-Home Program for Autologous Hematopoietic Stem Cell Transplantation. Transplant Cell Ther 2023; 29:111.e1-111.e7. [PMID: 36436783 DOI: 10.1016/j.jtct.2022.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/03/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
The Hospital at Home (HaH) model has been positioned as an appropriate therapeutic strategy for selected patients undergoing autologous hematopoietic stem cell transplantation (ASCT). This care model provides hospital-equivalent care, in terms of both quality and quantity, with medical and nursing staff that go to the patient's home. Here we describe our experience with a full HaH model for patients undergoing ASCT during the phase of aplasia. The patients met the eligibility criteria between January 1997 and December 2019 and were discharged from the hospital and admitted into the HaH-ASCT program on the same day they in which hematopoietic stem cells were infused. A total of 84 patients were included. The median patient age was 54 years (range, 16 to 74 years), and the median duration of participation in the HaH program was 17 days (range, 3 to 86 days). Only 10 of these patients (12%) required hospital readmission to the hematology department, 9 of them due to sepsis and 1 because of family care support claudication. Seventy-two patients (86%) experienced an episode of neutropenic fever during the HAH admission, with a median duration of 2 days (interquartile range [IQR], 1 to 11 days); all were treated with empiric i.v. antimicrobial therapy. Most patients (88%) presented with mucositis (44% with grade 3-4). Parenteral nutrition was administered in 26% of patients for a median of 6 days (IQR, 1 to 12 days). Most patients (94%) required at least 1 blood product transfusion at home. There was no transplantation-related mortality during the HaH-ASCT program or in the patients who were readmitted. With careful selection of patients and a comprehensive and well- experienced multidisciplinary team (doctors, nurses, and auxiliary nurses) in the HaH department and in close collaboration with the hematology department, complete at-home management of ASCT recipients immediately after transplantation is possible. This allows patients undergoing an aggressive procedure such as ASCT to remain in their own familiar environment, providing a better quality of life with a program that has demonstrated to be effective and safe, with a low incidence of complications and no associated mortality.
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Landau HJ, Orlando E, Rodriguez ES, Applebaum A, Mitchell HR, Peled JU, Khan N, Funnell T, Chung D, Scordo M, Shah GL, LeStrange NJ, Hambright KA, McElrath CM, Cazeau N, Devlin SM, Perales MA, Giralt SA. Pilot Trial of Homebound Hematopoietic Cell Transplantation. Transplant Cell Ther 2022; 28:832.e1-832.e7. [PMID: 36182105 PMCID: PMC9888402 DOI: 10.1016/j.jtct.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 09/14/2022] [Accepted: 09/20/2022] [Indexed: 02/02/2023]
Abstract
For eligible patients with multiple myeloma (MM) and amyloid light chain (AL) amyloidosis, high-dose chemotherapy and autologous hematopoietic cell transplantation (HCT) is a standard and widely used consolidation therapy. Autologous HCT requires specialized care at a transplantation center and investment from patients and caregivers. We studied the safety and feasibility of delivering transplantation care in a homebound setting to decrease the burden of therapy and increase access to autologous HCT. Patients with MM and AL amyloidosis undergoing autologous HCT were eligible if they resided in designated ZIP codes and had a full-time caregiver, Wi-Fi connection, HCT Comorbidity Index ≤3, and Karnofsky Performance Status score ≥80. High-dose melphalan (on day -2) and hematopoietic cell reinfusion (day 0) were administered in the outpatient clinic. Protocol-specific home care was provided from day +1 through engraftment. Patients were assessed and blood was drawn daily by advanced practice providers. Interventions were delivered by registered nurses. Attending physicians communicated daily through telemedicine. Quality of life, patient and caregiver satisfaction, and fecal microbiota profiling data were collected. Fifteen patients were enrolled and received transplantation care at home starting on day +1 following hematopoietic cell infusion. Patients remained in the program for an average of 12 days and required an average of 2 outpatient visits while receiving home care. Seven of 15 patients were admitted for a median of 4 days (range, 3 to 10 days); admission occurred on day +7 in 5 patients, on day +8 in 1 patient, and on day +12 in 1 patient for neutropenic fever in 2 patients, fever attributed to engraftment syndrome in 2 patients, diarrhea in 2 patients, and dehydration in 1 patient. Only 1 patient had a documented infection (Clostridioides difficile). One patient admitted with neutropenic fever required intensive care unit admission for a gastrointestinal bleed. Forty-seven percent of the patients experienced a grade ≥3 nonhematologic toxicity. There were no deaths on the study. Patients and caregivers reported high satisfaction with care. Microbiota diversity patterns were similar to those of autologous HCT recipients who did not receive post-HCT care at home, although a subset of the cohort maintained microbiota diversity throughout. Homebound HCT in an urban setting is safe and feasible, with less than one-half of patients requiring inpatient admission. Despite increased patient and caregiver responsibility in the homebound setting compared with an inpatient setting, patient and caregiver satisfaction was high. These results support expansion of homebound transplantation care programs.
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Affiliation(s)
- Heather J Landau
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Evelyn Orlando
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | | | - Allison Applebaum
- Counseling Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hannah-Rose Mitchell
- Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan U Peled
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Niloufer Khan
- Lymphoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Tyler Funnell
- Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David Chung
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael Scordo
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Gunjan L Shah
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nicole J LeStrange
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Katie A Hambright
- Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Courtney M McElrath
- Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Naomi Cazeau
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean M Devlin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sergio A Giralt
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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