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Garcés-Carrasco AM, Santacatalina-Roig E, Carretero-Márquez C, Chover-Sierra E, Martínez-Sabater A, Balaguer-López E. Post-Transplant Complications in Patients Undergoing Autologous Hematopoietic Cell Transplantation (HCT)-A Comparative Analysis of Home Care versus Hospitalized Patients. MEDICINA (KAUNAS, LITHUANIA) 2023; 60:44. [PMID: 38256305 PMCID: PMC10821161 DOI: 10.3390/medicina60010044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 11/29/2023] [Accepted: 12/22/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: The increase in indications for hematopoietic cell transplants (HCTs) has led to the development of new care options after said transplant, such as home care after transplantation, which improves the patients' quality of life. The main purpose of this research is to analyze the differences in the appearance of post-transplant complications between patients having underwent autologous HCT with at-home post-transplant modalities and those under in-hospital post-transplant care. Materials and Methods: An observational, analytical, longitudinal, and retrospective study of cases and controls. All transplanted people in the domiciliary model since 2020 are included as cases (20 subjects). For each case, two controls (40 subjects) are proposed among patients who received an autologous transplant in a hospital in the last five years with a similar demographic and pathological base profile in each case. Results: No significant differences were found between cases and controls, except for the Karnofsky value, which was higher in people receiving home treatment (91.7% vs. 87.74%; p = 0.05). The average number of days of the process post-transplantation was more significant at home (processing days 22.4 ± 2.6; post-transplantation days of 16.4 ± 2.08 versus 21.21 ± 4.18, with a mean of 15.51 ± 3.96 days post-transplant (days of the process p = 0.022; days post-transplant p = 0.002)). There is a more significant presence of neutropenic fever, mucositis, and positive blood cultures in the post-transplant patients who remain in the hospital. In contrast, the patients receiving home care post-transplantation undergo significantly more weight loss. Regarding the odds ratio of the appearance of adverse events, in the hospital setting, it is up to 8.5 times more likely to encounter neutropenic fever, 4.63 times more likely for mucositis, and 6.65 times more likely for the presence of pathogens in blood cultures. Conclusions: The home care modality in the post-transplant phase does not show an inferiority in conditions in the management and safety of the patient concerning the appearance of adverse events. However, more significant weight loss is detected in patients at home, and an increased risk of episodes of neutropenic fever, mucositis, and positive blood cultures for patients in hospital settings.
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Affiliation(s)
- Ana María Garcés-Carrasco
- Oncology and Hematology Department, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain (E.S.-R.)
| | - Enric Santacatalina-Roig
- Oncology and Hematology Department, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain (E.S.-R.)
- Nursing Department, Facultat d’Infermeria i Podologia, Universitat de València, 46010 Valencia, Spain; (E.C.-S.); (E.B.-L.)
| | - Carlos Carretero-Márquez
- Oncology and Hematology Department, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain (E.S.-R.)
| | - Elena Chover-Sierra
- Nursing Department, Facultat d’Infermeria i Podologia, Universitat de València, 46010 Valencia, Spain; (E.C.-S.); (E.B.-L.)
- Nursing Care and Education Research Group (GRIECE), GIUV2019-456, Nursing Department, Universitat de Valencia, 46010 Valencia, Spain
- Internal Medicine Department, Consorcio Hospital General Universitario de Valencia, 46014 Valencia, Spain
| | - Antonio Martínez-Sabater
- Oncology and Hematology Department, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain (E.S.-R.)
- Nursing Care and Education Research Group (GRIECE), GIUV2019-456, Nursing Department, Universitat de Valencia, 46010 Valencia, Spain
- Grupo Asociado de Investigación en Cuidados (INCLIVA, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain
| | - Evelin Balaguer-López
- Nursing Department, Facultat d’Infermeria i Podologia, Universitat de València, 46010 Valencia, Spain; (E.C.-S.); (E.B.-L.)
- Internal Medicine Department, Consorcio Hospital General Universitario de Valencia, 46014 Valencia, Spain
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Singhal S, Saadeh SS, Durani U, Kansagra A, Alkhateeb HB, Shah MV, Mangaonkar A, Kenderian S, Hashmi S, Patnaik MV, Litzow MR, Hogan WJ. Allogeneic Hematopoietic Stem Cell Transplantation in the Outpatient Setting: The Mayo Clinic Experience. Transplant Cell Ther 2023; 29:183.e1-183.e6. [PMID: 36584940 DOI: 10.1016/j.jtct.2022.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 12/29/2022]
Abstract
Hematopoietic stem cell transplantations (HSCT) are intensive and potentially curative modalities available for a variety of hematological diseases. Although alloHSCTs are typically performed in an inpatient setting, there has been increasing interest in moving them to the outpatient setting. AlloHSCTs are associated with a median length of hospital stay of 30 days. AlloHSCTs in the inpatient setting may increase patient exposure to nosocomial infections, drug-resistant organisms, rapid deconditioning with time spent in hospital beds, and loss of muscle mass. In this study, we aim to share outcomes of 856 consecutive alloHSCTs done in our institute over the past 2 decades. This is a single-center retrospective chart review encompassing 856 patients who underwent outpatient alloHSCTs between 2000 and 2017. Reduced-intensity conditioning, stem cell infusion, and much of the immediate follow-up in the early alloHSCT period was performed on an outpatient basis with daily evaluation, laboratory assessment, and intervention as needed. Rate of non-routine hospital admission was our primary outcome of interest. We also looked at various secondary outcomes, including causes of admission, median length of stay, and in-hospital mortality rate. Data analysis was performed using STATA statistical software Version 15. Descriptive statistics were used to summarize baseline demographic data and outcomes. Logistic regression modeling was used to identify predictors of hospital admission. We observed that about one third of our cohort never required admission to the hospital throughout the first 100 days after HSCT. Among those admitted, 6.6% experienced a direct admission to the intensive care unit, and the overall in hospital mortality was low at 5%. Furthermore, the median length of stay was noted to be decreased at 6 days compared to a median reported 30 days in existing literature. Overall, we observed favorable safety profile and outcomes with outpatient management of HSCTs.
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Affiliation(s)
- Sachi Singhal
- Department of Internal Medicine, Crozer-Chester Medical Center, Upland, Pennsylvania; Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Salwa S Saadeh
- Department of Internal Medicine, Section of Hematology and Medical Oncology, King Hussein Cancer Center, Amman, Jordan
| | - Urshila Durani
- Department of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Ankit Kansagra
- Department of Internal Medicine, UT Southwestern Medical Center, Texas
| | | | - Mithun V Shah
- Department of Hematology, Mayo Clinic, Rochester, Minnesota
| | | | - Saad Kenderian
- Department of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Shahrukh Hashmi
- Department of Hematology, Mayo Clinic, Rochester, Minnesota; Department of Hematology/Oncology, Sheikh Shakhbout Medical City/ Mayo Clinic, Abu Dhabi
| | | | - Mark R Litzow
- Department of Hematology, Mayo Clinic, Rochester, Minnesota
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Bhatia S, Dai C, Hageman L, Wu J, Schlichting E, Siler A, Funk E, Hicks J, Lim S, Balas N, Bosworth A, Te HS, Francisco L, Bhatia R, Forman SJ, Wong FL, Arora M, Armenian SH, Weisdorf DJ, Landier W. Financial Burden in Blood or Marrow Transplantation Survivors During the COVID-19 Pandemic: A BMTSS Report. J Clin Oncol 2023; 41:1011-1022. [PMID: 36455192 PMCID: PMC9928670 DOI: 10.1200/jco.22.00461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 07/05/2022] [Accepted: 10/20/2022] [Indexed: 12/03/2022] Open
Abstract
PURPOSE The financial burden experienced by blood or marrow transplant (BMT) survivors during the COVID-19 pandemic remains unstudied. We evaluated the risk for high out-of-pocket medical costs and associated financial burden experienced by BMT survivors and a sibling comparison group during the COVID-19 pandemic. METHODS This study included 2,370 BMT survivors and 750 siblings who completed the BMT Survivor Study survey during the pandemic. Participants reported employment status, out-of-pocket medical costs, and financial burden. Medical expenses ≥ 10% of the annual household income constituted high out-of-pocket medical costs. Logistic regression identified factors associated with high out-of-pocket medical costs and financial burden. RESULTS BMT survivors were more likely to incur high out-of-pocket medical costs (11.3% v 3.1%; adjusted odds ratio [aOR], 2.88; 95% CI, 1.84 to 4.50) than the siblings. Survivor characteristics associated with high out-of-pocket medical costs included younger age at study (aORper_year_younger_age, 1.02; 95% CI, 1.00 to 1.03), lower prepandemic annual household income and/or education (< $50,000 US dollars and/or < college graduate: aOR, 1.96; 95% CI, 1.42 to 2.69; reference: ≥ $50,000 in US dollars and ≥ college graduate), > 1 chronic health condition (aOR, 2.82; 95% CI, 2.00 to 3.98), ≥ 1 hospitalization during the pandemic (aOR, 2.11; 95% CI, 1.53 to 2.89), and being unemployed during the pandemic (aOR, 1.52; 95% CI, 1.06 to 2.17). Among BMT survivors, high out-of-pocket medical costs were significantly associated with problems in paying medical bills (aOR, 10.57; 95% CI, 7.39 to 15.11), deferring medical care (aOR, 4.93; 95% CI, 3.71 to 6.55), taking a smaller dose of medication than prescribed (aOR, 4.99; 95% CI, 3.23 to 7.70), and considering filing for bankruptcy (aOR, 3.80; 95% CI, 2.14 to 6.73). CONCLUSION BMT survivors report high out-of-pocket medical costs, which jeopardizes their health care and may affect health outcomes. Policies aimed at reducing financial burden in BMT survivors, such as expanding access to patient assistance programs, may mitigate the negative health consequences.
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Affiliation(s)
- Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
- Division of Pediatric Hematology, Oncology and Bone Marrow Transplantation, University of Alabama at Birmingham, Birmingham, AL
| | - Chen Dai
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | - Lindsey Hageman
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | - Jessica Wu
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | - Elizabeth Schlichting
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | - Arianna Siler
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | - Erin Funk
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | - Jessica Hicks
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | - Shawn Lim
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | - Nora Balas
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | | | - Hok Sreng Te
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Liton Francisco
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | - Ravi Bhatia
- Division of Hematology, Oncology and Bone Marrow Transplantation, University of Alabama at Birmingham, Birmingham, AL
| | - Stephen J. Forman
- Division of Hematology, Oncology and Bone Marrow Transplantation, University of Alabama at Birmingham, Birmingham, AL
| | | | - Mukta Arora
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | | | - Daniel J. Weisdorf
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Wendy Landier
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
- Division of Pediatric Hematology, Oncology and Bone Marrow Transplantation, University of Alabama at Birmingham, Birmingham, AL
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Hospital and outpatient models for Hematopoietic Stem Cell Transplantation: A systematic review of comparative studies for health outcomes, experience of care and costs. PLoS One 2021; 16:e0254135. [PMID: 34383780 PMCID: PMC8360565 DOI: 10.1371/journal.pone.0254135] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 06/07/2021] [Indexed: 11/19/2022] Open
Abstract
The number of Hematopoietic Stem Cell Transplantations has risen in the past 20 years. The practice of outpatient Hematopoietic Stem Cell Transplantation programs is increasing in an attempt to improve the quality of patient care and reduce the demand for hospital admission. A systematic review of 29 comparative studies between in-hospital and outpatient treatment of Hematopoietic Stem Cell Transplantation, with no restriction by outpatient regime was conducted. This study aims to analyse the current evidence on the effects of the outpatient model on patient-centred outcomes, comparing both in-hospital and outpatient models for autologous and allogeneic HSCT using the Triple Aim framework: health outcomes, costs and experience of care. We found evidence on improved health outcomes and quality of life, on enhanced safety and effectiveness and on reduced overall costs and hospital stays, with similar results on overall survival rates comparing both models for autologous and allogeneic patients. We also found that the outpatient Hematopoietic Stem Cell Transplantation is a safe practice as well as less costly, it requires fewer days of hospital stay both for autologous and allogeneic transplantations. Under a situation of an increasing number of transplants, rising healthcare costs and shortages of hospital capacity, incorporating outpatient models could improve the quality of care for people requiring Hematopoietic Stem Cell Transplantation programs.
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Geethakumari PR, Ramasamy DP, Dholaria B, Berdeja J, Kansagra A. Balancing Quality, Cost, and Access During Delivery of Newer Cellular and Immunotherapy Treatments. Curr Hematol Malig Rep 2021; 16:345-356. [PMID: 34089485 PMCID: PMC8179081 DOI: 10.1007/s11899-021-00635-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW The chimeric antigen receptor (CAR) T-cell therapy is currently changing the landscape of hematologic malignancies with multiple FDA-approved cell therapy products in the USA. The current administration process of the CAR T-cell therapy is complicated, labor-intensive, and expensive. RECENT FINDINGS The chimeric antigen receptor (CAR) T-cell therapy is currently changing the landscape of hematologic malignancies with multiple FDA-approved cell therapy products in the USA. The current administration process of the CAR T-cell therapy is complicated, labor-intensive, and expensive. This review article addresses the present-day challenges and discusses opportunities to optimize the access and affordability of the CAR T-cell therapy. The field of cellular immunotherapy is going to change the future of solid tumors and non-oncological diseases. However, this promising therapy poses challenges in the administration and management of quality in the current field of healthcare. We describe various novel approaches to manage challenges in improving access and improving widescale implementation of cellular therapies.
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Affiliation(s)
| | - Dheepthi Perumal Ramasamy
- Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, 2201 Inwood Road, Dallas, TX, 76034, USA
| | | | - Jesús Berdeja
- Sarah Cannon Research Institute and Tennessee Oncology, Nashville, TN, USA
| | - Ankit Kansagra
- Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, 2201 Inwood Road, Dallas, TX, 76034, USA.
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Colunga-Pedraza PR, Gómez-De León A, Rodríguez-Roque CS, Morcos-Sandino M, Colunga-Pedraza JE, Cantú-Rodriguez OG, Gutiérrez-Aguirre CH, Gómez-Almaguer D. Outpatient Haploidentical Stem Cell Transplantation Using Post-Transplant Cyclophosphamide Is Safe and Feasible. Transplant Cell Ther 2020; 27:259.e1-259.e6. [PMID: 33781529 DOI: 10.1016/j.jtct.2020.12.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/04/2020] [Accepted: 12/06/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hematopoietic stem cell transplantation (HSCT) feasibility has increased in the last decades because of haplo-HSCT, changes in chemotherapy schedules, and the possibility of an outpatient-based HSCT. The main barriers remain in low-middle income countries. There is a lack of information regarding haplo-HSCT with a myeloablative (MAC) regimen on an outpatient basis. OBJECTIVES Our primary objective was to determine if outpatient haplo-HSCT was feasible. STUDY DESIGN Single center, retrospective cohort, n=60 adult patients undergoing Haplo-HSCT. Descriptive statistical analysis, univariate and multivariate comparison. PATIENTS AND METHOD We analyzed 60 adult patients transplanted with an intended haplo-HSCT on an outpatient basis from 2015 to 2019 in our unit. A multivariate analysis was performed on risk factors for hospitalization. RESULTS Median age was 27 years (15-64). All patients underwent conditioning as outpatients, and none required hospitalization before day 0. Thirteen patients (21.6%) were followed completely in the outpatient clinic and 47 (78.3%) required hospitalization in a median of 3 days after infusion (range, 1-14). The median length of stay (LOS) was 8 days (IQR, 3-17). Fever secondary to cytokine release syndrome (CRS) was the most common reason for hospitalization occurring in 43/47 (91.5%), 4 were related to infection and 36 were related to CRS. In the univariate analysis, CRS, slower engraftment, and female sex were associated with the need for hospitalization. In the multivariate analysis, only CRS remained significant (OR 9.14 [95%CI, 1.58-56.46]). The 2-year overall survival (OS) was 41.7% for ambulatory transplant vs. 38% for those requiring hospitalization (P = 0.12). The 2-year event-free survival (EFS) was 33% for outpatient patients and 16.7% for those hospitalized (log-rank, P = 0.062). CONCLUSIONS We demonstrated the feasibility and safety of carrying out an outpatient haplo-HSCT, potentially resulting in cost savings and perhaps a higher quality of life.
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Affiliation(s)
- Perla R Colunga-Pedraza
- Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario Dr. José E. González, Department of Hematology, Internal Medicine Division, Monterrey, Nuevo León, Mexico
| | - Andrés Gómez-De León
- Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario Dr. José E. González, Department of Hematology, Internal Medicine Division, Monterrey, Nuevo León, Mexico
| | - Carlos Saúl Rodríguez-Roque
- Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario Dr. José E. González, Department of Hematology, Internal Medicine Division, Monterrey, Nuevo León, Mexico
| | - Michelle Morcos-Sandino
- Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario Dr. José E. González, Department of Hematology, Internal Medicine Division, Monterrey, Nuevo León, Mexico
| | - Julia E Colunga-Pedraza
- Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario Dr. José E. González, Department of Hematology, Internal Medicine Division, Monterrey, Nuevo León, Mexico
| | - Olga Graciela Cantú-Rodriguez
- Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario Dr. José E. González, Department of Hematology, Internal Medicine Division, Monterrey, Nuevo León, Mexico
| | - César Homero Gutiérrez-Aguirre
- Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario Dr. José E. González, Department of Hematology, Internal Medicine Division, Monterrey, Nuevo León, Mexico
| | - David Gómez-Almaguer
- Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario Dr. José E. González, Department of Hematology, Internal Medicine Division, Monterrey, Nuevo León, Mexico.
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Worldwide Network for Blood and Marrow Transplantation (WBMT) recommendations for establishing a hematopoietic stem cell transplantation program in countries with limited resources (Part II): Clinical, technical and socio-economic considerations. Hematol Oncol Stem Cell Ther 2020; 13:7-16. [DOI: 10.1016/j.hemonc.2019.08.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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8
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Is there no place like home for an allogeneic stem cell transplant? Bone Marrow Transplant 2020; 55:855-856. [PMID: 32060425 DOI: 10.1038/s41409-020-0828-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 01/29/2020] [Accepted: 02/03/2020] [Indexed: 11/08/2022]
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9
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Worldwide Network for Blood and Marrow Transplantation Recommendations for Establishing a Hematopoietic Stem Cell Transplantation Program in Countries with Limited Resources, Part II: Clinical, Technical, and Socioeconomic Considerations. Biol Blood Marrow Transplant 2019; 25:2330-2337. [DOI: 10.1016/j.bbmt.2019.04.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 04/07/2019] [Accepted: 04/09/2019] [Indexed: 11/23/2022]
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Kim W, Bangerter LR, Jo S, Langer S, Larkey L, Griffin J, Khera N. Feasibility and Acceptability of a 3-Day Group-Based Digital Storytelling Workshop among Caregivers of Allogeneic Hematopoietic Cell Transplantation Patients: A Mixed-Methods Approach. Biol Blood Marrow Transplant 2019; 25:2228-2233. [PMID: 31265918 DOI: 10.1016/j.bbmt.2019.06.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/13/2019] [Accepted: 06/26/2019] [Indexed: 11/19/2022]
Abstract
Family caregivers are essential partners for patients undergoing hematopoietic cell transplantation (HCT). The caregiving role is emotionally, physically, and financially demanding. Intervention efforts to provide relief for caregiver stress during HCT are highly warranted. Storytelling interventions are accruing evidence for efficacy in therapeutic contexts. The purpose of this study was to conduct a 3-full consecutive day digital storytelling (DST) workshop to build knowledge on caregivers' lived experiences during HCT, to pilot test DST with a small group of HCT caregivers, and to demonstrate feasibility and acceptability using qualitative and quantitative measures. Six adult caregivers of allogeneic HCT recipients (mean age, 60.2 years) attended a 3-day DST program (66% female, 83% white). All successfully created their personal audiovisual digital story (2 to 3 minutes long) and completed a survey. All participants rated the DST workshop as highly acceptable and therapeutic (mean score 5, on a scale of 1 to 5). Group discussions and interviews with participants further demonstrated high satisfaction and acceptability of the workshop format, setting, process, and structure. The survey results showed decreases in anxiety and depression from before to after the DST workshop with all participants showing change in the expected direction. This study demonstrates the feasibility and acceptability of a 3-day DST workshop as a distress-relieving tool for HCT caregivers. Future research is needed to test the efficacy of DST relative to a control condition.
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Affiliation(s)
- Wonsun Kim
- College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona; Mayo Clinic College of Medicine, Phoenix, Arizona.
| | - Lauren R Bangerter
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Rochester, Minnesota
| | - Soojung Jo
- College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona
| | - Shelby Langer
- College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona; Mayo Clinic College of Medicine, Phoenix, Arizona
| | - Linda Larkey
- College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona; Mayo Clinic College of Medicine, Phoenix, Arizona
| | - Joan Griffin
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Rochester, Minnesota
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Rangarajan HG, Smith LC, Stanek JR, Hall M, Abu-Arja R, Auletta JJ, O'Brien SH. Increased Health Care Utilization and Costs during Allogeneic Hematopoietic Cell Transplantation for Acute Leukemia and Myelodysplastic Syndromes in Adolescents and Young Adults Compared with Children: A Multicenter Study. Biol Blood Marrow Transplant 2019; 25:1031-1038. [DOI: 10.1016/j.bbmt.2019.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 01/01/2019] [Indexed: 12/11/2022]
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12
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Safety and Cost-effectiveness of Outpatient Administration of High-dose Chemotherapy in Children With Ewing Sarcoma. J Pediatr Hematol Oncol 2019; 41:e152-e154. [PMID: 30608490 DOI: 10.1097/mph.0000000000001396] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Children with Ewing sarcoma (ES) are subjected to an interval-compressed regimen with cycles of chemotherapy given every 2 weeks, which is nowadays considered to be the standard of care for individuals with such a case. We developed institutional clinical practice guidelines (CPG) applying outpatient administration in regard to this regimen. This study intends to evaluate our institutional experience with this regimen. METHODS We conducted a retrospective review of patients with ES who were treated using interval-compressed protocol of 14 cycles consisting of alternating cyclophosphamide, doxorubicin, vincristine (VDC) and ifosfamide, etoposide (IE) with a maximum dose of doxorubicin of 375 mg/m. Cycles were subsequently followed by G-CSF administration until count recovery was recorded. Patients treated using our guidelines from June 2013 to June 2015 were eligible for these guidelines. Patients younger than 3 years at the time of diagnosis were not eligible for outpatient administration of chemotherapy. RESULTS In total 12 patients with localized ES or lung-only metastasis were eligible. By the time of analysis, 153 cycles were administered to these patients. Eight cycles for 6 patients were administered on an inpatient basis while the rest (N=145) were administered in the outpatient chemotherapy unit. The median number of cycles per patient were 14 (with a range of 5 to 14). Ninety cycles (59%) were administered on time per CPG. The median interval between these cycles were 16 days (range, 12 to 36 days). The median interval between induction and consolidation cycles were 14 and 17 days, respectively. Neutropenia was reported at the time of each next cycle for 12 cycles. Transient gross hematuria was reported in 1 patient only. In addition, a cost saving of 21% (approximately US$ 4500) were achieved per patient. CONCLUSIONS Our study showed that the outpatient administration of interval-compressed regimen is safe and associated with acceptable adherence to this regimen.
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Caregiver availability and patient access to hematopoietic cell transplantation: social worker perspectives inform practice. Support Care Cancer 2019; 27:4253-4264. [DOI: 10.1007/s00520-019-04696-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 02/08/2019] [Indexed: 01/09/2023]
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Guru Murthy GS, Hari PN, Szabo A, Pasquini M, Narra R, Khan M, Abedin S, Chhabra S, Dhakal B, D'Souza A, Drobyski WR, Rizzo JD, Runaas L, Shah NN, Shaw B, Saber W, Fenske T, Hamadani M. Outcomes of Reduced-Intensity Conditioning Allogeneic Hematopoietic Cell Transplantation Performed in the Inpatient versus Outpatient Setting. Biol Blood Marrow Transplant 2018; 25:827-833. [PMID: 30572109 DOI: 10.1016/j.bbmt.2018.12.069] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 12/10/2018] [Indexed: 12/22/2022]
Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT) with reduced-intensity conditioning (RIC) is commonly performed as an inpatient procedure. The feasibility and outcomes of RIC allo-HCT in the outpatient setting is not known. We performed a single-center retrospective cohort study of patients aged ≥ 18years with hematologic malignancies who underwent RIC allo-HCT either in the inpatient or outpatient setting. Donor types included HLA-matched sibling and well-matched unrelated donors. The objectives were to compare the survival, complications, charges, and incidences of relapse, nonrelapse mortality (NRM), and acute and chronic graft-versus-host disease (GVHD) between the 2 groups. Between 2014 and 2017, 151 eligible patients were included, with 116 undergoing RIC allo-HCT in the inpatient setting and 35 patients undergoing RIC allo-HCT in the outpatient setting. Baseline characteristics were comparable between the 2 groups except for a higher proportion of patients with myeloma in the outpatient cohort (inpatient 15.5% versus outpatient 37.1%). The cumulative incidence of grades II to IV acute GVHD (inpatient 25.2% versus outpatient 25.7%), grades III to IV acute GVHD (inpatient 10.4% versus outpatient 8.5%), chronic GVHD (inpatient 38.3% versus outpatient 51.6%), NRM at 1 year (inpatient 10.8% versus outpatient 3.2%), and relapse (inpatient 24.8% versus outpatient 33.2%) did not significantly differ between the 2 cohorts. One-year progression-free survival (inpatient 64.4% versus outpatient 63.6%, P = .39) and overall survival (inpatient 73.8% versus outpatient 82.8%, P = .93) were also not significantly different between the 2 groups. The proportion of patients who developed neutropenic fever (inpatient 25.8% versus outpatient 8.5%, P = .03) and mucositis (inpatient 50.8% versus outpatient 8.5%, P < .001) and who required total parenteral nutrition (inpatient 20.6% versus outpatient 5.7%, P = .04) were more frequent in the inpatient cohort. About 51.5% of the outpatient cohort never required hospital admission in the first 100days. Outpatient HCT resulted in significantly lower charges than inpatient HCT in the first 100days (median charges: inpatient $339,621 versus outpatient $247,334; P < .001). On multivariate analysis the site of the HCT (outpatient versus inpatient) was not a significant predictor of either overall or progression-free survival. Outpatient RIC allo-HCT is feasible and safe with daily outpatient evaluation and aggressive supportive care resulting in outcomes comparable with those who received the transplant in the inpatient setting.
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Affiliation(s)
- Guru Subramanian Guru Murthy
- BMT & Cellular Therapy Program, Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Parameswaran N Hari
- BMT & Cellular Therapy Program, Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Aniko Szabo
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Marcelo Pasquini
- BMT & Cellular Therapy Program, Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ravi Narra
- BMT & Cellular Therapy Program, Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Muhammad Khan
- Division of Hospital Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sameem Abedin
- BMT & Cellular Therapy Program, Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Saurabh Chhabra
- BMT & Cellular Therapy Program, Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Binod Dhakal
- BMT & Cellular Therapy Program, Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anita D'Souza
- BMT & Cellular Therapy Program, Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - William R Drobyski
- BMT & Cellular Therapy Program, Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - J Douglas Rizzo
- BMT & Cellular Therapy Program, Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lyndsey Runaas
- BMT & Cellular Therapy Program, Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nirav N Shah
- BMT & Cellular Therapy Program, Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Bronwen Shaw
- BMT & Cellular Therapy Program, Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Wael Saber
- BMT & Cellular Therapy Program, Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Timothy Fenske
- BMT & Cellular Therapy Program, Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mehdi Hamadani
- BMT & Cellular Therapy Program, Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin.
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15
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Reid RM, Baran A, Friedberg JW, Phillips GL, Liesveld JL, Becker MW, Wedow L, Barr PM, Milner LA. Outpatient administration of BEAM conditioning prior to autologous stem cell transplantation for lymphoma is safe, feasible, and cost-effective. Cancer Med 2016; 5:3059-3067. [PMID: 27699999 PMCID: PMC5119960 DOI: 10.1002/cam4.879] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 04/22/2016] [Accepted: 07/27/2016] [Indexed: 11/11/2022] Open
Abstract
High-dose BEAM chemotherapy (BCNU, etoposide, Ara-C, and melphalan) followed by autologous hematopoietic stem cell transplantation is frequently used as consolidative therapy for patients with recurrent or refractory Hodgkin or non-Hodgkin lymphoma. The BEAM regimen has traditionally been administered over 6 days in the hospital, with patients remaining hospitalized until hematologic recovery and clinical stability. In an effort to reduce the length of hospitalization for these patients, our institution has transitioned from inpatient (IP) to outpatient (OP) administration of BEAM conditioning. Here, we report the results of an analysis of the feasibility, cost, complications, and outcomes for the initial group of patients who received OP BEAM compared to a prior cohort of patients who received IP BEAM. Patient and disease characteristics were comparable for the two cohorts, as were engraftment kinetics. Length of hospital stay was reduced by 6 days for the OP cohort (P < 0.001), resulting in a cost savings of more than $17,000 per patient. Fewer complications occurred in the OP cohort, including severe enteritis (P = 0.01), organ toxicities (P = 0.01), and infections (P = 0.04). Overall survival rate up to 3 years posttransplant was better for the OP cohort (P = 0.02), likely due to differences in posttransplant therapies. We conclude that OP administration of BEAM conditioning is safe and may offer significant advantages, including decreased length of hospitalization, reduced costs, decreased risks for severe toxicities and infectious complications, and likely improvement in patient satisfaction and quality of life.
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Affiliation(s)
- Robin M. Reid
- James P Wilmot Cancer Institute and Department of MedicineUniversity of Rochester Medical CenterRochesterNew York
- Rochester Regional HealthRochesterNew York
| | - Andrea Baran
- James P Wilmot Cancer Institute and Department of MedicineUniversity of Rochester Medical CenterRochesterNew York
| | - Jonathan W. Friedberg
- James P Wilmot Cancer Institute and Department of MedicineUniversity of Rochester Medical CenterRochesterNew York
| | - Gordon L. Phillips
- James P Wilmot Cancer Institute and Department of MedicineUniversity of Rochester Medical CenterRochesterNew York
- Wake Forest Baptist HealthWinston‐SalemNorth Carolina
| | - Jane L. Liesveld
- James P Wilmot Cancer Institute and Department of MedicineUniversity of Rochester Medical CenterRochesterNew York
| | - Michael W. Becker
- James P Wilmot Cancer Institute and Department of MedicineUniversity of Rochester Medical CenterRochesterNew York
| | - Lucy Wedow
- James P Wilmot Cancer Institute and Department of MedicineUniversity of Rochester Medical CenterRochesterNew York
| | - Paul M. Barr
- James P Wilmot Cancer Institute and Department of MedicineUniversity of Rochester Medical CenterRochesterNew York
| | - Laurie A. Milner
- James P Wilmot Cancer Institute and Department of MedicineUniversity of Rochester Medical CenterRochesterNew York
- Department of Pathology and Laboratory MedicineUniversity of Rochester Medical CenterRochesterNew York
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16
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Denzen EM, Thao V, Hahn T, Lee SJ, McCarthy PL, Rizzo JD, Ammi M, Drexler R, Flesch S, James H, Omondi N, Murphy E, Pederson K, Majhail NS. Financial impact of allogeneic hematopoietic cell transplantation on patients and families over 2 years: results from a multicenter pilot study. Bone Marrow Transplant 2016; 51:1233-40. [PMID: 27088381 PMCID: PMC5014617 DOI: 10.1038/bmt.2016.103] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 03/10/2016] [Accepted: 03/14/2016] [Indexed: 11/09/2022]
Abstract
Hematopoietic cell transplantation (HCT) is a procedure that can significantly influence the socioeconomic wellbeing of patients, caregivers and their families. Among 30 allogeneic HCT recipients and their caregivers enrolled on a pilot study evaluating the feasibility of studying financial impact of HCT, 16 agreed to participate in the long-term phase, completed a baseline questionnaire and received phone interviews at 6, 12, 18 and 24 months post-HCT. Analyses showed that by 2-years post-HCT, 54% of patients who previously contributed to household earnings had not returned to work and 80% of patients/caregivers reported transplant as having moderate to great impact on household income. However, patients’ level of confidence in their ability to meet household financial obligations increased from baseline to 2-years. A relatively large proportion of patients reported inability to pay for medical care through this time period. Case studies demonstrated patient individual perception of financial impact of HCT varies considerably, regardless of actual income. We demonstrate the feasibility of conducting a study to evaluate financial impact of allogeneic HCT through 2-years post-transplantation. Some patients/caregivers continue to experience significant long-term financial burden after this procedure. Our study lays the foundation for a larger evaluation of patient/caregiver financial burden associated with HCT.
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Affiliation(s)
- E M Denzen
- National Marrow Donor Program, Minneapolis, MN, USA
| | - V Thao
- School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - T Hahn
- Blood and Marrow Transplantation Program, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - S J Lee
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - P L McCarthy
- Blood and Marrow Transplantation Program, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - J D Rizzo
- Center for International Blood and Marrow Transplant Research, Milwaukee, WI, USA
| | - M Ammi
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN, USA
| | - R Drexler
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN, USA
| | - S Flesch
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN, USA
| | - H James
- National Marrow Donor Program, Minneapolis, MN, USA
| | - N Omondi
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - E Murphy
- National Marrow Donor Program, Minneapolis, MN, USA
| | - K Pederson
- National Marrow Donor Program, Minneapolis, MN, USA
| | - N S Majhail
- Blood and Marrow Transplant Program, Cleveland Clinic, Cleveland, OH, USA
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17
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Vaughn JE, Othus M, Powell MA, Gardner KM, Rizzuto DL, Hendrie PC, Becker PS, Pottinger PS, Estey EH, Walter RB. Resource Utilization and Safety of Outpatient Management Following Intensive Induction or Salvage Chemotherapy for Acute Myeloid Leukemia or Myelodysplastic Syndrome: A Nonrandomized Clinical Comparative Analysis. JAMA Oncol 2016; 1:1120-7. [PMID: 26355382 DOI: 10.1001/jamaoncol.2015.2969] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Adults with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) typically remain hospitalized after induction or salvage chemotherapy until blood cell count recovery, with resulting prolonged inpatient stays being a primary driver of health care costs. Pilot studies suggest that outpatient management following chemotherapy might be safe and could reduce costs for these patients. OBJECTIVE To compare safety, resource utilization, infections, and costs between adults discharged early following AML or MDS induction or salvage chemotherapy and inpatient controls. DESIGN Nonrandomized, phase 2, single-center study conducted at the University of Washington Medical Center. Over a 43-month period (January 1, 2011, through July 31, 2014), 178 adults receiving intensive AML or MDS chemotherapy were enrolled. After completion of chemotherapy, 107 patients met predesignated medical and logistical criteria for early discharge, while 29 met medical criteria only and served as inpatient controls. INTERVENTIONS Early-discharge patients were released from the hospital at the completion of chemotherapy, and supportive care was provided in the outpatient setting until blood cell count recovery (median, 21 days; range, 2-45 days). Controls received inpatient supportive care (median, 16 days; range, 3-42 days). MAIN OUTCOMES AND MEASURES We analyzed differences in early mortality, resource utilization including intensive care unit (ICU) days, transfusions per study day, and use of intravenous (IV) antibiotics per study day), numbers of infections, and total and inpatient charges per study day among early-discharge patients vs controls. RESULTS Four of the 107 early-discharge patients and none of the 29 control patients died within 30 days of enrollment (P=.58). Nine early-discharge patients (8%) but no controls required ICU-level care (P=.20). No differences were noted in the median daily number of transfused red blood cell units (0.27 vs 0.29; P=.55) or number of transfused platelet units (0.26 vs 0.29; P=.31). Early-discharge patients had more positive blood cultures (37 [35%] vs 4 [14%]; P=.04) but required fewer IV antibiotic days per study day (0.48 vs 0.71; P=.01). Overall, daily charges among early-discharge patients were significantly lower than for inpatients (median, $3840 vs $5852; P<.001) despite increased charges per inpatient day when readmitted (median, $7405 vs $5852; P<.001). CONCLUSIONS AND RELEVANCE Early discharge following intensive AML or MDS chemotherapy can reduce costs and use of IV antibiotics, but attention should be paid to complications that may occur in the outpatient setting.
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Affiliation(s)
- Jennifer E Vaughn
- Hematology/Oncology Fellowship Program, University of Washington, Seattle2Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington3now with Blue Ridge Cancer Care, Department of Medicine, Virginia Tech Carilion School of Med
| | - Megan Othus
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Morgan A Powell
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | | | - Paul C Hendrie
- Division of Hematology, Department of Medicine, University of Washington, Seattle
| | - Pamela S Becker
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington6Division of Hematology, Department of Medicine, University of Washington, Seattle
| | - Paul S Pottinger
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle
| | - Elihu H Estey
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington6Division of Hematology, Department of Medicine, University of Washington, Seattle
| | - Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington6Division of Hematology, Department of Medicine, University of Washington, Seattle8Department of Epidemiology, University of Washington, Seattle
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18
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Beaty RS, Bernhardt MB, Berger AH, Hesselgrave JE, Russell HV, Okcu MF. Inpatient versus outpatient vincristine, dactinomycin, and cyclophosphamide for pediatric cancers: Quality and cost implications. Pediatr Blood Cancer 2015; 62:1925-8. [PMID: 26152314 DOI: 10.1002/pbc.25610] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 05/01/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND Approximately 18% of the United States' gross domestic product is attributed to healthcare expenditures. Several studies have illustrated that shifting healthcare from the inpatient to the outpatient setting is more cost effective, in addition to improving patient satisfaction. Vincristine, dactinomycin, and cyclophosphamide (VAC) are used together to treat children with solid tumors. Our traditional treatment approach included a two day inpatient admission. The purpose of this project was to establish a process for the administration of VAC in the outpatient setting to improve satisfaction, and reduce costs. PROCEDURE We aimed to benchmark practice standards with other institutions, revised our treatment approach to permit outpatient administration, and implemented the new protocol in a stepwise manner. We collected caregiver satisfaction metrics through the use of surveys. Costs of encounters were obtained from administrative data. Total costs and costs by service type were compared using descriptive and mean comparisons. RESULTS Seven patients received a total of 31 cycles of VAC in the outpatient setting. The time to achieve an appropriate pre-chemotherapy specific gravity was reduced by a median of 120 min. In addition, time spent in the hospital setting was reduced by a mean of 27.2 hr. Adverse effects were minimal and all caregivers reported greater satisfaction with the outpatient regimen. Outpatient administration of VAC was $3,300 less on average compared to the inpatient administration. CONCLUSION Outpatient VAC provides a safe alternative for administration that reduces healthcare costs, reduces healthcare utilization, and improves patient satisfaction.
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Affiliation(s)
- Rachel S Beaty
- Department of Pharmacy, Texas Children's Hospital, Houston, Texas
| | | | - Amanda H Berger
- Department of Pharmacy, Texas Children's Hospital, Houston, Texas
| | | | - Heidi V Russell
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - M Fatih Okcu
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
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19
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Graff TM, Singavi AK, Schmidt W, Eastwood D, Drobyski WR, Horowitz M, Palmer J, Pasquini M, Rizzo DJ, Saber W, Hari P, Fenske TS. Safety of outpatient autologous hematopoietic cell transplantation for multiple myeloma and lymphoma. Bone Marrow Transplant 2015; 50:947-53. [PMID: 25867651 DOI: 10.1038/bmt.2015.46] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 01/18/2015] [Accepted: 02/03/2015] [Indexed: 12/22/2022]
Abstract
Autologous hematopoietic cell transplantation (Auto-HCT) is commonly an in-patient procedure. However, Auto-HCT is increasingly being offered on an outpatient basis. To better characterize the safety of outpatient Auto-HCT, we compared the outcome of 230 patients who underwent Auto-HCT on an in-patient vs outpatient basis for myeloma or lymphoma within a single transplant program. All outpatient transplants occurred in a cancer center day hospital. Hematopoietic recovery occurred earlier in the outpatient cohort, with median time to neutrophil recovery of 10 vs 11 days (P<0.001) and median time to platelet recovery of 19 vs 20 days (P=0.053). Fifty-one percent of the outpatient cohort never required admission, with this percentage increasing in later years. Grade 3-4 non-hematologic toxicities occurred in 29% of both cohorts. Non-relapse mortality at 1 year was 0% in the outpatient cohort and 1.5% in the in-patient cohort (P=0.327). Two-year PFS was 62% for outpatient vs 54% for in-patient (P=0.155). One- and two-year OS was 97% and 83% for outpatient vs 91% and 80% for in-patient, respectively (P=0.271). We conclude that, with daily outpatient evaluation and aggressive supportive care, outpatient Auto-HCT can result in excellent outcomes for myeloma and lymphoma patients.
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Affiliation(s)
- T M Graff
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - A K Singavi
- Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - W Schmidt
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - D Eastwood
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - W R Drobyski
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - M Horowitz
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - J Palmer
- Division of Hematology and Medical Oncology, Mayo Clinic, Scottsdale, AZ, USA
| | - M Pasquini
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - D J Rizzo
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - W Saber
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - P Hari
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - T S Fenske
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
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20
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Suh KJ, Kim I, Lim J, Ha H, Park S, Koh Y, Yoon SS, Park S. Total costs and clinical outcome of hematopoietic stem cell transplantation in adults with leukemia: comparison between reduced-intensity and myeloablative conditioning. Clin Transplant 2014; 29:124-33. [DOI: 10.1111/ctr.12492] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2014] [Indexed: 01/09/2023]
Affiliation(s)
- Koung Jin Suh
- Department of Internal Medicine; Seoul National University Hospital; Seoul Korea
| | - Inho Kim
- Department of Internal Medicine; Seoul National University Hospital; Seoul Korea
- Cancer Research Institute; Seoul National University College of Medicine; Seoul Korea
| | - Jin Lim
- Department of Internal Medicine; Seoul National University Hospital; Seoul Korea
| | - Hyerim Ha
- Department of Internal Medicine; Seoul National University Hospital; Seoul Korea
| | - Seongyeol Park
- Department of Internal Medicine; Seoul National University Hospital; Seoul Korea
| | - Youngil Koh
- Department of Internal Medicine; Seoul National University Hospital; Seoul Korea
- Cancer Research Institute; Seoul National University College of Medicine; Seoul Korea
| | - Sung-Soo Yoon
- Department of Internal Medicine; Seoul National University Hospital; Seoul Korea
- Cancer Research Institute; Seoul National University College of Medicine; Seoul Korea
| | - Seonyang Park
- Department of Internal Medicine; Seoul National University Hospital; Seoul Korea
- Cancer Research Institute; Seoul National University College of Medicine; Seoul Korea
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21
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Mank APM, Schoonenberg C, Bleeker K, Heijmenberg S, Heer KD, van Oers MHJ, Kersten MJ. Early discharge after high dose chemotherapy is safe and feasible: a prospective evaluation of 6 years of home care. Leuk Lymphoma 2014; 56:2098-104. [PMID: 25330445 DOI: 10.3109/10428194.2014.974039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
A single-center, prospective, non-randomized clinical study was performed to examine the safety and feasibility of early discharge in patients undergoing consolidation chemotherapy for acute leukemia, or autologous stem cell transplant for lymphoma or multiple myeloma. Patients were discharged into ambulatory care the day after the last chemotherapy administration and were subsequently seen at the ambulatory care unit three times a week. One hundred and one of 224 patients were ineligible for the program, mostly because of their medical situation, the lack of a caregiver or the travel time to the hospital. The remaining 123 patients were able to spend more than 70% of the time at home. In 44% of cycles they were never readmitted. This study demonstrates the safety, feasibility and benefits of managing carefully selected patients. Patients and their caregivers felt safe and comfortable at home, and the vast majority preferred home care to in-hospital treatment.
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Affiliation(s)
- Arno P M Mank
- Department of Hematology, Academic Medical Center , Amsterdam , The Netherlands
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22
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Khera N, Chang YH, Hashmi S, Slack J, Beebe T, Roy V, Noel P, Fauble V, Sproat L, Tilburt J, Leis JF, Mikhael J. Financial burden in recipients of allogeneic hematopoietic cell transplantation. Biol Blood Marrow Transplant 2014; 20:1375-81. [PMID: 24867778 DOI: 10.1016/j.bbmt.2014.05.011] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Accepted: 05/09/2014] [Indexed: 10/25/2022]
Abstract
Although allogeneic hematopoietic cell transplantation (HCT) is an expensive treatment for hematological disorders, little is known about the financial consequences for the patients who undergo this procedure. We analyzed factors associated with its financial burden and its impact on health behaviors of allogeneic HCT recipients. A questionnaire was retrospectively mailed to 482 patients who underwent allogeneic HCT from January 2006 to June 2012 at the Mayo Clinic, to collect information regarding current financial concerns, household income, employment, insurance, out-of-pocket expenses, and health and functional status. A multivariable logistic regression analysis identified factors associated with financial burden and treatment nonadherence. Of the 268 respondents (56% response rate), 73% reported that their sickness had hurt them financially. All patients for whom the insurance information was available (missing, n = 13) were insured. Forty-seven percent of respondents experienced financial burden, such as household income decreased by >50%, selling/mortgaging home, or withdrawing money from retirement accounts. Three percent declared bankruptcy. Younger age and poor current mental and physical functioning increased the likelihood of financial burden. Thirty-five percent of patients reported deleterious health behaviors because of financial constraints. These patients were likely to be younger, have lower education, and with a longer time since HCT. Being employed decreased the likelihood of experiencing financial burden and treatment nonadherence due to concern about costs. A significant proportion of allogeneic HCT survivors experience financial hardship despite insurance coverage. Future research should investigate potential interventions to help at-risk patients and prevent adverse financial outcomes after this life-saving procedure.
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Affiliation(s)
- Nandita Khera
- Division of Hematology/Oncology, Mayo Clinic, Phoenix, Arizona.
| | - Yu-hui Chang
- Division of Hematology/Oncology, Mayo Clinic, Phoenix, Arizona
| | - Shahrukh Hashmi
- Division of Hematology/Oncology, Mayo Clinic, Rochester, Minnesota
| | - James Slack
- Division of Hematology/Oncology, Mayo Clinic, Phoenix, Arizona
| | - Timothy Beebe
- Health Sciences Research Division, Mayo Clinic, Rochester, Minnesota
| | - Vivek Roy
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, Florida
| | - Pierre Noel
- Division of Hematology/Oncology, Mayo Clinic, Phoenix, Arizona
| | - Veena Fauble
- Division of Hematology/Oncology, Mayo Clinic, Phoenix, Arizona
| | - Lisa Sproat
- Division of Hematology/Oncology, Mayo Clinic, Phoenix, Arizona
| | - Jon Tilburt
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jose F Leis
- Division of Hematology/Oncology, Mayo Clinic, Phoenix, Arizona
| | - Joseph Mikhael
- Division of Hematology/Oncology, Mayo Clinic, Phoenix, Arizona
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23
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Khera N, Emmert A, Storer BE, Sandmaier BM, Alyea EP, Lee SJ. Costs of allogeneic hematopoietic cell transplantation using reduced intensity conditioning regimens. Oncologist 2014; 19:639-44. [PMID: 24797822 DOI: 10.1634/theoncologist.2013-0406] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Reduced intensity conditioning (RIC) regimens have allowed older patients and those with comorbidities to receive hematopoietic cell transplantation (HCT). We analyzed medical costs from the beginning of conditioning to 100 days after HCT for 484 patients and up to 2 years for 311 patients who underwent a RIC HCT at two institutions from January 2008 to December 2010. Multiple linear regression was used to analyze the association between clinical variables, center effect, and costs. Patient and transplant characteristics were comparable between the sites, although differences were seen in pretransplant performance scores. Significant predictors for lower costs for the first 100 days included a diagnosis of lymphoma/myeloma and use of human leukocyte antigen-matched related donors. Grade II-IV acute graft-versus-host disease (GVHD) was associated with higher costs. The overall short-term costs between the two institutions were comparable when adjusted for clinical variables (p = .43). Late costs between 100 days and 2 years after HCT were available for one cohort (n = 311); median costs during this period were $39,000 and accounted for 39% of costs during the first 2 years. Late costs were not associated with any pretransplant variables, but were higher with extensive chronic GVHD and death. After adjustment for clinical characteristics, the overall costs of the RIC transplants were similar between the two institutions despite different management approaches (inpatient vs. outpatient conditioning) and accounting methodologies. Use of unrelated/alternative donors, transplant for diseases other than lymphoma or myeloma, and acute GVHD were predictors for higher early costs, and extensive chronic GVHD and death were associated with higher late costs.
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Affiliation(s)
- Nandita Khera
- Division of Hematology/Oncology, Mayo Clinic in Arizona, Phoenix, Arizona, USA; Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Amy Emmert
- Division of Hematology/Oncology, Mayo Clinic in Arizona, Phoenix, Arizona, USA; Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Barry E Storer
- Division of Hematology/Oncology, Mayo Clinic in Arizona, Phoenix, Arizona, USA; Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Brenda M Sandmaier
- Division of Hematology/Oncology, Mayo Clinic in Arizona, Phoenix, Arizona, USA; Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Edwin P Alyea
- Division of Hematology/Oncology, Mayo Clinic in Arizona, Phoenix, Arizona, USA; Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Stephanie J Lee
- Division of Hematology/Oncology, Mayo Clinic in Arizona, Phoenix, Arizona, USA; Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
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Parsons SK, Pennarola BW. The plurality of payers’ perspectives on hematopoietic stem cell transplantation. Hematology 2013; 17 Suppl 1:S202-7. [DOI: 10.1179/102453312x13336169157211] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Affiliation(s)
- Susan K Parsons
- Health InstituteInstitute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
- Departments of Medicine and PediatricsTufts University School of Medicine, Boston, MA, USA
| | - Brian W Pennarola
- Health InstituteInstitute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
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Majhail NS, Rizzo JD, Hahn T, Lee SJ, McCarthy PL, Ammi M, Denzen E, Drexler R, Flesch S, James H, Omondi N, Pedersen TL, Murphy E, Pederson K. Pilot study of patient and caregiver out-of-pocket costs of allogeneic hematopoietic cell transplantation. Bone Marrow Transplant 2013; 48:865-71. [PMID: 23222378 PMCID: PMC3596484 DOI: 10.1038/bmt.2012.248] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 10/16/2012] [Accepted: 10/17/2012] [Indexed: 12/16/2022]
Abstract
Patient/caregiver out-of pocket costs associated with hematopoietic cell transplantation (HCT) are not well known. We conducted a pilot study to evaluate patient/caregiver out-of-pocket costs in the first 3 months after allogeneic HCT. Thirty patients were enrolled at three sites. Before HCT, participants completed a baseline survey regarding household income and insurance coverage. Subsequently, they maintained a paper-based diary to track daily out-of-pocket expenses for the first 3 months after HCT. Telephone interviews were conducted to follow-up on the missing/incomplete diaries and on study completion. Twenty-five patients/caregivers completed the baseline survey. Among these, the median pre-tax household income was $66 500 (range, $30-$375 000) and 48% had to temporarily relocate close to the transplant center. Insurance coverage was managed care plan (56%), Medicaid (20%), Medicare (17%) and other (8%). Twenty-two patients/caregivers completed 4 diaries; the median out-of-pocket expenses were $2440 (range, $199-$13 769). Patients/caregivers who required temporary lodging had higher out-of-pocket expenses compared with those who did not (median, $5247 vs $716). Patients/caregivers can incur substantial out-of-pocket costs over the first 3 months, especially if they need to temporarily relocate close to the transplant center. Our study lays the foundation for future research on the early and long-term financial impact of allogeneic HCT on patients/caregivers.
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Affiliation(s)
- N S Majhail
- National Marrow Donor Program, Minneapolis, MN 55413, USA.
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26
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Shi L, Zhang D. China's New Rural Cooperative Medical Scheme and Underutilization of Medical Care Among Adults Over 45: Evidence From CHARLS Pilot Data. J Rural Health 2013; 29 Suppl 1:s51-61. [DOI: 10.1111/jrh.12013] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Lu Shi
- Department of Health Services; UCLA Fielding School of Public Health; Los Angeles California
| | - Donglan Zhang
- Department of Health Services; UCLA Fielding School of Public Health; Los Angeles California
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27
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Majhail NS, Mau LW, Denzen EM, Arneson TJ. Costs of autologous and allogeneic hematopoietic cell transplantation in the United States: a study using a large national private claims database. Bone Marrow Transplant 2013; 48:294-300. [PMID: 22773126 PMCID: PMC3469749 DOI: 10.1038/bmt.2012.133] [Citation(s) in RCA: 118] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 05/30/2012] [Accepted: 06/01/2012] [Indexed: 01/06/2023]
Abstract
There is a lack of multi-center cost-identification studies for hematopoietic cell transplantation (HCT). We used a single longitudinal administrative claims database representing a national, commercially insured population to evaluate the feasibility of identifying HCT recipients and to establish a cohort of autologous and allogeneic HCT recipients to study inpatient and outpatient direct medical costs from transplant hospitalization through first 100 days post-transplantation. Using ICD-9 procedure and diagnosis codes, we identified 3365 patients who had received their first transplant in the United States between 2007 and 2009 (autologous, 1678, allogeneic, 1320, graft source not specified, 367). The median 100-day total costs for autologous HCT were $99,899 (interquartile range (IQR), $73,914-140,555), and for allogeneic HCT were $203,026 (IQR, $141,742-316 ,426). The majority of costs (>75%) occurred during the initial transplant hospitalization for both autologous and allogeneic HCT recipients. Costs were greater among pediatric (< or =20 years) compared with adult (>20 years) recipients and this difference was more pronounced with allogeneic HCT. Using a claims database representing a national HCT population, we highlight the high costs associated with autologous and allogeneic HCT. Our study lays the foundation for using claims data for future research on economic aspects of HCT.
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Affiliation(s)
- N S Majhail
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN 55413, USA.
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28
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Preussler JM, Denzen EM, Majhail NS. Costs and cost-effectiveness of hematopoietic cell transplantation. Biol Blood Marrow Transplant 2012; 18:1620-8. [PMID: 22484549 PMCID: PMC3678555 DOI: 10.1016/j.bbmt.2012.04.001] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 04/02/2012] [Indexed: 11/15/2022]
Abstract
Interest is growing in economic and comparative effectiveness analyses, with increasing emphasis on optimizing healthcare resources and costs. Limited information is available on the economic aspects of hematopoietic cell transplantation (HCT). We review contemporary literature on the costs and cost-effectiveness of HCT in the United States and worldwide. Published studies confirm the high costs associated with HCT, although the reported costs are highly variable, related to the differing methodologies used across studies. We examine the challenges in reviewing costs and cost-effectiveness across studies specific to HCT and highlight factors identified as associated with higher costs of HCT. We also discuss opportunities for future research in this area.
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Affiliation(s)
- Jaime M. Preussler
- Health Services Research Program, National Marrow Donor Program, Minneapolis, Minnesota
| | - Ellen M. Denzen
- Health Services Research Program, National Marrow Donor Program, Minneapolis, Minnesota
| | - Navneet S. Majhail
- Health Services Research Program, National Marrow Donor Program, Minneapolis, Minnesota
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
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29
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Martino M, Montanari M, Bruno B, Console G, Irrera G, Messina G, Offidani M, Scortechini I, Moscato T, Fedele R, Milone G, Castagna L, Olivieri A. Autologous hematopoietic progenitor cell transplantation for multiple myeloma through an outpatient program. Expert Opin Biol Ther 2012; 12:1449-62. [DOI: 10.1517/14712598.2012.707185] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Abstract
Given the rapidly rising healthcare costs, it is important to understand the economic costs of hematopoietic cell transplantation (HCT), a procedure that is being used more frequently in the treatment of various hematologic disorders. Studies have reported a wide range of costs for HCT, from $36 000 to $88 000 (USD) for a single autologous transplantation for the initial hospitalization, to $200 000 (USD) or more for a myeloablative allogeneic procedure involving an unrelated donor. Common posttransplantation complications, such as infections and GVHD, have been shown to be significant cost drivers. Comparisons across studies are limited by differences in patient populations, cost ascertainment methods, and length of follow-up. This article summarizes the current state of knowledge about costs and cost-effectiveness of HCT, highlighting the challenges in conducting these studies and identifying important areas for future research. We discuss the need for more value-based assessments of HCT using high-quality approaches to measuring costs and outcomes so that potential future efforts to contain costs are well informed and appropriate.
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31
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Sive J, Ardeshna KM, Cheesman S, le Grange F, Morris S, Nicholas C, Peggs K, Statham P, Goldstone AH. Hotel-based ambulatory care for complex cancer patients: a review of the University College London Hospital experience. Leuk Lymphoma 2012; 53:2397-404. [PMID: 22591143 DOI: 10.3109/10428194.2012.694430] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Since 2005, University College London Hospital (UCLH) has operated a hotel-based Ambulatory Care Unit (ACU) for hematology and oncology patients requiring intensive chemotherapy regimens and hematopoietic stem cell transplants. Between January 2005 and 2011 there were 1443 patient episodes, totaling 9126 patient days, with increasing use over the 6-year period. These were predominantly for hematological malignancy (82%) and sarcoma (17%). Median length of stay was 5 days (range 1-42), varying according to treatment. Clinical review and treatment was provided in the ACU, with patients staying in a local hotel at the hospital's expense. Admission to the inpatient ward was arranged as required, and there was close liaison with the inpatient team to preempt emergency admissions. Of the 523 unscheduled admissions, 87% occurred during working hours. An ACU/hotel-based treatment model can be safely used for a wide variety of cancers and treatments, expanding hospital treatment capacity, and freeing up inpatient beds for those patients requiring them.
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Affiliation(s)
- Jonathan Sive
- Department of Haematology, University College London Hospital, London, UK.
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32
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Faucher C, Le Corroller Soriano AG, Esterni B, Vey N, Stoppa AM, Chabannon C, Mohty M, Michallet M, Bay JO, Genre D, Maraninchi D, Viens P, Moatti JP, Blaise D. Randomized study of early hospital discharge following autologous blood SCT: medical outcomes and hospital costs. Bone Marrow Transplant 2011; 47:549-55. [PMID: 21725375 DOI: 10.1038/bmt.2011.126] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We report the first randomized study comparing early hospital discharge with standard hospital-based follow-up after high-dose chemotherapy (HDCT) and PBSCT. Patients aged 18-65 years, with an indication of PBSCT for non-leukemic malignant diseases were randomly assigned between two arms. Arm A consisted of early hospital discharge (HDCT during hospitalization, discharge at day 0, home stay with a caregiver, outpatient clinic follow-up). In arm B patients were followed up as inpatients. In total 131 patients were analyzed (66 in arm A and 65 in arm B). Patient characteristics and hematological reconstitution were comparable between the two groups. In arm A, 26 patients were actually discharged early. Patients in group A spent fewer days in hospital (11 vs 12 days, P=0.006). This strategy resulted in a 6% mean cost reduction per patient when compared with the conventional hospital-based group. The early discharge approach within the French health system, while safe and feasible, is highly dependent on social criteria (caregiver availability and home to hospital distance). It is almost always associated with conventional hospital readmission during the aplasia phase, and limits cost savings when considering the whole population of patients benefiting from HDCT in routine clinical practice.
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Affiliation(s)
- C Faucher
- Institut Paoli-Calmettes-Regional Center for Cancer Research and Treatment, Marseilles, France.
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Cooke L, Grant M, Eldredge DH, Maziarz RT, Nail LM. Informal caregiving in Hematopoietic Blood and Marrow Transplant patients. Eur J Oncol Nurs 2011; 15:500-7. [PMID: 21306952 DOI: 10.1016/j.ejon.2011.01.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Revised: 01/13/2011] [Accepted: 01/15/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE Hematopoietic cell transplant patients are among the most vulnerable and acutely ill cancer populations (Bevans et al., 2008). The responsibility of caring for the daily physical and psychosocial needs of these patients after transplant is placed mostly on family caregivers (Williams, 2007). The purpose of this descriptive correlational research study was to describe caregiving experiences of 56 caregivers of HCT patients 3-12 months following transplant. METHODS & SAMPLE: Patients and caregivers were recruited from two west coast regional transplant programs in the United States. Variables studied were: relationship quality, rewards of caregiving, predictability, role strain, patient function, caregiving activities, and caregiver quality of life (QOL). KEY RESULTS Results indicated that all areas of role strain are significantly negatively correlated with caregiver's QOL. Predictability was negatively associated with problem solving and emotional strain indicating that as the level of predictability of the situation decreases, caregiver strain and problem solving increase. Predictability was positively correlated to caregiver QOL indicating that as the situation is more predictable caregiver QOL increases. Emotional strain, problem-solving strain, and usual care strain were significantly positively related, indicating that emotional strain and problem-solving strain increased together. As usual care strain increased, so did problem-solving strain and emotional strain. CONCLUSIONS Suggestions for interventions include assessing and responding to caregiver issues such as emotional strain, problem-solving strain, usual care strain, unpredictability, and QOL. Examples of caregiver-focused interventions include providing timely appropriate information about these caregiver concerns including elements that make the caregiving situation predictable, and incorporating best practices for preventing and minimizing caregiver emotional strain.
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Affiliation(s)
- Liz Cooke
- City of Hope, Nursing Research & Education, Duarte, CA 91010, USA.
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34
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Solomon SR, Matthews RH, Barreras AM, Bashey A, Manion KL, McNatt K, Speckhart D, Connaghan DG, Morris LE, Holland HK. Outpatient myeloablative allo-SCT: a comprehensive approach yields decreased hospital utilization and low TRM. Bone Marrow Transplant 2009; 45:468-75. [PMID: 19767781 DOI: 10.1038/bmt.2009.234] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Historically, myeloablative allogeneic hematopoietic SCT (HSCT) has required prolonged in-patient hospitalization due to the effects of mucosal toxicity and prolonged cytopenias. We explored the safety and feasibility of outpatient management of these patients. A total of 100 consecutive patients underwent a matched-related donor myeloablative allogeneic HSCT for a hematologic malignancy at a single institution. Patients were hospitalized briefly for stem-cell infusion and thereafter only for complications more safely managed in the in-patient setting. The median hospital length of stay from the start of the preparative regimen to day +30 and day +100 post-transplant was 12 and 15 days, respectively. Planned hospital discharge occurred in 79 patients after stem cell infusion. Patients were readmitted to hospital at median of day +7 post transplant, with neutropenic fever being the primary cause for readmission. In total, 18 patients required no in-patient care in the first 100 days. Non-relapse mortality at day 100 and 6 months was 10 and 15%, respectively, for all patients, and 0 and 5%, respectively, for standard risk patients. In summary, outpatient myeloablative allogeneic HSCT with expectant in-patient management can be accomplished safely with low treatment-related morbidity and mortality. Clinical outcomes seem comparable to those reported for traditional in-patient management.
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Affiliation(s)
- S R Solomon
- Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA 30342, USA.
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35
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Stiff PJ. Managing hematopoietic stem-cell transplant resources: the case for outpatient transplantation. Leuk Lymphoma 2009; 50:6-7. [DOI: 10.1080/10428190802663221] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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36
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Anastasia A, Giglio F, Mazza R, Sarina B, Todisco E, Bramanti S, Castagna L. Early discharge after high-dose melphalan and peripheral blood stem cell reinfusion in patients with hematological and non-hematological disease. Leuk Lymphoma 2009; 50:80-4. [DOI: 10.1080/10428190802535098] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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37
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Schlesinger A, Paul M, Gafter-Gvili A, Rubinovitch B, Leibovici L. Infection-control interventions for cancer patients after chemotherapy: a systematic review and meta-analysis. THE LANCET. INFECTIOUS DISEASES 2009; 9:97-107. [DOI: 10.1016/s1473-3099(08)70284-6] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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38
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Saito AM, Cutler C, Zahrieh D, Soiffer RJ, Ho VT, Alyea EP, Koreth J, Antin JH, Lee SJ. Costs of allogeneic hematopoietic cell transplantation with high-dose regimens. Biol Blood Marrow Transplant 2008; 14:197-207. [PMID: 18215780 DOI: 10.1016/j.bbmt.2007.10.010] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2007] [Accepted: 10/25/2007] [Indexed: 01/06/2023]
Abstract
To characterize the costs of allogeneic hematopoietic cell transplantation with high-dose regimens (HDCT), we analyzed clinical information and costs of 315 HDCT recipients during a 4-year study period beginning in 2000. Multivariate analyses were performed to identify pre- and/or post-HDCT factors predicting higher costs within the first year. Overall survival (OS) at 100 days and 1 year were 80% and 58%, respectively. The median cost and days of hospitalization were $102,574 in 2004 US dollars and 36 days in the hospital for 100 days, and $128,800 and 39 days in the hospital for 1 year. Early costs, defined as costs within the first 100 days, accounted for 84% of total costs within the first year. Inpatient costs comprise 94% of the early costs, but only 61% of the later costs defined as costs incurred between 101 days and 1 year. Of the pre-HDCT factors, unrelated donors and advanced disease risk were significantly associated with increased cost. When post-HDCT events were also considered, these pre-HDCT factors were no longer independently predictive of high cost. Instead, severe complications post-HDCT were associated with higher costs, increasing total costs $20,228 on average. If no complications occurred, the mean cost within the first year was $79,222. These results provide cost estimates for complicated and uncomplicated HDCT procedures, as well as costs for management of specific transplant complications.
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Affiliation(s)
- Akiko M Saito
- Division of Medical Oncology, Dana-Farber Cancer Institute, and Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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39
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Yabroff KR, Warren JL, Brown ML. Costs of cancer care in the USA: a descriptive review. ACTA ACUST UNITED AC 2007; 4:643-56. [PMID: 17965642 DOI: 10.1038/ncponc0978] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2006] [Accepted: 06/14/2007] [Indexed: 11/09/2022]
Abstract
Although many studies assessing the cost of cancer care have been conducted in the US, to date, these studies and the underlying methods used to estimate costs have not been reviewed systematically. We conducted a descriptive review of the published literature on the cost of cancer care in the US, and identified 60 papers published between 1995 and 2006 pertinent to our study. We found heterogeneity across the studies in terms of the settings, populations studied, measurement of costs, and study methods. We also identified limitations in the generalizability of findings, the misclassification of patient groups and costs, and concerns with study methods. Among studies that reported costs of cancer care in multiple phases of care and for multiple tumor sites, costs were generally highest in the initial year following diagnosis and the last year of life, and lower in the continuing phase (i.e. the period between the initial and last year of life phases), following a 'u-shaped' curve. Within phase of care, costs for lung and colorectal cancer care were generally higher than those for breast and prostate cancer care, however, the long-term or lifetime costs for each type of cancer were more similar, reflecting the differences in survival and costs in each phase between the different disease types.
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Affiliation(s)
- K Robin Yabroff
- Health Services and Economics Branch, Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD 20892-7344, USA.
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40
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Nicolau JE, Melo LMMPD, Sturaro D, Saboya R, Dulley FL. Evaluation of early hospital discharge after allogeneic bone marrow transplantation for chronic myeloid leukemia. SAO PAULO MED J 2007; 125:174-9. [PMID: 17923943 PMCID: PMC11020587 DOI: 10.1590/s1516-31802007000300009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2006] [Revised: 06/08/2006] [Accepted: 05/24/2007] [Indexed: 11/22/2022] Open
Abstract
CONTEXT AND OBJECTIVE The increasing number of patients waiting for bone marrow transplantation in our service led to the implement of an early hospital discharge program with the intention of reducing the interval between diagnosis and transplantation. In this study we analyzed the results from early discharge, with outpatient care for patients with chronic myeloid leukemia who underwent allogeneic bone marrow transplantation. DESIGN AND SETTING Retrospective study at the Bone Marrow Transplantation Unit of Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo. METHODS We compared clinical outcomes within 100 days post-transplantation, for 51 patients with chronic myeloid leukemia (CML) who received partially outpatient-based allogeneic hematopoietic stem cell transplantation, and the results were compared with a historical control group of 49 patients who received inpatient-based hematopoietic stem cell transplantation. RESULTS There were significantly fewer days of hospitalization (p = 0.004), Pseudomonas-positive cultures (p = 0.006) and nausea and vomiting of grade 2-3 (p < 0.001) in the outpatient group. There were no significant differences in mortality between the groups and no deaths occurred within the first 48 days post-transplantation in the outpatient group. CONCLUSIONS This partially outpatient-based hematopoietic stem cell transplantation program allowed an increased number of transplantations in our institution, in cases of CML and other diseases, since it reduced the median length of hospital stay without increasing morbidity and mortality.
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Affiliation(s)
- José Eduardo Nicolau
- Bone Marrow Transplantation Unit, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
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41
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Yu YB, Gau JP, You JY, Chern HH, Chau WK, Tzeng CH, Ho CH, Hsu HC. Cost-effectiveness of postremission intensive therapy in patients with acute leukemia. Ann Oncol 2007; 18:529-34. [PMID: 17164232 DOI: 10.1093/annonc/mdl420] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND We assessed the cost-effectiveness of high-dose arabinoside (HiDAC)-based and allogeneic stem-cell transplantation (alloSCT)-based therapy in patients with acute leukemia. PATIENTS AND METHODS We analyzed the outcome, cost and cost-effectiveness of 106 patients treated from January 1994 to January 2002 [94 acute myelogenous leukemia (AML)/12 acute lymphoblastic leukemia (ALL)]. Forty-two young patients at either intermediate or unknown cytogenetic risk received postremission intensive therapy (24 HiDAC-based/18 alloSCT-based therapy). RESULTS After a median follow-up of 50 months, the estimated 7-year overall survival for the HiDAC-based group showed a tendency to be higher than the alloSCT-based group (48% versus 28%, P = 0.1452). The HiDAC-based group spent a significantly lower total cost ($US51,857 versus 75,474, P = 0.004) than the alloSCT-based group. Cost-effectiveness analysis showed that the mean cost per year of life saved for the HiDAC-based group is considerably less expensive than the alloSCT-based group ($US11,224 versus 21,564). The reduced total cost for the HiDAC-based group originated from lower cost in room fees, medication, laboratory and procedure, but not in blood transfusion and professional manpower fees. CONCLUSION For the postremission therapy in young AML patients at either intermediate or unknown cytogenetic risk, cost-effectiveness of HiDAC-based therapy compares favorably with that of alloSCT-based therapy, which deserves further clinical trials.
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MESH Headings
- Adult
- Aged
- Antineoplastic Combined Chemotherapy Protocols/economics
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Arabinonucleosides/administration & dosage
- Cost-Benefit Analysis
- Drug Costs
- Female
- Follow-Up Studies
- Health Care Costs
- Humans
- Kaplan-Meier Estimate
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/economics
- Leukemia, Myeloid, Acute/mortality
- Leukemia, Myeloid, Acute/surgery
- Male
- Middle Aged
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/drug therapy
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/economics
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/mortality
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/surgery
- Stem Cell Transplantation/economics
- Taiwan
- Time Factors
- Transplantation, Autologous/economics
- Transplantation, Homologous/economics
- Treatment Outcome
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Affiliation(s)
- Y-B Yu
- Division of Hematology and Oncology, Department of Medicine, Taipei-Veterans General Hospital, Taiwan 11217, Republic of China
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Stiff P, Mumby P, Miler L, Rodriguez T, Parthswarthy M, Kiley K, Porter N, Batiste R, Wojtowitz S, Lichtenstein S, Fox-Geiman M, Toor A. Autologous hematopoietic stem cell transplants that utilize total body irradiation can safely be carried out entirely on an outpatient basis. Bone Marrow Transplant 2006; 38:757-64. [PMID: 17057729 DOI: 10.1038/sj.bmt.1705525] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
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 Dollars 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.
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Affiliation(s)
- P Stiff
- Bone Marrow Transplant Program, Loyola University Medical Center, Maywood, IL 60153, USA.
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Leger C, Sabloff M, McDiarmid S, Bence-Bruckler I, Atkins H, Bredeson C, Zhang H, Huebsch L. Outpatient autologous hematopoietic stem cell transplantation for patients with relapsed follicular lymphoma. Ann Hematol 2006; 85:723-9. [PMID: 16832675 DOI: 10.1007/s00277-006-0149-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2005] [Accepted: 05/15/2006] [Indexed: 10/24/2022]
Abstract
Autologous stem cell transplantation (ASCT) has emerged as a viable option for the treatment of relapsed follicular non-Hodgkin's lymphoma. We report on the outpatient experience of 60 patients who underwent ASCT for this condition. The median age was 51 years (30-65). Pre-transplantation conditioning regimens consisted of either etoposide/melphalan/TBI, CBV or BEAM. Patients participated in this transplant program for a median of 20.5 days (14-78), and 58.4% of the total program days were spent in the outpatient setting. Six patients were well enough to be treated solely as outpatients. Ninety percent of patients required at least one inpatient admission (median 7 days), and 70% of first inpatient transfers occurred within the first week following transplant and always before day +12. There were no predictors for prolonged inpatient stays. Febrile neutropenia and gastrointestinal toxicity were the main reasons for inpatient transfers. No outpatient required an urgent admission to the ICU or died in the outpatient setting. The treatment-related mortality at days 30 and 100 was 0 and 1.7%, respectively. The overall and progression-free survivals at 5 years were 65.7 and 56.1%, respectively. Outpatient ASCT with total body irradiation is feasible, safe, and effective for patients with relapsed follicular lymphoma.
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Affiliation(s)
- Chantal Leger
- St. Paul's Hospital and University of British Columbia, 440-1144 Burrard Street, Vancouver, BC, Canada.
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Bradley CJ. The need for online information on the economic consequences of cancer diagnosis, treatment, and survivorship. J Med Internet Res 2005; 7:e29. [PMID: 15998620 PMCID: PMC1550665 DOI: 10.2196/jmir.7.3.e29] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2005] [Accepted: 02/19/2005] [Indexed: 11/13/2022] Open
Abstract
The Internet is commonly used to provide treatment information to patients diagnosed with cancer. Notably missing from the existing websites is information on the cost of cancer care in terms of medical costs to the patient and work-related consequences. The purpose of this paper is to describe what is known about the economic cost of cancer and to describe how this information can be structured so that it is of more benefit to patients. This paper first provides an overview of the information available regarding medical expenses and productivity costs associated with cancer survivorship, particularly with respect to cancer and employment. Second, it draws attention to the sparse economic information available online to cancer survivors. Patients can find information on sources of financial assistance, but they cannot estimate from the available information the cost of their care or anticipate the impact that cancer and its treatment may have on their jobs. Finally, a strategy for filling the void in online economic cancer information is described. Substantial opportunity exists to provide economic information to cancer patients and their families. The Internet is a natural forum for gathering and disseminating economic information. A unique advantage of the Internet is its ability to put information immediately in the hands of cancer patients and their families—assisting them to become informed consumers and skilled negotiators.
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Affiliation(s)
- Cathy J Bradley
- Department of Health Administration and Massey Cancer Center, Virginia Commonwealth University, Richmond, VA 23298, USA.
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Hornberger JC, Best JH. Cost utility in the United States of rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone for the treatment of elderly patients with diffuse large B-cell lymphoma. Cancer 2005; 103:1644-51. [PMID: 15756658 DOI: 10.1002/cncr.20956] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Findings from the Groupe d'Etude des Lymphomes Adultes LNH 98-5 study showed that rituximab added to combined cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) prolonged progression-free survival and overall survival in adults age >/= 60 years with diffuse large B-cell non-Hodgkin lymphoma (DLBCL). The current study was conducted to investigate the incremental cost utility of the addition of rituximab to CHOP (R-CHOP) compared with CHOP alone. METHODS Clinical prognosis of the time to disease progression and death was estimated using published evidence from the LNH 98-5 study (n = 399 patients) that was linked mathematically to published long-term outcome data on patients with DLBCL. Drug-acquisition costs were based on published data from formulary pricing sources, and the costs of cancer surveillance and end-of-life care were based on published literature sources. The authors assessed cost utility as the difference in costs between R-CHOP and CHOP divided by the increase in expected overall survival adjusted for quality of life. RESULTS Over 5 years, it was projected that R-CHOP would prolong overall survival by 1.04 years. The mean cumulative cost of CHOP was 3358 dollars, and the mean cost of R-CHOP was 17,225 dollars, resulting in a cumulative net increase of 13,867 dollars. The posttreatment cancer surveillance cost for CHOP was 3950 dollars, compared with 5202 dollars for R-CHOP. It was estimated that R-CHOP would have a cost-utility ratio of 19,297 dollars per year of life gained compared with CHOP when adjusted for quality of life. R-CHOP remained cost effective over wide ranges of variables in sensitivity analyses. CONCLUSIONS Compared with CHOP alone, it was predicted that R-CHOP would be cost effective in elderly patients with DLBCL.
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MESH Headings
- Aged
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/economics
- Antibodies, Monoclonal, Murine-Derived
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/economics
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Costs and Cost Analysis
- Cyclophosphamide/administration & dosage
- Cyclophosphamide/economics
- Disease Progression
- Disease-Free Survival
- Doxorubicin/administration & dosage
- Doxorubicin/economics
- Drug Costs
- Humans
- Lymphoma, B-Cell/drug therapy
- Lymphoma, B-Cell/economics
- Lymphoma, B-Cell/pathology
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/economics
- Lymphoma, Large B-Cell, Diffuse/pathology
- Mathematics
- Middle Aged
- Prednisone/administration & dosage
- Prednisone/economics
- Quality of Life
- Rituximab
- Survival Rate
- Time Factors
- United States
- Vincristine/administration & dosage
- Vincristine/economics
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Affiliation(s)
- John C Hornberger
- Department of Clinical Economics, Acumen LLC/The SPHERE Institute, Burlingame, California, USA.
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Abstract
The aim of this mini-review (Griffiths, 2002) was to assess whether outpatient autologous haematopoietic stem cell transplant (AHSCT) is as effective as the traditional inpatient approach in terms of bed occupancy and morbidity. The Cochrane Library, Medline, Embase and CINAHL databases were searched for relevant studies. No systematic reviews or randomized control trials were found and after applying inclusion criteria, four non-randomized control trials were identified. The studies were conducted in North America, where high costs associated with AHSCT have led to the development of outpatient programmes designed specifically to reduce use of costly inpatient facilities. From the evidence available, it appears that outpatient AHSCT is not associated with increased morbidity and studies found either in favour of the intervention group or that there was no statistically significant difference between the two groups. The studies were unanimous in their findings that outpatient AHSCT is associated with a significantly reduced bed occupancy outcome. These findings may have a significant implication for the advancing practice and workload of community nurses. It is evident that good quality trials are needed in the UK to better and more relevantly address this question before implementing such programmes but it seems that outpatient AHSCT is achievable in carefully selected patients.
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Affiliation(s)
- Louise Ritchie
- Department of Haematology, Royal Free Hospital, London, UK.
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Hwang JP, Lam TP, Cohen DS, Donato ML, Geraci JM. Hematopoietic stem cell transplantation among patients with leukemia of all ages in Texas. Cancer 2004; 101:2230-8. [PMID: 15484218 DOI: 10.1002/cncr.20628] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Hematopoietic stem cell transplantation (HSCT) is an effective but expensive medical procedure to which some ethnic minorities, the elderly, and those without insurance have been shown to have limited access. The purpose of the current study was to determine whether socioeconomic factors were associated with HSCT usage rates in patients with leukemia. METHODS The authors identified 6574 patients with acute lymphocytic leukemia, chronic lymphocytic leukemia, acute myelogenous leukemia, chronic myelogenous leukemia, or other leukemias from the 1999 Texas Hospital Inpatient Discharge Public Use Data File. Of these patients, 1604 received an autologous or allogeneic HSCT. The authors assessed patients' ethnicity, payer status, age, gender, and comorbid medical conditions. Logistic regression was used to control for patient characteristics and to evaluate associations among payer status, ethnicity, and HSCT use. P < or = 0.05 indicated statistical significance. RESULTS Patients who self-paid had the highest rate of HSCT use in all age groups (32%; P < or = 0.01) and in the adult group (36%; P = 0.11). Elderly patients with Medicare had a low rate of HSCT use (17%; P = 0.13). Logistic regression showed no statistically significant associations between payer status or ethnicity and HSCT use. However, elderly women were significantly less likely to undergo HSCT than elderly men (odds ratio, 0.34; P < or = 0.01). CONCLUSIONS The lack of statistically significant differences in HSCT use among adult patients with leukemia was surprising because previous studies had shown differences in HSCT by ethnicity and insurance.
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Affiliation(s)
- Jessica P Hwang
- Department of General Internal Medicine, Ambulatory Treatment and Emergency Care, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
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Rodger MA, Gagné-Rodger C, Howley HE, Carrier M, Coyle D, Wells PS. The outpatient treatment of deep vein thrombosis delivers cost savings to patients and their families, compared to inpatient therapy. Thromb Res 2004; 112:13-8. [PMID: 15013267 DOI: 10.1016/j.thromres.2003.09.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2003] [Accepted: 09/29/2003] [Indexed: 11/29/2022]
Abstract
BACKGROUND The outpatient treatment of deep vein thrombosis (DVT) with low-molecular-weight heparin (LMWH) has been shown to be cost-effective from the perspective of a third party payer. The aim of this study is to determine if some or all of these cost savings to third party payers are shifted to patients and their families. METHODS A prospective cohort study with micro-costing of patient/family costs was conducted at the thrombosis units of The Ottawa Hospital. Costs were determined by administering a questionnaire at the end of the patients' heparin therapy. Over a period of 4 months, consecutive patients presenting at the thrombosis units were approached at the initiation of their heparin therapy; 44 patients consented to participate and completed questionnaires were obtained for 41. RESULTS The mean patient/family costs associated with outpatient therapy were significantly less than those associated with inpatient therapy (219.42 dollars versus 402.93 dollars, p=0.003); a savings of 190.91 dollars per patient. Even when lost income to patients/families was ignored, mean patient/family costs remained significantly less for outpatient therapy (72.00 dollars versus 134.29 dollars, p=0.004); a savings of 62.30 dollars per patient. Furthermore, patients preferred outpatient to inpatient therapy by almost 3:1 (30 versus 11, respectively). INTERPRETATION The outpatient treatment of DVT does not result in any net shifting of costs to patients and their families, and further, brings about cost savings. Given the cost savings associated with and the preference of patients for outpatient care, this study further supports the shift of DVT therapy from the inpatient unit to the outpatient clinic.
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Barr RD, Feeny D, Furlong W. Economic evaluation of treatments for cancer in childhood. Eur J Cancer 2004; 40:1335-45. [PMID: 15177493 DOI: 10.1016/j.ejca.2004.01.033] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2003] [Revised: 01/13/2004] [Accepted: 01/13/2004] [Indexed: 11/21/2022]
Abstract
Treatment of cancer in childhood is an expensive undertaking for the health-care system and for the affected families. As there is a substantial burden of treatment-related morbidity, it is important to determine whether the effects of treatment are worth these monetary costs, especially from a societal perspective. Economic evaluation affords a comparison of the costs and consequences (effects) of relevant therapeutic alternatives. Preference-based measures of health-related quality of life are particularly useful for assessing the effects of treatment, for these tools integrate mortality and morbidity. These measures provide utility scores that can be used as weights on survival data to compute quality-adjusted life years (QALYs). Costs are incurred both within and outside of the health-care system. The former should include those in front-line patient care departments (e.g. nursing); the pro-rated share of the expenses of service departments (e.g. materials management) to those in the front line; and the fully allocated costs for capital invested in lands, building and equipment. The latter are costs borne by families that are both out-of-pocket (e.g. for over-the-counter drugs) as well as related to time spent in providing care, which may involve foregone income. Costs and consequences should be subject to discounting; a process for converting those items incurred in the future into contemporary equivalents. Economic evaluation provides estimates of incremental discounted costs per discounted QALY gained. By almost any interpretative standard this appears attractive with respect to cancer in childhood. Examples are provided with the encouragement that economic evaluation be undertaken in more clinical trials in paediatric oncology.
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Affiliation(s)
- Ronald D Barr
- Haematology/Oncology, McMaster Children's Hospital, Hamilton Health Sciences, and Pediatrics, Pathology and Medicine, McMaster University, Hamilton, Ont., Canada.
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Abstract
Economic evaluation is a comparison of the costs and consequences of alternative healthcare interventions. Consequences are best assessed as utilities; quality-adjusted measures of effectiveness. Although few substantive data are available, it appears that hematopoietic stem cell transplantation is even more cost-effective in children than in adults.
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Affiliation(s)
- Ronald D Barr
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada.
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