In situ off-line extracorporeal photopheresis conducted in a real-life situation at a Hemobiotherapy Department in France: A comparison of costs vs on-line procedure

BACKGROUND

The off-line extracorporeal photopheresis (ECP) procedure requires photosensitization in an external cell therapy laboratory as per the French regulatory requirement. This regulation results in higher time and costs compared with the on-line alternative performed entirely at the patient's bedside. Recently, full in situ execution of the off-line procedure has been implemented in the Pitié-Salpêtrière Hospital Hemobiotherapy Department (Paris, France). This report summarizes the center's experience regarding the organizational and costs impacts of this change compared with the on-line procedure.

MATERIAL AND METHODS

ECP was broken down into stages, and several procedures were monitored prospectively in real-life settings. The total costs associated with both procedures were the sum of the fixed costs and variable costs related to all stages of the procedures, nursing-time costs, property costs, and patient-related production loss costs.

RESULTS

Eight off-line ECP and fourteen on-line ECP procedures were monitored during five consecutive days. Procedure duration was not different (median 137.5 vs 154.0 minutes, P = .29). Times and costs associated with nursing were higher but offset by lower fixed costs of the off-line ECP. Total direct costs per procedure associated with using the off-line ECP were significantly lower than those of the on-line procedure (459.6 ± 7.1 EUR vs 953.8 ± 6.5 EUR; P = .0002). Similar results were observed when including the costs of patient production loss.

CONCLUSIONS

As a competitive time procedure, the in situ off-line method proved to be cost-efficient by effectively offering similar patient treatment per year compared with the on-line procedure.

Service improvement in a nurse-led clinic for extracorporeal photopheresis

The skin tumour unit at one London hospital has been providing extracorporeal photopheresis (ECP) treatment since 2012, using an online fully integrated system. This report summarises 9 years of continuous process improvement, which has enabled the team to meet the growing demand for ECP treatments for cutaneous T-cell lymphoma (CTCL) and graft-versus-host disease (GvHD) patients. The unit formed a partnership with a lean-management company to go through the process of evaluation of capacity constraints, design layout and patient scheduling.

METHODS

Increased capacity year-on-year and over the 9-year period was calculated based on data collected from records. The authors reviewed the nurse staffing resources allocated for ECP treatments over the same period, and financial value created by the continuous improvement (additional number of treatments multiplied by the national tariff for ECP treatments).

RESULTS

In 2012 the average number of ECP treatments per nurse per week was 11. With the implementation of the new planning tool, and improved working practices, the average number of treatments per nurse per week has more than doubled to 23. Nurse staffing was maintained at 4 nurses per shift to deliver ECP treatments. The unit recorded additional revenue of approximately £3.2 million in 2020 compared with 2012.

CONCLUSIONS

The team has successfully increased the capacity of the service to deliver treatments without incurring any additional nursing costs, resulting in more patients with CTCL and GvHD being able to access ECP treatment and a cost benefit for the Trust. The service continues in its mission to grow and provide a superior patient experience.

Cost comparison of extracorporeal photopheresis technologies at the European Institute of Oncology

BACKGROUND

Stem Cell Mobilization and Collection Unit at Istituto Europeo di Oncologia (IEO; Milan, Lombardia) provides extracorporeal photopheresis (ECP) therapy to treat graft-vs-host disease (GvHD) using offline procedures. ECP can be administered via an integrated single device (online procedure). Total cost of performing ECP at IEO vs an integrated device was assessed using a micro-costing approach.

METHODS

Ten offline ECP procedures for GvHD were monitored using Time-Driven Activity-Based Costing methodology, which utilized costs of resources, and time spent by patients/healthcare personnel with each resource. Details of ECP steps were recorded (pre-/post-treatment clinical evaluations, biological sampling, cannulation, apheresis, irradiation, reinfusion time). Time and cost comparisons between offline (combination of equipment/devices) and online technologies (THERAKOS™ CELLEX™ Photopheresis System) were performed. Cost variables: consumables, personnel, equipment, and laboratory tests. Personnel costs for online procedures were calculated using published time estimates and IEO hourly rates. Costs recorded in 2018 euros.

RESULTS

Median duration of IEO offline ECP procedures (296 minutes) was greater than that reported for CELLEX ECP delivery (120 minutes). Total cost of offline ECP (€1134.57 [$1314.57]/procedure) was greater than that reported for online delivery (€1063.95 [$1232.74]/procedure). IEO performs ~84 ECP procedures/y, which would require ~412 hours/y vs 168 hours/y for online procedures; suggesting €5932.08 [$6873.72]/y savings with online procedures.

CONCLUSIONS

This assessment highlights potential resource time savings with online procedures. Time saved could allow increased activity with the same resources, at a department level. Potential non-monetary benefits include reduced time burden on patients, increased availability of hospital staff and improved patient safety.

Is Lean sustainable in today's NHS hospitals? A systematic literature review using the meta-narrative and integrative methods

Purpose

Methodological variance and quality, heterogeneity of value and divergent approaches are reasons for the varied results of Lean interventions in healthcare despite ongoing global popularity. However, there is piecemeal evidence addressing the sustainability of initiatives-the aim of this review is to use an integrative approach to consider Lean's sustainability and the quality of available evidence in today's National Health Service (NHS).

Data sources

A literature review of AMED, CINAHL, Cochrane, JBI, SCOPUS, DelphiS, MEDLINE, EMBASE, MIDIRS, Web of Science and PsycINFO electronic databases was conducted.

Study selection

Peer-reviewed studies in NHS hospitals/trusts that concerned undiluted, service-wide Lean adoption and contained quantitative data were included. Reference lists were consulted for evidence via a snowball approach. Methodological quality was assessed using an adapted critical appraisal tool.

Data extraction

Research design, method of intervention, outcome measures and sustainability were extracted.

Results of data synthesis

Electronic searches identified 12 studies eligible for inclusion. This comprised of five quasi-experimental designs (one mixed-method), three multi-site analyses, one action research, one failure mode and effects analysis, one content analysis of annual reports and one systematic review. Six articles considered sustainability with two of these providing measured successes. Despite diverse and positive outcomes studies lacked scientific rigour, failed to consider confounding issues, were at risk of positive bias and did not demonstrate sustainability with any statistical significance.

Conclusion

Lean has ostensible value but it is difficult to draw a conclusion on efficacy or sustainability. Higher quality scientific research into Lean and the effect of staffing cultures on initiatives are needed to ascertain the extent that Lean can affect healthcare quality and subsequently be sustained.

A transition from using multi-step procedures to a fully integrated system for performing extracorporeal photopheresis: A comparison of costs and efficiencies

Introduction

The Pitié Salpêtrière Hospital Hemobiotherapy Department, Paris, France, has been providing extracorporeal photopheresis (ECP) since November 2011, and started using the Therakos^® CELLEX^® fully integrated system in 2012. This report summarizes our single‐center experience of transitioning from the use of multi‐step ECP procedures to the fully integrated ECP system, considering the capacity and cost implications.

Materials and Methods

The total number of ECP procedures performed 2011–2015 was derived from department records. The time taken to complete a single ECP treatment using a multi‐step technique and the fully integrated system at our department was assessed. Resource costs (2014€) were obtained for materials and calculated for personnel time required. Time‐driven activity‐based costing methods were applied to provide a cost comparison.

Results

The number of ECP treatments per year increased from 225 (2012) to 727 (2015). The single multi‐step procedure took 270 min compared to 120 min for the fully integrated system. The total calculated per‐session cost of performing ECP using the multi‐step procedure was greater than with the CELLEX^® system (€1,429.37 and €1,264.70 per treatment, respectively).

Conclusions

For hospitals considering a transition from multi‐step procedures to fully integrated methods for ECP where cost may be a barrier, time‐driven activity‐based costing should be utilized to gain a more comprehensive understanding the full benefit that such a transition offers. The example from our department confirmed that there were not just cost and time savings, but that the time efficiencies gained with CELLEX^® allow for more patient treatments per year.