Haematologists in Tasmania have shown that outpatient ASCT is safe, feasible and appears to reduce costs through significantly reduced median length of hospital stays.
In a retrospective audit of 231 patients undergoing ASCT at the Royal Hobart Hospital (2008- 2018), 58% had outpatient ASCT defined as patients who received conditioning as an outpatient and were subsequently managed with either an elective admission during the cytopenic period or admission only if medically indicated.
The study included Hodgkin and non-Hodgkin lymphoma patients receiving carmustine-etoposide-cytarabine-melphalan (BEAM) conditioning and multiple myeloma, plasma cell leukaemia and amyloidosis patients receiving melphalan (MEL) conditioning.
Patients qualified as suitable for outpatient ASCT by their transplant physician also had to have a carer 24/7 and have accommodation less than an hour from hospital.
The audit found median admission length was significantly longer for inpatient BEAM-ASCT (21 days), than outpatient BEAM-ASCT with planned elective admission during nadir (10 days) and outpatient BEAM-ASCT with medically indicated admission (9 days).
The investigators, led by Dr Xuan Ni Tan, found no significant differences in engraftment, febrile neutropenia rates or mortality between the BEAM-ASCT subgroups.
Similarly for the melphalan cohort, median admission lengths were significantly longer in the inpatient group (17 days) compared to outpatient MEL-ASCT with planned elective admission (8 days) and outpatient MEL-ASCT group with medically indicated admission (7 days).
With both conditioning regimens, the most common reasons for non-elective admission were febrile neutropenia and mucositis.
There were no significant differences in engraftment, febrile neutropenia rates or mortality between BEAM-ASCT subgroups although more outpatient BEAM-ASCT required ICU/HDU admission than other BEAM-ASCT subgroups.
“This is an important finding and warrants further study, given the impact it would have upon ICU/HDU beds, a limited and expensive medical resource,” the study said.
There were no significant differences in neutrophil and platelet engraftment, febrile neutropenia rates and ICU admission between the MEL-ASCT subgroups.
The study, published in the Internal Medicine Journal, said the estimated cost savings for reduced length of stay with outpatient ASCT were $16,712 for BEAM-ASCT and $13,444 for MEL-ASCT.
“Whilst we hypothesise that outpatient autografts lead to significant cost-savings, we recognise that our cost estimates are based upon simplified gross figures and need to be interpreted with caution. Additional costs borne by patients and carers, as well as accommodation and transport costs for rural and regional patients have not been considered.”
The study authors concluded that their experience of outpatient ASCT was even more relevant in the context of the COVID-19 pandemic, which has driven widespread use of telehealth and minimal contact with hospitals and healthcare settings.
“With the increasing numbers of autografts being performed and rising healthcare cost, optimisation of healthcare provision in the outpatient setting should be the focus moving forward.”
A model to follow
Dr Tan, now a haematology fellow at Sir Charles Gairdner Hospital in WA, told the limbic their findings could be useful for others interested in setting up an outpatient ASCT program.
“Certainly the impetus for us to publish this was so people who are trying to set up their outpatient service can use this as some documentation that they can present to hospital executives. It’s to garner support not just from clinical communities but from those in hospital service provision and planning.”
She said while there appeared to be eventual cost savings, outpatient ASCT required significant upfront investment to increase day ward capacity.
Dr Tan also noted that clinicians had to be comfortable in managing these patients as outpatients.
“When they are receiving chemotherapy patients are actually quite well because the mature cells are still hanging around in the body. As those cells die off gradually, it’s the 1-2 weeks after completion of conditioning chemotherapy when they get sick.”
She said it was important to highlight that the patients who required ICU/HDU admission had actually been inpatients for a period of time before they required intensive care.
“They had already had 48 hours of stabilisation as an inpatient. Our argument is that had they been inpatients the whole way, they would have ended up in ICU anyway but we can’t actually prove that because of the retrospective nature of the study.”