High-Dose Chemotherapy With Autologous Stem Cell Rescue in the Outpatient Setting
High-Dose Chemotherapy With Autologous Stem Cell Rescue in the Outpatient Setting
Intensive outpatient care is rapidly becoming the primary mode of care for selected patients undergoing high-dose chemotherapy with autologous peripheral blood stem cell (PBSC) transplantation. Although the traditional inpatient model of care may still be necessary for high-risk patients, published data suggest that outpatient care is safe and feasible during or after administration of high-dose chemotherapy and autologous PBSC transplant. Blood and marrow transplant (BMT) centers have developed programs to provide more outpatient care under three basic models: an early discharge model, a delayed admission model, and a comprehensive, or total, outpatient model. This review will describe these models of care and address the elements necessary for the development of an outpatient BMT program, including patient selection, staff development, and patient and caregiver education. Available supportive care strategies to facilitate outpatient care will also be highlighted. Clinical outcome data and pharmacoeconomic analyses evaluating various outpatient BMT programs, as well as limited quality-of-life evaluations, will be reviewed. [ONCOLOGY 14(2):171-185, 2000]
Advances in the field of blood and marrow transplantation (BMT) leading to decreased morbidity and mortality have facilitated a shift in care of the transplant patient from the hospital to the outpatient clinic. One major factor that has facilitated this shift is the increased use of peripheral blood–derived stem cells (PBSCs) instead of bone marrow–derived stem cells as autologous rescue following administration of high-dose chemotherapy.
The use of PBSCs is associated with shorter periods of neutropenia and thrombocytopenia, as well as potentially less severe regimen-related toxicities.[2-4] In addition, improvements in supportive care strategies, including antibiotic algorithms for prophylaxis and treatment, antiemetic regimens, and transfusion protocols, have allowed patients to be cared for safely in the outpatient setting.
The potential advantages of outpatient care for BMT patients include improved patient satisfaction and quality of life by allowing them to remain in their home environment or in a nearby hotel. In addition, the elimination of a prolonged hospital stay may potentially decrease the convalescent period by keeping the patient more active and responsible during the transplant process. Published data in cancer patients support these potential advantages of outpatient care during BMT.[6,7]
Despite the potential impact of outpatient care on quality of life, thus far, the primary end points evaluated have been safety, feasibility, and pharmacoeconomics.[8,9] Numerous studies have documented the safety and feasibility of outpatient care during or after administration of high-dose chemotherapy with autologous PBSC rescue.[10-14] In terms of pharmacoeconomics, autologous BMT has traditionally been an expensive procedure, with historical costs exceeding $100,000 per patient. Attempts to decrease this cost have been fueled by the general pressure to decrease health care costs and the increasing use of global-fee contracts for BMT, in which the provider assumes the financial risk for all BMT services.[15,16]
Establishment of an outpatient component of care early in the BMT process requires prudent patient selection, intensive planning and education, trained staff, and appropriately equipped facilities. This review will address the logistic requirements and published outcomes for various outpatient BMT care models.
Three models of outpatient care have been described in the literature and are represented schematically in Figure 1.
Early Discharge Model
The first outpatient care model described, the early discharge model, was implemented by Peters et al at Duke University. In this program, high-dose chemotherapy is administered on the hospital BMT unit. After the completion of high-dose chemotherapy and stabilization of gastrointestinal toxicities, patients are discharged to the outpatient BMT clinic and followed on a daily basis.
During this period of intensive outpatient visits, patients are readmitted to the inpatient BMT unit only if they develop such complications as neutropenic fever, refractory gastrointestinal toxicities, or other clinical scenarios that cannot be managed in the outpatient setting. By implementing this approach, Peters et al reported a reduction in BMT-associated hospital stays from 24.5 to 7 days.
Delayed Admission Model
Another model described less extensively in the literature, but used in numerous autologous transplant centers, is the delayed admission model of Weaver et al. In this model, high-dose chemotherapy is administered in the outpatient setting, and patients are then admitted to the hospital for supportive care management.
Although the delayed admission approach can decrease the duration of hospitalization as compared to the traditional inpatient model, patients generally require 2 weeks of hospitalization during the supportive care period. For example, although the delayed admission model is referred to as an outpatient BMT program, Weaver et al reported that 96% of 80 patients with lymphoma undergoing autologous transplantation required hospitalization for a median of 14 days.
Total Outpatient Model
Recently, a more extensive approach to outpatient care has been described, which can be defined as a total, or comprehensive, outpatient model.[12-14] In this model, both high-dose chemotherapy administration and supportive care management are conducted in the outpatient setting, with patients hospitalized for complications that cannot be managed in the clinic or at home.
Of the three outpatient models, the total outpatient approach is associated with the shortest duration of hospitalization, but it is the most labor intensive for the outpatient BMT clinic. The comprehensive outpatient care model requires extensive coordination and implementation of resources, often including the establishment of specialty designated outpatient clinics and home health care programs.
Providing care to the BMT patient in the outpatient setting requires the availability and establishment of numerous facility and staff resources. The extent to which certain resources are needed depends on the established outpatient care model. Essential resources for every model include a designated outpatient and inpatient care facility.
Most outpatient programs have an equipped outpatient facility that operates during regular business or extended hours. The mechanisms used to provide after-hours or weekend care vary among centers, however. Options implemented include extended clinic hours or direct admission to the hospital for any complications occurring after hours. Another option that may minimize hospitalization is the establishment of a hospital-based outpatient treatment room for weekend and emergency visits. Provision of after-hours care may also depend on the level of home health care nursing and infusion services available.
The availability of dedicated, specialized staff is crucial to the success of an outpatient BMT program. Essential staff members include inpatient and outpatient BMT-trained nurses, pharmacy services specializing in high-dose therapy, laboratory and blood-banking support, medical and surgical consultants, and hematopoietic cell therapy support services.
In addition to these essential staff members, which are common to all outpatient models, other personnel have been added or adapted within various centers based on need and available resources. For example, the level of home health care involvement among outpatient BMT programs ranges from minimal to extensive. The model of Peters et al provides only minimal home health care support and, at one point, used home health care professionals primarily for ambulatory pump needs.
In contrast, the model of Geller et al integrates BMT-designated home health care nursing staff into the daily care of the patient. In this model, the BMT home health care staff consists of inpatient BMT nurses who rotate weekly. During the home health care week, their only responsibility is to answer telephone calls, make home visits for initial assessments and follow-up care, and provide primary nursing care to patients seen in the weekend outpatient BMT clinic.
Complete integration of home health care into the outpatient BMT program can expand the comprehensiveness of the program and help eliminate the need for short hospital stays to initiate intravenous antibiotics for a first neutropenic febrile episode. However, in other models with less home health care involvement or prolonged clinic hours, patients may be admitted to the hospital for evaluation and initiation of intravenous antibiotics.[10,11]
Before determining the appropriateness of outpatient care, the BMT candidate first undergoes the routine pre-BMT evaluation to determine eligibility. This evaluation includes an assessment of clinical eligibility based on disease restaging, organ function, and performance status, as well as a psychosocial assessment and investigation of insurance coverage.