Ambulatory high‐dose methotrexate administration among pediatric osteosarcoma patients in an urban, underserved setting is feasible, safe, and cost‐effective

Abstract

Background. We describe the safety, feasibility, and provide a cost-estimate of outpatient high-dose methotrexate administration (HDMTX) among an urban, underserved population. Procedure. A retrospective analysis of ambulatory HDMTX administration among osteosarcoma patients, at Montefiore Medical Center's Children's Hospital (Bronx, NY) was performed. HDMTX (12 g/m 2 ) was given intravenously (IV) over 4 hr after urine alkalinization. Patients were discharged home to continue IV hydration and alkalinization delivered via a home infusion pump. Families were instructed to monitor urine pH overnight and management was adjusted according to our institution's treatment algorithm until MTX level ≤0.1 mol/L. A cost estimate was performed to assess the difference in costs for outpatient versus hypothetical inpatient administrations. Results. Of the 97 ambulatory HDMTX administrations, 99% were successfully completed. One patient failed outpatient administration secondary to home infusion pump malfunction. This patient successfully completed subsequent courses as an outpatient. Most patients (72%) had a MTX level of <10 mol/L at 24 hr post-HDMTX. No patients were found to have a MTX level of >50 mol/L at 24 hr. About 26% of courses were associated with grade III or IV neutropenia, 4% were associated with grade III or IV thrombocytopenia and 1% were associated with grade III/IV leukopenia. Compared to a hypothetical hospital inpatient stay, the hospital costs for ambulatory HDMTX were an average of $1400 less per cycle. Conclusion. Ambulatory HDMTX administration among an underserved, urban population is safe, feasible, and cost-effective. Pediatr Blood Cancer.

Risk factors associated with delayed methotrexate clearance and increased toxicity in pediatric patients with osteosarcoma

“…Overall, we have described the pharmacologic risk profile of HD‐MTX in a cohort of pediatric patients with OS. Risk factors described in our study should be considered at the time of design of new protocols for outpatient administration of HD‐MTX in pediatric OS . Understanding these risk factors may also be beneficial in counseling and individualizing supportive care measures for these patients.…”

Inpatient versus outpatient vincristine, dactinomycin, and cyclophosphamide for pediatric cancers: Quality and cost implications

“…Chemotherapy admissions are, on average, 2 days longer and twice as costly as other childhood admissions . Several studies have suggested that the outpatient administration of chemotherapy can be cost effective for patients and institutions . Shifting healthcare from the inpatient to the outpatient setting can also free up inpatient beds and resources for more acute patients.…”

“…In the outpatient setting, 99% (97 administrations) of high‐dose methotrexate administrations were completed successfully and cost the hospital approximately $1,407 less than a hypothetical inpatient hospital stay ( P < 0.001). This represented approximately $12,663 cost savings per patient . Stevens and coworkers examined the costs savings associated with administering intravenous methotrexate and cytosine arabinoside to pediatric patients with acute lymphoblastic leukemia through a home‐based approach compared to inpatient.…”

Systematic review of international evidence on the effectiveness and costs of paediatric home care for children and young people who are ill

“…This identified only one pilot RCT that would definitely have met our inclusion criteria (on home oxygen for acute bronchiolitis; Tie et al . 2009) and one health economics study that would possibly have met our inclusion criteria (on ambulatory chemotherapy; Mahadeo et al . 2010).…”