Outcomes of Reduced-Intensity Conditioning Allogeneic Hematopoietic Cell Transplantation Performed in the Inpatient versus Outpatient Setting

Abstract

A B S T R A C T 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 18 years 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 100 days. Outpatient HCT resulted in significantly lower charges than inpatient HCT in the first 100 days (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.

Allogeneic Hematopoietic Cell Transplantation in the Outpatient Setting

“…Outpatient HCT is not a novel idea but until recently has predominantly been reserved for autologous stem cell transplant, particularly in myeloma patients [7,8]. Several centers have published their data regarding outpatient allogeneic HCT using RIC/NMA and myeloablative conditioning regimens and have demonstrated safety and feasibility [3,9,10]. The present data from Fred Hutchinson Cancer Center corroborates that.…”

“…The outpatient approach to transplant should decrease hospital admissionÀrelated expenses. Guru Murthy et al [9] demonstrated cost savings within the first 100 days of transplant when comparing outpatient RIC allogeneic HCT with their inpatient cohort (median total charges, $247,334 versus $339,621, respectively). Although overall expenses are decreased by outpatient transplant, specific cost savings for institutions and patients may be more difficult to demonstrate.…”

Outcomes of second hematopoietic stem cell transplantation using reduced‐intensity conditioning in an outpatient setting

“…HSCT in outpatient settings has demonstrated to be safe and efficient 13,33 . It also showed no inferiority in survival and lower costs when compared with inpatient protocols 14 . However, there is a lack of information focused on second HSCT in outpatient settings and results in this report provide evidence of a good risk‐benefit balance.…”

“…The relatively low toxicity of RIC makes outpatient HSCT possible without increasing the morbimortality 13 . Furthermore, the costs of hematopoietic transplants are considerably reduced when performed in an outpatient setting, 14 which is very important in low‐middle income countries, as recently summarized 15 . Data about the efficacy and cost structure of the outpatient transplantation program in our center have been previously reported 16,17 ; however, information regarding outpatient second HSCT using RIC is scarce, with only one study available in the literature 18 .…”

Allogeneic Hematopoietic Cell Transplantation in the Outpatient Setting

“…A recent single-center retrospective study compared complications and survivals among 116 inpatients and 35 outpatients treated with reduced-intensity conditioning (RIC) conditioning before allogeneic HCT [23]. Short-term outcomes were comparable among both cohorts, with inpatients experiencing 1-year NRM of 10.8% compared with 3.2% among outpatients.…”