Resource Utilization and Safety of Outpatient Management Following Intensive Induction or Salvage Chemotherapy for Acute Myeloid Leukemia or Myelodysplastic Syndrome

Abstract

Importance Adults with acute myeloid leukemia (AML) typically remain hospitalized after induction or salvage chemotherapy until blood count recovery, with resulting prolonged inpatient stays being a primary driver of healthcare cost. Pilot studies suggest that outpatient management following chemotherapy might be safe and could reduce cost for these patients. Objective To compare safety, resource utilization, infections and cost between adults discharged early following AML induction or salvage chemotherapy and inpatient controls. Design Non-randomized phase 2 study. Setting Single center study conducted at the University of Washington Medical Center in Seattle, WA. Participants Over a 43-month period (January 1, 2011 – July 31, 2014), 178 adults receiving intensive AML chemotherapy were enrolled. After completion of chemotherapy, 107 met pre-designated medical and logistical criteria for early discharge (ED), while 29 met medical criteria only and served as inpatient controls. Interventions for Clinical Trials ED patients were discharged from the hospital at the completion of chemotherapy, and supportive care was provided in the outpatient setting until count recovery (median 21 days, range 2–45 days). Controls received inpatient supportive care (median 16 days, range 3–42 days). Main Outcome Measures 1) differences in early mortality 2) differences in resource utilization (ICU days, transfusions/study-day and IV antibiotics/study-day) 3) numbers of infections and 3) total and inpatient charges/study-day between early discharge patients and controls. Results Four patients discharged early (4%) but no controls died within 30 days of enrollment (p=0.58). Nine patients discharged early (8%) but no controls required intensive care unit-level care (p=0.20). No differences were noted in the average daily number of red blood cell (p=0.55) or platelet (p=0.31) transfusions. Patients discharged early did have more positive blood cultures (p=0.04) but required fewer days of IV antibiotics (p=0.007). Overall, daily charges among discharged patients were significantly lower (median $3,840 vs. $5,852; p<0.001) despite increased charges per inpatient day when readmitted (median $7,405 vs. $6,267; p<0.001). Conclusions and Relevance Early dischargefollowing intensive AML chemotherapy can reduce cost and use of IV antibiotics, but attention should be paid to complications that may occur in the outpatient setting. This study was registered at www.ClinicalTrials.gov (NCT01235572).

Outpatient care of patients with acute myeloid leukemia: Benefits, barriers, and future considerations

“…In the study by Ruiz-Argüelles et al, the early discharge of AML patients following completion of induction chemotherapy led to an average savings of 1700 USD per patient [25]. Consistent with this estimate, we found approximate cost savings of 2000 USD charged per patient discharged early compared to inpatient controls in both the pilot and phase 2 studies conducted at the UW/SCCA [27,28]. Efforts to quantify fiscal gains from changes in clinical practice are often hindered by the inherent difficulties in calculating healthcare costs, particularly in the U.S. For example, we utilized hospital “charges” as a surrogate for healthcare cost in our studies.…”

“…Based on the data obtained in our pilot study, we then conducted a larger, comparative, non-randomized phase 2 prospective study, in which we enrolled 178 adults AML or high-risk MDS patients after receipt of induction or re-induction chemotherapy [28]. Within 72 h of chemotherapy completion, patients were reassessed medically and deemed eligible for early discharge if they had an ECOG performance status of 0–1, bilirubin level less than or equal to 3 times the upper limit of normal, glomerular filtration rate at least 25% of the lower limit of normal, and no clinical signs of heart failure or bleeding.…”

“…To our knowledge, all studies of outpatient AML management that have assessed cost outcomes have done so from the perspective of the healthcare institution [25,27,28]. One limitation of this approach is that it does not address the financial costs assumed by the patient and his/her caregiver(s).…”

Forgotten public health impacts of cancer – an overview

“…These results confirm the findings of earlier studies, which showed that outpatient high-dose chemotherapy and autologous stem cell transplantation are efficient, effective, and acceptable (114,115). More recently even, the challenge of shifting towards outpatient care has been raised for other cancers, also with favourable outcomes: the treatment by vincristine, dactinomycin, and cyclophosphamide for children with solid tumours, as outpatient instead of the traditional twoday inpatient stay, has proven safe, cheaper, and more satisfactory for the patient (116); outpatient delivery of chemotherapy for acute lymphoblastic leukaemia/ lymphoma was safe and not associated with increased toxicity as compared to inpatient delivery (117); outpatient management after chemotherapy for adults with acute myeloid leukaemia or myelodysplastic syndrome reduced costs and use of IV antibiotics (118). In other terms, the administration of chemotherapy in outpatient settings produces comparable outcomes while increasing patients' satisfaction and reducing costs.…”

Acute myeloid leukemia: 2016 Update on risk‐stratification and management

“…Recent data suggest this is unnecessary if, as outpatients, patients reside close to a hospital, have a caregiver readily available, and are prepared to visit a dedicated outpatient facility several times weekly [122]. Similarly, randomized data suggest no value in a diet free of fresh fruits and vegetables ("a neutropenic diet") [123].…”