Time to diagnosis and associated costs of an outpatient vs inpatient setting in the diagnosis of lymphoma: a retrospective study of a large cohort of major lymphoma subtypes in Spain

Abstract

BackgroundMainly because of the diversity of clinical presentations, diagnostic delays in lymphoma can be excessive. The time spent in primary care before referral to the specialist may be relatively short compared with the interval between hospital appointment and diagnosis. Although studies have examined the diagnostic intervals and referral patterns of patients with lymphoma, the time to diagnosis of outpatient compared to inpatient settings and the costs incurred are unknown.MethodsWe performed a retrospective study at two academic hospitals to evaluate the time to diagnosis and associated costs of hospital-based outpatient diagnostic clinics or conventional hospitalization in four representative lymphoma subtypes. The frequency, clinical and prognostic features of each lymphoma subtype and the activities of the two settings were analyzed. The costs incurred during the evaluation were compared by microcosting analysis.ResultsA total of 1779 patients diagnosed between 2006 and 2016 with classical Hodgkin, large B-cell, follicular, and mature nodal peripheral T-cell lymphomas were identified. Clinically aggressive subtypes including large B-cell and peripheral T-cell lymphomas were more commonly diagnosed in inpatients than in outpatients (39.1 vs 31.2% and 18.9 vs 13.5%, respectively). For each lymphoma subtype, inpatients were older and more likely than outpatients to have systemic symptoms, worse performance status, more advanced Ann Arbor stages, and high-risk prognostic scores. The admission time for diagnosis (i.e. from admission to excisional biopsy) of inpatients was significantly shorter than the time to diagnosis of outpatients (12.3 [3.3] vs 16.2 [2.7] days; P < .001). Microcosting revealed a mean cost of €4039.56 (513.02) per inpatient and of €1408.48 (197.32) per outpatient, or a difference of €2631.08 per patient.ConclusionsAlthough diagnosis of lymphoma was quicker with hospitalization, the outpatient approach seems to be cost-effective and not detrimental. Despite the considerable savings with the latter approach, there may be hospitalization-associated factors which may not be properly managed in an outpatient unit (e.g. aggressive lymphomas with severe symptoms) and the cost analysis did not account for this potentially added value. While outcomes were not analyzed in this study, the impact on patient outcome of an outpatient vs inpatient diagnostic setting may represent a challenging future research.

What is the relevance of an ambulatory quick diagnosis unit or inpatient admission for the diagnosis of pancreatic cancer? A retrospective study of 1004 patients

“…Although there were no differences in the time to diagnosis between the 2 approaches, the costs of inpatients’ diagnosis were nearly the double than those of QDU patients. Because the high costs of hospitalization and the reported advantages for patients of a hospital-based ambulatory versus inpatient management, [ 15 , 17 ] an ambulatory instead of an inpatient diagnostic evaluation may be preferable in patients with suspected pancreatic cancer. However, it may be argued that admission has an added value for diagnosis since it is associated with issues which may not be properly treated or managed in an ambulatory setting.…”

“…Indeed, mostly owing to delayed investigations ordered by PC physicians, patients with suspected cancer, even with an appropriate performance status, have been traditionally hospitalized to speed-up diagnosis. [ 12 , 16 , 17 ] However, admission for diagnostic workup of such patients may only increase the costs of hospitalization, contributing to increased expenditures in healthcare. To avoid delays and potentially avoidable admissions, the Spanish healthcare system created in the 2000s hospital based-ambulatory facilities called quick diagnosis units (QDUs).…”

Pulmonary Presentation of Kaposi-Sarcoma in a Renal Transplant Recipient

“…During this encounter, however, the inpatient lymph node biopsy was indicated due to generalized lymphadenopathy of unclear etiology and worsening clinical status [8]. A study has shown that inpatient excisional biopsies may lead to quicker diagnoses in hematologic disease, but outpatient ones are more cost-effective [9]. In immunocompromised patients, a high index of suspicion is required to prompt a full skin exam and potentially earlier inclusion of an excisional lymph node biopsy.…”

Trends in Hospitalization of Patients with Potentially Serious Diseases Evaluated at a Quick Diagnosis Clinic

“…As far as we can tell, there are no previous reports analyzing temporal trends including clinical characteristics and causes of hospitalizations for patients evaluated at quick diagnosis units. Evidence for the role of quick diagnosis units as an alternative ambulatory care model to inpatient admission comes mainly from level 2a and 2b studies, including two systematic reviews [11,33] and observational studies (prospective and retrospective) [16][17][18][19][20]24,25]. A systematic review reported in 2014 by independent US authors selected for final review four studies that focused on quick diagnosis units, of which three had been published in Spanish medical journals [33].…”

“…Different, mainly observational studies revealed that these units were as clinically effective as inpatient admission to reach a diagnosis, with similar diagnostic times. While patient reported satisfaction was also similar or higher than conventional hospitalization, quick diagnosis units proved cost-effective with associated costs significantly lower than the same costs applied to the evaluation of the same conditions in the hospital setting [ 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 ].…”