Study shows less hospital time for outpatient stem cell transplants
Significant cost savings found while procedure is safe, effective, researchers say
Multiple myeloma patients undergoing a stem cell transplant in an outpatient setting spent about a week less in the hospital than those undergoing the procedure in an inpatient setting, a new study demonstrated.
Data also showed that outpatient transplant — which does not require the patient to be hospitalized before or during the procedure — was as safe and effective, while resulting in significant cost savings related to hospitalization and medication reimbursements.
“We’re working to reduce drug costs and trying to be really cognizant of the fact that the costs of chemotherapy and cancer treatment are just exorbitant,” Andy Maldonado, one of the study’s authors at the Medical University of South Carolina (MUSC)’s Hollings Cancer Center, said in a university news story. “This is just one way that we’re trying to reduce costs for patients, and we had really great clinical outcomes as well.”
The study, “Effectiveness, safety and cost implications of outpatient autologous hematopoietic stem cell transplant for multiple myeloma,” was published in the journal Hematology/Oncology and Stem Cell Therapy.
Autologous hematopoietic stem cell transplant (AHSCT) is a standard treatment for people with multiple myeloma, a cancer affecting white blood cells that normally produce antibodies.
The procedure first involves the collection of a patient’s healthy blood stem cells, or those that can give rise to all types of blood cells, after treatment with an agent that simulates their movement from bone marrow to the bloodstream. Patients then undergo a conditioning regimen, which kills all blood cells in the bone marrow including cancer cells. Healthy blood stem cells are transplanted back into the patient to allow the body to make new and healthy blood cells.
Because the conditioning regimen can increase risk of infections, the steps from conditioning to transplant generally have been done in inpatient hospital settings, with patients being hospitalized for about four days before post-transplant discharge.
Outpatient AHSCT safe, effective, feasible, reports say
Still, several reports suggest that outpatient AHSCT is feasible, safe, and effective, especially if patients are closely followed and treated with preventive antimicrobial agents.
“The ability to safely complete transplants in the outpatient setting can potentially provide a significant cost benefit to patients and health institutions,” the researchers wrote.
In 2018, MUSC’s Hollings Cancer Center, a National Cancer Institute (NCI)-designated cancer center, established an AHSCT program with outpatient conditioning, outpatient stem cell infusion, and outpatient follow-up.
This is being applied to all AHSCT-eligible myeloma patients, unless the patient has additional health conditions requiring inpatient care or they do not have appropriate caregiver support.
Now, Maldonado and colleagues at Hollings Cancer Center compared the outcomes of 50 patients who underwent the inpatient procedure between August 2016 and April 2018 and the first 50 myeloma patients on the outpatient program, between May 2018 and October 2019.
“This study aimed to highlight the effectiveness, safety, and cost implications of outpatient vs inpatient [AHSCT] at a tertiary academic medical center,” the researchers wrote.
Results showed the outpatient group took significantly less time to achieve neutrophil engraftment — indicating the growth of new neutrophils, a type of white blood cell — than the inpatient group (median of 14.5 vs. 16 days). Similar findings were seen for platelets, the tiny blood cells that are involved in blood clotting (median of 19 vs. 21 days).
In the outpatient group, 88% of patients required hospital admission within the first two weeks after the transplant, while 90% of those who underwent the inpatient procedure required readmission following discharge.
While the rates of hospitalization were similar between the groups, patients undergoing the outpatient procedure were significantly less likely to need more than one hospitalization (4% vs. 26%) and spent significantly fewer days in the hospital (median of 8.5 vs. 15.5 days).
A group difference in hospital days was observed even after researchers accounted for the initial four-day hospitalization period in the inpatient group.
“So there is a seven-day reduction in the length of hospital stay and that actually is a very effective strategy,” said Hamza Hashmi, MD, another of the study’s authors and a specialist in blood cancers.
Reasons for a hospital stay longer than the expected four-day period in the inpatient group included febrile neutropenia, a high fever associated with a low neutrophil count; severe swelling of the mouth and gut requiring aggressive treatment; and/or lack of reliable caregiver support.
The use of growth factors to promote post-transplant blood cell production was more common in outpatients than inpatients (50% vs. 18%). This may explain the shorter time for neutrophil and platelet engraftment in the outpatient group, the researchers noted.
Neutropenic fever occurred in 80% of outpatient cases, of whom 60% received a growth factor during their hospitalization. The time to neutrophil engraftment was significantly shorter for patients given growth factors relative to those who were not (13 vs. 15 days), but no differences were seen for platelet engraftment or hospital stay duration.
The incidence of infection was similar between inpatient and outpatient groups (28% vs. 30%), suggesting “outpatient transplants are not associated with an increased risk of infections,” the researchers wrote.
Cost savings higher with outpatient group
Moreover, given that reimbursement rates for the conditioning agent melphalan are different between the outpatient and inpatient settings, Maldonado explained, outpatient purchase and administration of the therapy resulted in an estimated cost savings of $216,000 for every 50 patients.
Cost reductions associated with the outpatient procedure were also derived from “the reduction in total hospital days and readmission rates,” the team wrote. The latter is associated with differences in how the Centers for Medicare and Medicaid Services reimburses for initial hospitalizations versus readmissions.
“Outpatient [AHSCT] for patients with [multiple myeloma] is a safe and effective way to save costs and reduce the total length of hospital stays,” the researchers concluded.
Hashmi noted this study demonstrates one of the benefits of working in an NCI-designated cancer center.
“NCI designation plays a major role in having research ideas implemented into practice and then showing the benefit in regard to outcomes for patients,” Hashmi said.
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