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Early post-chemotherapy discharge may be safe, cost-effective for patients with AML, MDS
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The early discharge of patients with acute myeloid leukemia or myelodysplastic syndrome following intensive chemotherapy can reduce costs and the use of IV antibiotics, according to results of a nonrandomized, phase 2 study.
Most patients with AML or myelodysplastic syndrome (MDS) remain hospitalized 3 to 4 weeks following chemotherapy during remission induction. Prolonged inpatient care after chemotherapy is the primary driver of costs in caring for adults with AML or MDS and, thus, researchers sought to evaluate whether a shift to outpatient management would safely reduce costs.
Jennifer E. Vaughn
“I believe our results are thought provoking,” Jennifer E. Vaughn, MD, MSPH, an assistant professor in the department of internal medicine at Virginia Tech Carilion School of Medicine and Research Institute told HemOnc Today. “They demonstrate that the implementation of early discharge patients has the potential to save healthcare ‘costs’ and appears to be safe, as the numbers of deaths and ICU stays in the discharged group were not statistically greater than those who remained as inpatients after chemotherapy.”
Vaughn and colleagues compared the safety, resource use and health care charges for patients who were discharged early following either induction or salvage chemotherapy.
The analysis includes data from 178 patients with AML or MDS who received intensive chemotherapy between 2011 and 2014. Of these patients, 107 met the predesignated criteria for early discharge within the first 72 hours after completing chemotherapy, and 29 served as inpatient controls.
Patients who were discharged received supportive care in the outpatient setting until blood cell count recovery (median, 21 days; range, 2-45). Control patients received supportive care (median, 16 days; range, 3-42).
More patients in the early discharge arm died within 30 days of enrollment onto the study (n = 4 vs. 0; 3.7% vs. 0%) and required care in the hospital ICU (n = 9 vs. 0; 8% vs. 0%); however, these differences did not reach statistical significance.
No significant differences occurred in the median daily number of transfused red blood cells (0.27 vs. 0.29) or transfused platelets (0.26 vs. 0.29) between the two arms. However, early discharge patients had more positive blood cultures than the inpatient group (35% vs. 14%; P = .04) but required fewer IV antibiotic days per study day (0.48 vs. 0.71; P = .01).
“On the whole, the early mortality rate in the discharged group was not greater than what has been historically experienced by AML patients undergoing intensive chemotherapy,” Vaughn said. “However, the complications that occurred in the discharged group highlight the need for close supervision in the outpatient setting. Institutions who undertake this practice do need to have strict policies in place for readmission and rapid management of foreseeable complications.”
Daily median charges appeared significantly lower for the outpatient cohort ($3,840 vs. $5,852; P < .001). However, patients who were readmitted (86.9%) had significantly greater median charges per inpatient day after readmission than controls ($7,405 vs. $5,852; P < .001).
Researchers noted they did not collect data on costs such as lodging, caregiver time, transportation, home care and prescription costs, or nursing and child care expenses that may bring a disproportionate burden onto patients beyond what is covered by their health care insurance.
Although the results of this study suggest a shift toward outpatient care, the researchers warned that many complications can still occur.
“For institutions with the ability to provide outpatient supportive care to AML patients, we believe our results provide reassurance that it can be done safely and with reduced cost to the health care system,” Vaughn said. “However, there are other implications for patients, particularly with regard to their quality of life. While not addressed in our study, most of us would generally assume that the majority of patients prefer the opportunity to recover in their home environment. However, there may be other considerations, including the transference of cost and care burden to the patients and their families. As more and more institutions are considering a move toward implementing this practice, I believe these factors need to be further explored.” – by Anthony SanFilippo
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Mikkael Sekeres, MD, MS
In this highly innovative study by Vaughn and colleagues, the authors do the unthinkable: willingly discharge patient with acute myeloid leukemia undergoing remission induction or salvage chemotherapy, as the blood counts of these patients are still nadiring. Discharged patients were selected for a lack of medical and logistical contraindications, and were able to enjoy a significant percentage of days (61%) out of the hospital. Their outpatient care also resulted in significantly lower average daily charges. The opportunity to be cared for at home — or, more commonly, very frequently in the outpatient clinic — did come at a price, in the form of an almost uniform likelihood of readmission and a higher rate of bacteremia. It should also be noted that the only patients who died early or who were admitted to intensive care units were in the cohort that had been discharged prior to the recovery of their blood counts. So in sum, although early discharge of patients with AML receiving intensive chemotherapy is likely appealing from the standpoint of convenience (to some patients) and costs (for most insurers), it is not yet ready to be considered a standard of care given these safety concerns.
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