High-Dose Chemotherapy With Autologous Stem Cell Rescue in the Outpatient Setting

Three technical developments have facilitated the widespread application of this technology in the community setting. First, increased familiarity with standardized conditioning regimens has made the toxicity of high-dose chemotherapy predictable.[1] Second, the use of cytokine-mobilized peripheral blood stem cells (PBSCs) that contain larger numbers of CD34+ cells, compared to bone marrow autologous grafts, has shortened the period of post-transplant neutropenia.[2,3] Third, the development of effective, standard supportive care measures for the transplant maneuver has permitted patients to be managed in the outpatient setting throughout the administration of their conditioning regimen, as well as during the post-transplant recovery phase. Economic Forces That Support Outpatient Transplants The article by Dix and Geller reviews the technical advances and logistic infrastructure in supportive care that have helped make outpatient transplants possible. Clinical outcomes related to the complications of transplantation appear to be similar when comparing inpatient and outpatient transplant models.[4] A major impetus for the shift toward outpatient transplants is economic—transplant centers negotiate with third-party insurers for global “case-rate” contracts that pay a fixed reimbursement for the transplant procedure.[5] The increasing number of academic and private practice centers that offer transplant services has increased competition for these contracts, leading to decreases in the reimbursement that the transplant center receives from third-party insurers. In order to decrease the cost of caring for patients in the hospital during the transplant maneuver, transplant centers have adapted by delivering some, or all, of their care in the outpatient setting. Successful transplant centers have integrated care across inpatient, outpatient, and in-home settings to preserve optimal clinical outcomes while reducing hospital days. The challenge for the next decade will be to find the appropriate “mix” of these different care settings. The article by Dix and Geller describes three models of outpatient care. In the “early discharge” model, patients are discharged from the inpatient setting at the completion of high-dose chemotherapy. In the “delayed admission” model, patients receive both high-dose conditioning chemotherapy and the autologous transplant in the outpatient setting. Patients are admitted to the hospital if they develop significant mucositis, enteritis, or neutropenic fever. In the “comprehensive outpatient” model championed by the authors, patients are supported throughout the entire transplant maneuver in the outpatient setting. Each model has resulted in decreased hospitalization rates and median lengths of stay, as compared with historical cohorts of patients transplanted and supported throughout the period of neutropenia in the hospital setting.[4,6] The economic consequences of the comprehensive outpatient care model are best illustrated in the authors’ Figure 3. In traditional hospital-based transplant models, 75% of the total revenue from managed care contracts went to the hospital, with 25% of the revenue supporting the costs of outpatient care—a reflection of the relative distribution of resources across inpatient and outpatient settings.[4] In the model described by Dix and Geller, hospital charges for inpatient care comprised only 4% of the total cost, with all hospital-related charges comprising only 20% of the total. In a study by Rizzo et al, 17 patients undergoing a transplant incurred only 29% of their charges in an