Transcript document

Can Stem Cell Transplants be
performed in Out-patient Setting?
Patrick J. Stiff M.D., M. Parthasarathy M.S. MT,SBB, P. Mumby PhD,
A.Toor M.D, T. Rodriguez M.D., S. Wojtowicz R.N.,OCN,
S. Zakrzewski R.N.,
K. Potocki APN,
R. Batiste APN,
M.Volle APN,
K. Kiley APN,
N. Porter APN,
S.Williams R.N., C. Shipp BSN,HP
B. Buturusis M.S. MBA, N. Mohideen M.D., S. Lichtenstein M.S.
Opportunity Statement
Loyola’s BMT program is growing @ 15%
/yr, creating a back log of patients waiting
for potentially curative therapy. This delay
in starting treatment decreases their
chances for cure or may cause the relapse of
disease.
This delay caused dissatisfaction for
patients and their referring physicians and
may result in potential patients seeking
treatment elsewhere.
Desired Outcome
• To decrease cost of transplants for the
institution and patients
• To improve patient satisfaction and quality
of life
• To decrease the waiting time for transplant
• To increase the capacity to perform more
allogeneic transplant by moving
autotransplants to out patient setting
• To make the program more attractive to
payors in the competitive Chicago market
Most likely causes for Current
Opportunity
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Lack of space for additional patient rooms
in BMT (inpatient) Unit to accommodate
growth in referrals
Some patients prefer out-patient over inpatient care
Other National centers have started outpatient BMT programs
We wish to continue our Stature of the #1
BMT program in Illinois.
Solutions Implemented
To accommodate the growing program and
increased demand for beds:
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We expanded the transplant program to the out
patient setting
Chose Autologous Transplants for this pilot program
because the mortality rate is low (1-2%)
Built a uniquely designed 13-bed outpatient
transplant unit / Stem Cell Collection facility
Developed the new out-patient Protocol and built the
team to perform out-patient Autologous transplants
Established coordination of Homecare at night by
providing better education to patients and care givers
Solutions Implemented (continued)
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Improvements were made in medical supportive
care for infection control, pain management and
anti-emetic medications.
Psychological assessment and follow up was
added to the existing social & spiritual support
for the transplant program, including various
aspects of quality of life
Patients were provided with options for nearby
temporary housing by negotiating contracts with
local hotels
Efforts are made through social worker to provide
economic and housing assistance to needy families
Results and Analysis
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In 3 yr period 100 TBI based autotransplants
were performed in out-patient unit, with a
total of 212 auto transplants by the end of
2002
Results were compared to the 32 TBI based inpatient Auto transplants performed in the
same time period
The program was successful with 0%
mortality rate and 72% never required a
hospital stay despite a week of 0.0 Neutrophil
count.
Waiting period for transplant has been
decreased by 4 to 6 weeks
Results and Analysis
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Out-patients are equivalent to inpatients with
regard to:
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Engraftment
Timely completion of transplant
30 and 100 day mortality
Quality of life scores in our patients were
comparable to published results from inpatient
samples
Psychological distress in our sample was slightly
better than some reports in BMT literature
Patients were more active and satisfaction
improved
Data for CY 2002 alone show an actual cost savings
of $550,000 for 35 out-patient transplants ($16,000
savings per transplant)
Results and Analysis
Autologous Transplants
Out patient
In Patient
60
40
20
0
1999
2000
2001
2002
Results and Analysis
Autologous Transplants
TBI
40
20
0
1999
2000
2001
2002
Non- TBI
Survival 4 yr follow up: Out-Patient vs In-Patient
Survival: Out-Patient vs In-Patient
100
Percent Alive
80
60
40
Log-Rank Statistic= 4.842 df= 1 p= 0.0278
20
Out-Patient
In-Patient
0
0
10
20
30
40
Out-P atient:(n= )
(86)
(58)
(38)
(25)
(10)
In-P atient:(n= )
(28)
(25)
(10)
(8)
(3)
Months
100 days Survival: Out-Patient vs In-Patient
100 Day Survival
1.0
.8
.6
.4
In-patient
.2
Out-patient
0.0
0
20
40
60
Days
80
100
120
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Conclusions
Quality care can be provided at a reduced cost (40%)
We provided care in the out-patient setting that was
comparable to the in-patient BMTU, at a substantial savings
for the Medical Center
Quality of life analysis demonstrated that participants not
only did well but suffered no increased stress associated with
out-patient transplant
Future Directions
A new protocol for Allogeneic non-myelo ablative transplants in
the out-patient unit has started based on these findings
In addition to psychosocial support for patients, a support group
will be offered to the care givers in the out patient setting
More accurate data on Quality of Life for care givers will be
collected under an IRB approved protocol for pre and post
transplant period