Outpatient-Based BMT Cuts Costs in Hematologic Cancer

SAN DIEGO—A continuum of inpatient-outpatient care (IPOP) for adult patients with hematologic malignancies undergoing bone marrow transplant (BMT) lowered costs to insurers by 7.1% without significantly shifting costs to patients in a study from Johns Hopkins.

Moreover, the program of enhanced outpatient care proved to be as safe as traditional inpatient BMT, reported J. Douglas Rizzo, MD, at the 39th Annual Meeting of the American Society of Hematology.

Of 115 BMT patients (allogeneic and autologous) in the study, 14 were enrolled in the IPOP group. Eligibility for IPOP included ability to speak English, availability of a caregiver, lack of major comorbidity, and insurance approval, said Dr. Rizzo, a fellow in the Robert Wood Johnson Clinical Scholars Program at Johns Hopkins. IPOP patients were slightly younger (mean, 46 vs 40 years) but otherwise similar to those in the inpatient group.

The outpatient-based program provided intensive ambulatory support to patients from induction through count recovery, including outpatient management of complications.

When not on site receiving care, IPOP patients and their caregivers lived in a local hotel facility, through an arrangement contracted by the hospital and covered by a living allowance included in the hospitalization costs.

As expected, the IPOP group spent a significantly lower mean number of days in the hospital (22 vs 46.8) and had markedly lower mean inpatient hospital charges ($61,000 less per patient).

However, IPOP patients spent an average of 21.6 days receiving intensive ambulatory care in a special outpatient facility, leading to substantially greater outpatient charges (nearly $50,000 more than incurred by the traditional inpatient-based group). These outpatient charges offset all but about $11,000 of the inpatient cost savings.

In a subgroup analysis, the investigators found a 34% decrease in charges to payers for standard-risk patients in the IPOP program, compared with those receiving traditional inpatient care. However, there was no decrease in charges to payers for high-risk patients in the IPOP program.

“Importantly,” Dr. Rizzo commented, “there was no cost shifting to patients.” Direct nonmedical costs and indirect medical costs were estimated by surveying patients who survived at least 1 year after BMT (51 of 70 survivors responded to the survey).

The survey found no significant differences between the two groups in terms of out-of-pocket expenses for transportation, lodging, meals, home nursing, household assistance, child care, or medication. Furthermore, survivor reports revealed no differences in lost income, involuntary retirement or unemployment, or length of disability.

The frequency of major clinical complications, including mechanical ventilation, dialysis, and acute graft-vs-host disease, was similar in the two groups. Mortality rates at 1 year were lower in the IPOP group, but the difference was not statistically significant.

Study accrual was limited by payer concerns, Dr. Rizzo noted. “We anticipated much greater participation in the IPOP program, but found that payers were reluctant to allow patients to enroll for various reasons, including the living allowance.” Other limitations of the study included the small number of patients, particularly in the IPOP group, and the fact that the out-of-pocket cost study was limited to 1-year survivors.

Obstacles to Outpatient Care

A study from H. Lee Moffitt Cancer Center and Research Institute at the University of South Florida, Tampa, found several unanticipated obstacles to high-dose chemotherapy and peripheral blood stem cell rescue in the outpatient setting.

Of the first 75 consecutive patients considered for such treatment in this study, only 18 (24%) were deemed eligible for outpatient transplant. Obstacles included psychological factors (29%), patient refusal (13%), complex medical history (9%), lack of caregiver (12%), and financial limits (12%).

“I think this issue is regional and probably depends on the particular institution,” said Neeraj Sharma, MD, of H. Lee Moffitt, who presented the study at the ASH meeting. “I also think that the psychological barrier—largely, the anxiety factor—has more to do with lack of adequate patient education. As we develop a track record and patients see that this approach can be successful, I think this will become less of an issue.”