Total Outpatient Program Cuts Transplant Cost

LUXEMBOURG-In an effort to beat the skyrocketing costs of high-dosechemotherapy and transplantation, physicians at the Scripps Clinic,La Jolla, Calif, have launched a total outpatient therapy programthat attempts to eliminate expensive hospital admissions.

"There is no question that high costs are a major impedimentto the widespread use of transplantation," said Barry Meisenberg,MD, at the 7th International Symposium of the Multinational Associationof Supportive Care in Cancer.

He emphasized that outpatient chemotherapy with stem-cell support,followed by prophylactic antibiotics and daily outpatient visits,can safely trim as much as 40% off bills that traditionally runbetween $100,000 and $150,000.

The Scripps Clinic approach was modeled after a program that originatedat Duke University Medical School in 1992, but with several importantdifferences, said Dr. Meisenberg, director of the Bone MarrowTransplant Program at Scripps.

Patients at Duke receive their high-dose chemotherapy as inpatientsand are then discharged for outpatient supportive care. Afteremploying this so-called subtotal outpatient strategy in 84 patients,Scripps oncologists inaugurated their total outpatient program,in which patients undergo high-dose chemotherapy and follow-upas outpatients.

To accomplish this, Dr. Meisenberg's group modified their chemotherapyregimens to exclude drugs that necessitate continuous bladderirrigation, hyperhy-dration, and hourly monitoring of fluid inputand output. In addition, while Duke physicians combine bone marrowtransplants with stem-cell reinfusion, the Scripps team uses peripheralblood stem cells only.

Finally, the Duke program has been limited to women with breastcancer treated with cisplatin (Platinol), cyclophosphamide (Cytoxan,Neosar), and carmustine (BiCNU), while Scripps has expanded theconcept to include patients with other solid tumors, non-Hodgkin'slymphoma, and multiple myeloma, who undergo treatment with a varietyof intensive regimens.

Prerequisites for a total outpatient program, Dr. Meisenberg noted,include a motivated patient and home caregiver, the briefest possibleperiod of pancyto-penia, an informed nursing staff, successfulcontrol of nausea and vomiting, access to infusion pumps for fluids,and effective antibiotic prophylaxis. "One can deliver supportivecare in an outpatient setting as long as you are prepared for7-day-a-week follow-up and have a plan for nighttime problems,"he said.

Prior to chemotherapy, Scripps patients are premedicated withlorazepam, diphenhydramine, and prochlorperazine, and then, throughoutchemotherapy, they receive a continuous infusion of antieme-ticsdelivered by an ambulatory pump. The day after completing chemotherapy,patients begin antibiotic prophylaxis with ciprofloxacin (Cipro)plus rifampin.

Patients are required to visit the hospital daily for a completephysical examination, complete blood count, and chemistry panel,while caregivers are asked to keep a diary that monitors vitalsigns, oral input, urine and stool output, medication schedule,and number and severity of emetic episodes.

Should fever develop, vancomycin and tobramycin are added to theciprofloxacin regimen, and cytokines are given routinely afterstem-cell reinfusion. Fever coupled with either mucositis or hypo-tensionrepresents grounds for hospital admission, Dr. Meisenberg said,but uncomplicated fever does not.

"Complete elimination of bacteremia is what we are after,"he said, observing that while two thirds of patients in the Scrippsoutpatient program have experienced neutropenic fever, only 2%have had clinically documented infections, and none have developedbacteremia.

Of the 40 patients who have completed total outpatient therapyat the Scripps Clinic since February, 1995, three quarters neverrequired hospital admission, he noted. Overall, these patientsaveraged 2.8 days of hospitalization, in contrast to an 18-dayaverage for patients who opted for traditional inpatient treatment,and an 8-day average for patients who underwent subtotal outpatientcare. Most important, treatment-related mortality was less than1%.

"This can be done safely in the great majority of patientsand has a high acceptability among patients. The lower costs allowmore patients to receive high-dose chemotherapy than would otherwisebe the case," he commented.