title: Inpatient versus outpatient vincristine, dactinomycin, and cyclophosphamide for pediatric cancers: Quality and cost implications.
abstract: BACKGROUND
  Approximately 18% of the United States' gross domestic product is attributed to healthcare expenditures. Several studies have illustrated that shifting healthcare from the inpatient to the outpatient setting is more cost effective, in addition to improving patient satisfaction. Vincristine, dactinomycin, and cyclophosphamide (VAC) are used together to treat children with solid tumors. Our traditional treatment approach included a two day inpatient admission. The purpose of this project was to establish a process for the administration of VAC in the outpatient setting to improve satisfaction, and reduce costs.
  
  
  METHODS
  We aimed to benchmark practice standards with other institutions, revised our treatment approach to permit outpatient administration, and implemented the new protocol in a stepwise manner. We collected caregiver satisfaction metrics through the use of surveys. Costs of encounters were obtained from administrative data. Total costs and costs by service type were compared using descriptive and mean comparisons.
  
  
  RESULTS
  Seven patients received a total of 31 cycles of VAC in the outpatient setting. The time to achieve an appropriate pre-chemotherapy specific gravity was reduced by a median of 120 min. In addition, time spent in the hospital setting was reduced by a mean of 27.2 hr. Adverse effects were minimal and all caregivers reported greater satisfaction with the outpatient regimen. Outpatient administration of VAC was $3,300 less on average compared to the inpatient administration.
  
  
  CONCLUSIONS
  Outpatient VAC provides a safe alternative for administration that reduces healthcare costs, reduces healthcare utilization, and improves patient satisfaction.
authors.affiliation: Department of Pharmacy, Texas Children's Hospital, Houston, Texas.
authors.forename: Rachel S
authors.initials: RS
authors.lastname: Beaty
authors.affiliation: Department of Pharmacy, Texas Children's Hospital, Houston, Texas.
authors.forename: M Brooke
authors.initials: MB
authors.lastname: Bernhardt
authors.affiliation: Department of Pharmacy, Texas Children's Hospital, Houston, Texas.
authors.forename: Amanda H
authors.initials: AH
authors.lastname: Berger
authors.affiliation: Department of Nursing, Texas Children's Hospital, Houston, Texas.
authors.forename: Joy E
authors.initials: JE
authors.lastname: Hesselgrave
authors.affiliation: Department of Pediatrics, Baylor College of Medicine, Houston, Texas.
authors.forename: Heidi V
authors.initials: HV
authors.lastname: Russell
authors.affiliation: Department of Pediatrics, Baylor College of Medicine, Houston, Texas.
authors.forename: M Fatih
authors.initials: MF
authors.lastname: Okcu
mesh_terms: D000293:Adolescent; D000553:Ambulatory Care / Q000191:economics* / Q000592:standards; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000008:administration & dosage / Q000191:economics*; D002648:Child; D002675:Child, Preschool; D003365:Costs and Cost Analysis; D003520:Cyclophosphamide / Q000008:administration & dosage / Q000191:economics; D003609:Dactinomycin / Q000008:administration & dosage / Q000191:economics; D005260:Female; D006801:Humans; D007223:Infant; D007297:Inpatients; D008297:Male; D010045:Outpatients; D011787:Quality of Health Care / Q000191:economics* / Q000592:standards; D014481:United States; D014750:Vincristine / Q000008:administration & dosage / Q000191:economics
chemical_list: D003609:Dactinomycin; D014750:Vincristine; D003520:Cyclophosphamide
keywords: chemotherapy; pediatric oncology; quality of life