Resource Utilization and Safety of Outpatient Management Following Intensive Induction or Salvage Chemotherapy for Acute Myeloid Leukemia or Myelodysplastic Syndrome: A Nonrandomized Clinical Comparative Analysis.
OBJECTIVE
Adults with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) typically remain hospitalized after induction or salvage chemotherapy until blood cell count recovery, with resulting prolonged inpatient stays being a primary driver of health care costs. Pilot studies suggest that outpatient management following chemotherapy might be safe and could reduce costs for these patients.


OBJECTIVE
To compare safety, resource utilization, infections, and costs between adults discharged early following AML or MDS induction or salvage chemotherapy and inpatient controls.


METHODS
Nonrandomized, phase 2, single-center study conducted at the University of Washington Medical Center. Over a 43-month period (January 1, 2011, through July 31, 2014), 178 adults receiving intensive AML or MDS chemotherapy were enrolled. After completion of chemotherapy, 107 patients met predesignated medical and logistical criteria for early discharge, while 29 met medical criteria only and served as inpatient controls.


METHODS
Early-discharge patients were released from the hospital at the completion of chemotherapy, and supportive care was provided in the outpatient setting until blood cell count recovery (median, 21 days; range, 2-45 days). Controls received inpatient supportive care (median, 16 days; range, 3-42 days).


METHODS
We analyzed differences in early mortality, resource utilization including intensive care unit (ICU) days, transfusions per study day, and use of intravenous (IV) antibiotics per study day), numbers of infections, and total and inpatient charges per study day among early-discharge patients vs controls.


RESULTS
Four of the 107 early-discharge patients and none of the 29 control patients died within 30 days of enrollment (P=.58). Nine early-discharge patients (8%) but no controls required ICU-level care (P=.20). No differences were noted in the median daily number of transfused red blood cell units (0.27 vs 0.29; P=.55) or number of transfused platelet units (0.26 vs 0.29; P=.31). Early-discharge patients had more positive blood cultures (37 [35%] vs 4 [14%]; P=.04) but required fewer IV antibiotic days per study day (0.48 vs 0.71; P=.01). Overall, daily charges among early-discharge patients were significantly lower than for inpatients (median, $3840 vs $5852; P<.001) despite increased charges per inpatient day when readmitted (median, $7405 vs $5852; P<.001).


CONCLUSIONS
Early discharge following intensive AML or MDS chemotherapy can reduce costs and use of IV antibiotics, but attention should be paid to complications that may occur in the outpatient setting.
Hematology/Oncology Fellowship Program, University of Washington, Seattle2Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington3now with Blue Ridge Cancer Care, Department of Medicine, Virginia Tech Carilion School of Med.
Jennifer E
JE
Vaughn
Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.
Megan
M
Othus
Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.
Morgan A
MA
Powell
Seattle Cancer Care Alliance, Seattle, Washington.
Kelda M
KM
Gardner
Seattle Cancer Care Alliance, Seattle, Washington.
Donelle L
DL
Rizzuto
Division of Hematology, Department of Medicine, University of Washington, Seattle.
Paul C
PC
Hendrie
Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington6Division of Hematology, Department of Medicine, University of Washington, Seattle.
Pamela S
PS
Becker
Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle.
Paul S
PS
Pottinger
Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington6Division of Hematology, Department of Medicine, University of Washington, Seattle.
Elihu H
EH
Estey
Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington6Division of Hematology, Department of Medicine, University of Washington, Seattle8Department of Epidemiology, University of Washington, Seattle.
Roland B
RB
Walter
D061605:Administration, Intravenous; D000328:Adult; D000368:Aged; D000553:Ambulatory Care / Q000191:economics / Q000706:statistics & numerical data*; D000900:Anti-Bacterial Agents / Q000008:administration & dosage; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use*; D001803:Blood Transfusion / Q000706:statistics & numerical data; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D003422:Critical Care / Q000706:statistics & numerical data; D016527:Drug Costs; D005260:Female; D006295:Health Resources / Q000191:economics / Q000706:statistics & numerical data*; D017721:Hospital Costs; D006801:Humans; D060828:Induction Chemotherapy / Q000009:adverse effects / Q000191:economics / Q000706:statistics & numerical data*; D007902:Length of Stay; D015470:Leukemia, Myeloid, Acute / Q000175:diagnosis / Q000188:drug therapy* / Q000191:economics / Q000401:mortality; D008297:Male; D008875:Middle Aged; D009190:Myelodysplastic Syndromes / Q000175:diagnosis / Q000188:drug therapy* / Q000191:economics / Q000401:mortality; D009894:Opportunistic Infections / Q000188:drug therapy / Q000382:microbiology; D010351:Patient Discharge / Q000191:economics; D010359:Patient Readmission; D016879:Salvage Therapy / Q000009:adverse effects / Q000191:economics / Q000706:statistics & numerical data*; D013997:Time Factors; D016896:Treatment Outcome; D014861:Washington; D055815:Young Adult
D000900:Anti-Bacterial Agents