OUT-PATIENT INTENSIVE CHEMOTHERAPY FOR ACUTE LEUKEMIA: A STUDY SHOWING A SAFE AND COSTEFFECTIVE MODEL OF CARE AT THE LEEDS CANCER CENTER.

Abstract

Background In our centre, delivery of intensive chemotherapy for patients with acute leukemia and post chemotherapy monitoring has been increasingly provided in an outpatient setting since 2013. Our ambulatory pathway was developed due to the increasing scale and complexity of new hematological therapies, which has placed a premium upon the use and availability of inpatient beds and staffing resources. The first cycle of induction chemotherapy remains inpatient only. If this is well tolerated, subsequent cycles are given in an outpatient setting to appropriate patients with daily monitoring in our ambulatory care unit. Patients require admission only when unwell and receive daily blood tests and in-person reviews until blood count recovery. Patients are advised to contact our 24-hour emergency helpline if they have a fever or feel unwell; they must live within a 30-minute commute or stay in our patient hotel to ensure prompt review and treatment. Aims The purpose of the study is to assess the safety of outpatient monitoring post intensive chemotherapy for patients second and subsequent cycles of chemotherapy as well as to assess the financial impact of less inpatient bed days. Methods Data was collected for 353 patients receiving 1010 cycles of intensive chemotherapy for either acute myeloid leukemia (AML) or acute lymphoblastic leukemia (ALL) since 2013. Results Since 2013, 414 cycles (41%) of chemotherapy have been given as an outpatient. 152/414 (37%) cycles of outpatient chemotherapy (OPC) were managed solely via ambulatory care. Of the remaining 262 cycles which required admission at some point, 144 patients were admitted for routine neutropenic monitoring. Prior to 2021 we routinely admitted patients when the neutrophil count fell below 0.5x109/l, however this is no longer our practice based upon lack of benefit. Fever and/or suspected infection were the most common reason for acute admissions; 101 patients were admitted for this reason. Patients having OPC required less treatment dose antibiotics and antifungals during their recovery post chemotherapy with a mean of 5.7 days of antibiotics and 0.9 days of treatment dose antifungals, compared to a mean of 13.8 days of antibiotics and 2.3 days of treatment dose antifungals for those receiving inpatient chemotherapy. This data was not available in 284/1010 cycles as they were prior to electronic records. There were a total of 33 deaths, 10 of which were patients having received OPC. In all 10 cases, patients had been admitted for treatment of infection and no deaths occurred within 24 hours of OPC. In total over 11 years, we have saved 8968 inpatient overnight stays using OPC and ambulatory monitoring. We estimate that this will have saved the trust ,260,539 (using Guest et al, BMJ Open 2020;10:e033367) since 2013. During the last financial year, 1399 inpatient overnight stays were avoided saving820,639. Summary/Conclusion Overall, this model of care allows us to provide safe and effective chemotherapy and monitoring as an outpatient. Our patients can stay at home or in our hotel, requiring admission only if unwell, leading to substantial improvements in quality of life whilst undergoing treatment, and require less treatment dose antibiotics and antifungals compared to inpatients. There is also a significant financial gain to the department from reducing the number of inpatient bed days required, freeing up scarce resources for the benefit of other patients.