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					        Can Stem Cell Transplants be
         performed in Out-patient
                 Setting?


Patrick J. Stiff M.D., M. Parthasarathy M.S. MT,SBB, P. Mumby PhD,
A.Toor M.D, T. Rodriguez M.D., S. Wojtowicz R.N.,OCN,
S. Zakrzewski R.N.,   R. Batiste APN,   K. Kiley APN,   N. Porter APN,
K. Potocki APN,   M.Volle APN,     S.Williams R.N., C. Shipp BSN,HP
B. Buturusis M.S. MBA, N. Mohideen M.D., S. Lichtenstein M.S.
    Opportunity Statement
Loyola’s BMT program is growing @ 15%
/yr, creating a back log of patients waiting
for potentially curative therapy. This delay
in starting treatment decreases their
chances for cure or may cause the relapse of
disease.

This delay caused dissatisfaction for
patients and their referring physicians and
may result in potential patients seeking
treatment elsewhere.
      Desired Outcome
• To decrease cost of transplants for the
  institution and patients
• To improve patient satisfaction and quality
  of life
• To decrease the waiting time for transplant
• To increase the capacity to perform more
  allogeneic transplant by moving
  autotransplants to out patient setting
• To make the program more attractive to
  payors in the competitive Chicago market
      Most likely causes for
       Current Opportunity
   Lack of space for additional patient rooms
    in BMT (inpatient) Unit to accommodate
    growth in referrals
   Some patients prefer out-patient over in-
    patient care
   Other National centers have started out-
    patient BMT programs
   We wish to continue our Stature of the #1
    BMT program in Illinois.
      Solutions Implemented
To accommodate the growing program and
  increased demand for beds:
   We expanded the transplant program to the out
    patient setting
   Chose Autologous Transplants for this pilot program
    because the mortality rate is low (1-2%)
   Built a uniquely designed 13-bed outpatient
    transplant unit / Stem Cell Collection facility
   Developed the new out-patient Protocol and built the
    team to perform out-patient Autologous transplants
   Established coordination of Homecare at night by
    providing better education to patients and care givers
        Solutions Implemented
              (continued)
   Improvements were made in medical supportive
    care for infection control, pain management and
    anti-emetic medications.
   Psychological assessment and follow up was
    added to the existing social & spiritual support
    for the transplant program, including various
    aspects of quality of life
   Patients were provided with options for nearby
    temporary housing by negotiating contracts with
    local hotels
   Efforts are made through social worker to provide
    economic and housing assistance to needy families
      Results and Analysis
   In 3 yr period 100 TBI based autotransplants
    were performed in out-patient unit, with a
    total of 212 auto transplants by the end of
    2002
   Results were compared to the 32 TBI based in-
    patient Auto transplants performed in the
    same time period
   The program was successful with 0%
    mortality rate and 72% never required a
    hospital stay despite a week of 0.0 Neutrophil
    count.
   Waiting period for transplant has been
    decreased by 4 to 6 weeks
      Results and Analysis
   Out-patients are equivalent to inpatients with
    regard to:
               Engraftment
               Timely completion of transplant
               30 and 100 day mortality
   Quality of life scores in our patients were
    comparable to published results from inpatient
    samples
   Psychological distress in our sample was slightly
    better than some reports in BMT literature
   Patients were more active and satisfaction
    improved
   Data for CY 2002 alone show an actual cost savings
    of $550,000 for 35 out-patient transplants ($16,000
    savings per transplant)
      Results and Analysis
            Autologous Transplants
            Out patient     In Patient
60



40



20



0
     1999        2000     2001       2002
       Results and Analysis

        Autologous Transplants     TBI   Non- TBI

40




20




0
     1999     2000    2001       2002
 Survival 4 yr follow up: Out-Patient vs In-
                    Patient
                                               Surv iv al: Out-Patient v s In-Patient

                       100



                       80
       Percent Alive




                       60



                       40                         Log-Rank Statistic= 4.842 df= 1 p= 0.0278



                       20
                                    Out-Patient
                                    In-Patient

                        0

                            0         10                    20                30              40
Out-Pa ti en t:(n = )       (86 )      (58 )                (38 )             (25 )           (10 )
 In-Pati e nt:(n= )         (28 )      (25 )                (10 )              (8)            (3)


                                                         Months
100 days Survival: Out-Patient vs In-Patient
                  100 Day Survival
   1.0



    .8



    .6



    .4

                                                 In-patient

    .2
                                                 Out-patient

   0.0
         0   20    40    60    80    100   120

                        Days
                       Conclusions
•   Quality care can be provided at a reduced cost (40%)
•   We provided care in the out-patient setting that was
    comparable to the in-patient BMTU, at a substantial savings
    for the Medical Center
•   Quality of life analysis demonstrated that participants not
    only did well but suffered no increased stress associated with
    out-patient transplant
                       Future Directions
•   A new protocol for Allogeneic non-myelo ablative transplants in
    the out-patient unit has started based on these findings
•   In addition to psychosocial support for patients, a support group
    will be offered to the care givers in the out patient setting
•   More accurate data on Quality of Life for care givers will be
    collected under an IRB approved protocol for pre and post
    transplant period

				
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