Inpatient or Outpatient Consolidation Therapy: Which is Better?| Leora Boussi, MD | #ASH24

Hi, my name is Leora Boussi, I'm a fellow at Memorial Sloan-Kettering in New York. And thank you so much to Healthtree for having me to talk a little bit more about our project entitled Outpatient versus Inpatient Hidac Consolidation for AML: The MSKCC experience, on behalf of all of my coauthors and all the patients who were involved in this study.

So just to give you a little bit of background, so sort of standard management for fit patients with AML, is intensive chemotherapy followed by something called consolidation with high dose cytarabine, also known as Hidac, and historically Hidac has been administered in the inpatient setting. So inside the hospital, and some of the reasons for that are sort of prolonged low blood counts, infection risks that can come in that context.

Transfusion needs, supportive care needs and also sort of logistical challenges of administering chemotherapy in the outpatient setting. However, there's been sort of improvements in, antibody orthotic prevention medicines for patients going through chemotherapy. There are some concerns about getting infections in the hospital itself and also sort of the increasing financial burden associated with, hospitalization for chemotherapy.

All of those things have kind of, raised the question of can we treat our patients with chemotherapy, in the outpatient setting. And in the case of our project, specifically looking at hidac and there's sort of limited data to guide that decision making process. Which led us to, look back, at all of the patients we have treated with hidac at our center between 2014 and 2023, and to analyze the different, demographic features, clinical features, and sort of compare those two groups to get a better idea of this question.

And so in terms of sort of the baseline characteristics of the two groups, we had 198 patients who received hidac during that time with, at Sloan Kettering, and 59 of them received their chemotherapy in the hospital, and 139 of them received it, outside the hospital. So on the outpatient basis, and, the group that got it inpatient was a little bit older.

They had a median age of 64 compared to 57 in the outpatient group, and they had slightly higher performance scores, meaning their, their functional status or their physical capabilities were, a little bit better in the group that got it outpatient. And otherwise all their characteristics were pretty similar, their disease, qualities and risks, how many cycles they got, what year they got, treatment, things like that were all pretty similar across the two groups.

And so the first thing we wanted to look at was how many days per cycle of hidac, Because it's patients usually receive a number of cycles at this treatment, where patients spending time in hospital. And so, we found that the inpatient group was spending a median of 7.5 days per cycle in the hospital, and the outpatient group was spending 0.8 days per cycle in the hospital.

So that was sort of a significant difference between those two groups. And then, you know, we wanted to look at what are sort of the toxicities or the bad things, the things we struggle with on chemotherapy were those enriched were those happening more frequently in the outpatient group to a worse degree. One thing we looked at was febrile neutropenia.

So developing a fever when your blood counts are low and the incidence of that. And we actually found that the incidence was similar between the two groups over the course of the cycles. We also looked at things like major bleeding, admission to the intensive care unit and, dying deaths during treatment, which is very, very rare but can on rare occasions occur.

And we found the rates of those things were similar between the inpatient and outpatient treated groups. And, you know, in addition to sort of the short term toxicities, we also want to look at longer term outcomes. So is survival comparable. Are people having earlier relapses if they're getting treated outpatient. Which we wouldn't expect, but kind of wanted to show that that wasn't the case.

And we found that, at two years, the rate of relapse free survival and overall survival were similar, comparable between the two groups. So no statistically significant difference there. And lastly, we were interested in looking at what are the ramifications in terms of cost, because of course, being in the hospital in terms of, cost to the patient, cost to the health care system at large is something we need to consider, especially in this day and age.

So, what we found using sort of published metrics of, costs for the individual components of a hidac consolidation cycle. We sort of took those numbers and added up all of the times patients were being seen in the lab, being seen in clinic, spending time in the hospital getting chemotherapy, either in the hospital or outside the hospital.

And we found that, for a cycle of consolidation and inpatient, it was going to cost about $37,000, roughly. Whereas for, you know, a cycle of chemotherapy outpatient, it was closer to $13,000. So that's a that was a substantial difference. And that's not necessarily money that a patient is paying directly, but these are sort of, based on, Medicare fees and reimbursements and numbers that we pulled from, you know, published sources that, you know, were reasonable estimates of these interventions.

So that's obviously a major thing. And what we were kind of able to conclude from all of this was that outpatient administration of hidac consolidation is, safe and cost effective. You know, compared to inpatient, which is, you know, associated with longer time in the hospital and higher costs, and that, you know, when looking at things like that, we worry about like febrile neutropenia or those fevers when your counts or your white blood cell counts are low, major bleeding, ICU admission, death during treatment.

All of these things weren’t comparable between the two groups. So we weren't really seeing a major downside to doing the strategy. And that's pretty much the work in a nutshell.

I think we would hope that, you know, the standard of care at our center up until 2014 was to do it in the hospital. Since 2014, we've tried to mostly do things in the outpatient setting. And, you know, it's at the discretion of the treating, doctor, whether that happens or not. You know, if you have somebody who's maybe a little bit older or, you're worried about how they're going to do at home, maybe they don't.

They live alone or they don't have family with them to help them at home. That might be someone who's still, There might also going to be instances where doing it in the hospital makes sense. And I would say the other challenge with this approach is it relies on, you know, having the patient having having a caregiver at home.

You know, having nursing staff and nurse escort to help, you know, with the with checking in on the patients and things like that when they're having these things done at home. So I think there are still going to be some instances where doing it in the hospital. Make sense? But I think based on the data that we have, I think the goal would be to make this a more widespread approach.

Thanks so much again to Healthtree for having me to talk about this. I just like to shout out the other coauthors who worked on this project with me, for all their support and contribution. So, Hannah Burton, Andriy Derkach, David Nemirovsky, Jenna Ciervo, Eytan Stein, Sheng Cai, Martin Tallman, all sort of, you know, made such significant contributions.

And, we're really excited about the next steps of this work.