FEATURE
while patients in the autologous group spent 52 per-
cent of their days at home. Febrile neutropenia was
the main reason for returning to the clinic.
The researchers found that, overall, patients
treated at home had low rates of infectious complica-
tions, with only four patients developing bloodstream
infections.
Patients reported high quality of life with home-
based HCT, Dr. Sung added. “They were so happy to
be at home and they felt greater freedom,” he said.
“They were able to eat better, exercise better, and
they just felt better overall.”
Dr. Sung also reported that the at-home HCT
model was well received by physicians and caregiv-
ers. “Although outpatient transplant has a lot of
benefits for the patient, it puts a lot of strain on the
caregiver, like having to get patients out of bed and
dressed and to the clinic on time for their appoint-
ments,” Dr. Sung said. “At-home transplant will
have great effects on the caregivers, as well as the
patients.”
Based on the success of the phase I study, the
researchers are now conducting a National Cancer
Institute–funded randomized, phase II trial com-
paring home care versus standard care. The study,
which focuses on patients undergoing allogeneic
HCT, aims to demonstrate that staying in their usual
environment preserves patients’ gut microbiomes
and reduces the incidence of graft-versus-host
disease.
Although there may be higher upfront costs
to the program, Dr. Sung believes that shorten-
ing hospital stays and preventing complications
will have tremendous cost savings for health-care
systems.
Hospice at Home
Palliative-care specialists have long advocated for
earlier integration of palliative services in patients’
care plans, and surveys have revealed that most
patients would prefer dying at home. Still, most
patients with hematologic disorders never make it to
hospice care and often die in the hospital.
As Adam J. Olszewski, MD, and colleagues
found in a review of hospice use among Medicare
beneficiaries with leukemia, dependence on red
blood cell transfusions is a substantial barrier to ac-
cessing palliative or end-of-life services. 9 Fewer than
half (47%) of transfusion-dependent patients were
enrolled in hospice before death, and often just for a
few days.
Home-based models could augment palliative
services for transfusion-dependent patients as they
reach the end of life. Rather than entering a clinic to
receive these services, they could be treated at home.
“Many hospices won’t do transfusion support
from a practical standpoint, because they can’t
handle the cost or the logistics,” said Thomas
LeBlanc, MD, an associate professor of Medicine at
Duke University School of Medicine and co-author
on the study. “They don’t have a way, for example, to
get blood to the person’s home or they don’t feel they
could safely do that.”
Now, to bring more hematology patients the
end-of-life care they need, researchers are exploring
the possibility of offering transfusions at home as
part of hospice care.
Jennifer Holter-Chakrabarty, MD, an associate
professor of medicine at the Stephenson Cancer
Center at the University of Oklahoma and a member
of the ASH Committee on Government Affairs, is
ASHClinicalNews.org
participating in a pilot project studying the effects of
at-home transfusion services on patients’ quality of
life and clinical outcomes.
The study will include 20 patients, half of whom
will receive palliative care as they normally would
(with transfusions in a center according to standard
hospice guidelines) and half of whom will receive
home-based transfusions (either on a weekly sched-
ule, or on an as-needed basis to manage symptoms).
“If we can prove that home-based transfusions
can be done in this setting, I bet we will see a huge
difference in patients’ quality of life,” Dr. Holter-
Chakrabarty said. She also believes this home-based
model may increase the overall number of hematol-
ogy patients who are able to benefit from hospice
services.
“[At-home care for
sickle cell disease]
can be done, but ...
not everybody will fit
the perfect profile of
a patient who would
get IV medication at
home.”
—IFEYINWA OSUNKWO, MD, MPH
The researchers also will need to allay clinicians’
concerns about safety of at-home transfusions:
Transfusion-related reactions can be severe and, with-
out the continual support available in the clinic, these
complications could be problematic for patients.
“I think that the fears about this being a seri-
ous issue are probably overstated,” Dr. LeBlanc said.
“Several groups, mostly out of Europe, have published
results showing that they have implemented home-
based transfusion programs without any significant
problems like that.”
For example, in a 2018 study published in
Transfusion, clinicians operating a Hospital at Home
program in Spain that provided home transfusions
found that, over three decades of existence, the rate
of adverse events was just 2.68 percent. 10
The rate “decreased significantly with time,” the
authors reported, adding that at-home transfusion
was performed “on selected patients by dedicated
Hospital at Home units with well-trained staff, un-
der specific protocols.”
Taking the Long Way Home
Shifting services to the home setting has improved
patients’ quality of life and reduced overall health-
care costs in the management of many diseases, but
the researchers who spoke with ASH Clinical News
acknowledged that it won’t be feasible in all settings
or conditions.
In SCD, for example, opioids have been pre-
scribed to help patients manage painful episodes
without requiring those patients to come to the
hospital. But, in response to the growing opioid
epidemic in the U.S., physicians have become more
conservative with opioid prescribing. According
to Dr. Osunkwo, health-care organizations also are
moving away from providing IV pain medicines
at home, given the concerns about the suitability
of the home environment, accessibility, complica-
tions, and staffing.
Providing at-home treatment may also discourage
patients from taking personal responsibility for their
care. If patients can receive IV fluids at home, Dr.
Osunkwo said, they might be less motivated to drink
fluids on their own.
“It can be done, but I think you have to realize
that not everybody will fit the perfect profile of a
patient who would get IV medication at home,” she
said. The decision to provide at-home treatment
requires a close evaluation of patients’ eligibility for
the intervention, psychosocial makeup, and level of
family or caregiver support.
To solve the issues around accessibility, many
at-home programs rely on telemedicine. It’s often
an effective means of bringing patient and doc-
tor together, regardless of the miles between them.
The challenge, however, lies in getting paid for these
services.
“Insurance companies will pay for telemedicine
services if there is a lack of specialists in a patient’s
county,” Dr. Osunkwo explained. However, she
noted, “if you think about it, there may be hematol-
ogists within a rural county, but no specialists with
SCD expertise.” Proving the need for specialized
SCD care (and reimbursement for that care) remains
a challenge.
At-home programs are positioned to help solve
many problems associated with inpatient hospitaliza-
tions – improving access to care, improving quality
of life, lowering infection risk – but the model has
its problems. Clinicians have expressed concerns
about maintaining continuity of care or treatment
adherence if a home-based program doesn’t include
sufficient monitoring and follow-up.
Health-care systems may be able to save money
on resources, but transitioning to a home-based
model also could make organizations more vulner-
able to malpractice claims or delay reimbursement
for services.
“There is a lot that we can do at home, but what-
ever we do, it needs to be safe,” Dr. Leff concluded.
—By Jill Sederstrom ●
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