Editor ’ s Corner
Shouts & Mumblings : A Transplant in Every Kitchen
“ Patients with various blood-related cancers … receive transplants of bone marrow and peripheral blood stem cells to restore stem cells that were destroyed by high doses of chemotherapy or radiation therapy or both . After being treated with anti-cancer drugs or radiation , the patient receives the harvested stem cells , which travel to the bone marrow and begin to produce new blood cells . Stem cell transplantation is not on the Centers for Medicare & Medicaid Services ’ ( CMS ) list of inpatient-only procedures , and according to an independent medical review contractor , stem cell transplantation is routinely performed as an outpatient procedure .”
— 2016 report from the U . S . Department of Health and Human Services ’ ( HHS ) Office of Inspector General , “ Medicare Did Not Pay Selected Inpatient Claims for Bone Marrow and Stem Cell Transplant Procedures in Accordance with Medicare Requirements ( A-09-14- 02037 )”; HHS and Centers for Medicare & Medicaid Services , MLN Matters Number SE1624 , May 1 , 2017 .
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The content of the Editor ’ s Corner is the opinion of the author and does not represent the official position of the American Society of Hematology unless so stated .
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MS HAS GONE ON A hiring rampage of late , seeking independent medical review contractors who can identify interventions that have been performed unnecessarily within the highly technical and sterile confines of large , tertiary-care hospitals . These medical review contractors – for whom a health-care background is optional – have been applauded for their innovative approaches to deconstructing medical procedures into their elemental components . They make these procedures sound safer and , thus , better-suited to the outpatient or medical home setting .
Here are their recommendations for health-care practices that are expected to routinely relocate to home-care environments in the near future .
Allogeneic Hematopoietic Cell Transplantation Here ’ s what you ’ ll need : Some bone marrow cells , which are basically like soupy Kool-Aid and can be delivered to the home using a service such as UberRUSH ; an intravenous line , which even an emergency medical services worker can place in a variety of settings ( such as a community soccer field when a parent feels faint after his 8-year-old has a nice assist ); and some breath mints to mitigate that “ not-so-fresh ” preservative taste as the cells infuse . The procedure can be performed by a visiting nurse as the patient sits in a chair near the kitchen table , followed by instructions for the patient to call the general home health-care number in the event of a fever within 48 hours , but only between the hours of 8 a . m . and 4 p . m ., Monday through Friday . One followup visit from the nurse and one visit from a physical therapist , to be scheduled as needed . Free “ You , Too , Can Diagnose Graft- Versus-Host Disease !” pamphlet to be provided .
Cardiac Transplantation The heart is basically a muscle , and a New York Heart Association class IV heart failure is like having a slight muscle pull , as might occur when running down the soccer field for an assist , except you have to replace the muscle . This can be performed in a patient ’ s living room , on a couch or La-Z-Boy recliner , using a 3-inch paring knife , a clean washcloth , and a sewing kit ( which can be obtained at no cost from the bathroom of a moderately priced hotel within the Fairmont or Hilton hotel chains ). The donor heart should be transported to the recipient ’ s house via UPS 3-Day Select shipping , so the patient will need a companion who can sign for the package . The box will also include a manual with aesthetically pleasing diagrams that indicate how to remove and replace the impaired organ ( similar to the assembly instructions for the Ikea Godmorgon bathroom sink cabinet with 4 drawers ) – along with an Allen wrench .
Hip , Knee , Joint NOS Repair / Replacement , Right or Left Similar to the previously mentioned procedure for cardiac transplantation , but following assembly instructions for the Ikea Förhöja wall cabinet / writing board .
Separation of Conjoined Twins Home births are ubiquitous , particularly in underserved parts of the world without basic health care . We project that
Mikkael A . Sekeres , MD , MS , is director of the Leukemia Program at the Cleveland Clinic in Cleveland , OH .
these will become widespread in the United States within 6 months of adoption of our mind-numbingly obvious recommendations . In the rare case of complicated births of identical twins joined in utero , we recommend laying the twins in their crib and applying gentle pressure to each twin simultaneously , if separation is desired .
Therapeutic Plasma Exchange for Thrombotic Thrombocytopenic Purpura This one is a doozy to even say , so we considered removing it altogether from coverage . But , in response to decades of complaints from hematology fellows being called to the hospital in the middle of the night to evaluate patients for suspected thrombotic thrombocytopenic purpura ( TTP ) – when those patients had platelet counts of 148,000 /µ L and were able to correctly answer only two out of three “ orientation ” questions – we now provide an easy , at-home alternative . After the patient is diagnosed with TTP by a qualified emergency room physician , he or she should be discharged to his or her place of residence , with planned follow-up by a visiting nurse within 48 hours . In the meantime , a family member can obtain a refrigerator water supply line and rent a 6,500-watt Honda power generator ( model number : EG6500CLAT ) from their local Home Depot for groin line and plasma exchange purposes , respectively . The intervention can be performed in the patient ’ s bathtub , with 1-month follow-up scheduled with the patient ’ s primary-care doctor , as needed .
Patients insisting on having any of the above medical procedures completed in a hospital setting may have to pay out-ofpocket expenses for any and all components , even with supplemental insurance coverage , and will incur additional facility fees .
Mikkael Sekeres , MD , MS Editor-in-Chief
12 ASH Clinical News July 2017 Bonus Mid-Year Edition