Shifting certain elements of oncology care from outpatient clinics to a patient’s home proved safe and feasible, and most patients preferred it, according to a recent study conducted in Belgium.
Specifically, almost 90% of patients said they were “highly satisfied” with the oncologic home hospitalization (OHH) model — which included administering subcutaneous cancer drugs in the home (full OHH) and providing nursing assessments prior to therapy (partial OHH) — and close to 80% reported an improvement in their quality of life compared to standard ambulatory cancer care.
The study, published in November in JCO Global Oncology, adds to a growing literature evaluating the safety, feasibility, and potential quality-of-life benefits associated with providing cancer care at home.
Although this program has only been evaluated at the project level, given the findings, “it is likely to be implemented as standard of care after the project is completed,” study author Koen Van Eygen, MD, of the Cancer Centre, General Hospital Groeninge, Kortrijk, Belgium, told Medscape Medical News.
While many countries have implemented elements of an oncology-at-home model, the United States has been slower to make this shift, particularly when it comes to delivering chemotherapy at home, given safety, feasibility, and cost concerns.
“Historically, the home has not been considered a site for cancer care, so it is really paradigm changing to see delivery models that include in their continuum home care,” said Kathi Mooney, PhD, RN, FAAN, distinguished professor at the University of Utah College of Nursing, Salt Lake City. Mooney runs a program at the Huntsman Cancer Institute called Huntsman at Home that provides hospital-level care to patients at home, including hydration, electrolytes, and total parenteral nutrition, though not chemotherapy.
A recent study evaluating Huntsman at Home found that “bringing the hospital into the home” improved patient outcomes. More specifically, over the first 30 days following hospital admission, Mooney and colleagues reported that patients in the Huntsman at Home program had 56% lower odds of unplanned hospitalizations (P = .001), 45% lower odds of emergency department visits (P = .037), and 50% lower cumulative charges (P = .001) compared to those receiving usual care. However, this care did not include administering chemotherapy at home.
In the current randomized-controlled clinical study, Van Eygen and colleagues wanted to demonstrate the quality of a locally implemented model for OHH, as compared to standard ambulatory cancer care. The authors evaluated quality based on several parameters, including patient-reported quality of life, satisfaction, preferences, service use, and cost, as well as safety.
The cohort included patients who lived within a 30-minute drive from the hospital and had been diagnosed with a solid tumor or hematologic malignancy for which they were starting or restarting active treatment for curative, palliative, or supportive care.
Participants were randomly assigned to OHH (n = 74) or standard of care (n = 74) and were followed for 12 weeks. Within the intervention group, five patients were eligible for the full OHH protocol and 69 for partial OHH. The study did not specify the subcutaneous cancer drugs administered at home or the safety protocols integrated into the OHH model.
Overall, Van Eygen and colleagues reported that patients who received full OHH had significantly fewer hospital visits on average (5.6 vs 13.2; P = .011). For patients who received partial OHH, waiting times for therapy administration were reduced by 45% per visit (2.6 hours vs 4 hours; P < .001).
Overall, 88% of patients in both OHH groups reported being highly satisfied with the model, and 77% reported a positive impact on their quality of life. At the end of the study, 60% of patients in both study arms preferred OHH over the standard of care.
In addition, the authors reported “no adverse events linked to the home-intervention” during the study. And among patients completing a questionnaire about patient-reported experiences and safety, the majority reported feeling as safe, if not more so, at home compared to the oncology day care unit; only one patient felt safer at the day care unit.
According to Van Eygen, these data demonstrate the feasibility of moving oncology care to the home for appropriate patients.
“In these projects, a common protocol has been developed and found to be safe and efficient,” he said. “All [patients] relied on existing healthcare structures — either nursing teams from the hospital that visited patients at home or home care nurses who received a special training and accreditation.”
Despite the general preference for OHH in the study, Van Eygen noted that ultimately, patients and providers may be reluctant to change procedures they know work and feel comfortable with.
“Oncologists and hematologist indeed [showed] some resistance since [an OHH model] effectively means less direct control, but in the course of the projects, most of them acknowledged that treatment at home is safe, if done within a proper care pathway,” he said.
Commenting on the study, Mooney noted that focusing on decreasing the time for chemotherapy infusions was a “novel” and important element of this study.
“It is hard to appreciate the wear and tear on patients each time they receive treatment,” said Mooney, adding that shortening this time “clearly improves the patient experience.”
Mooney added that continuing to study the value of providing chemotherapy at home as well as acute-episode cancer care that manages treatment side effects and toxicities is important.
“The home may offer a delivery pathway that is safe, improves patient experience and outcomes, and is cost-effective” Mooney said.
On the cost front, the authors did not collect sufficient data to conduct a thorough cost-effectiveness analysis. However, Van Eygen said an initial estimate found that treatment at home was about 10% to 15% more expensive for the health insurance system.
However, this initial estimate is likely high, he explained, given patient volumes in the study were relatively small and the model has not yet become routine care. Plus, he added, cost-efficiency will differ significantly between countries with different healthcare systems and strategies for financing care.
In the US, for instance, Mooney explained that current reimbursement models, which only reimburse for traditional episodic home healthcare visits, represent a major challenge for implementing and sustaining home-based oncology programs.
“In redesigning delivery models to include home-based cancer services, aligned reimbursement mechanisms, and integration with hospital and clinic-based documentation systems will be needed,” Mooney emphasized. “A true continuum of care for cancer patients will help to ease the heavy burden of cancer treatment and follow-up care at a bricks-and-mortar cancer facility for patients.”
The study was supported by Kom Op Tegen Kanker (Stand up to Cancer) and the Flemish cancer society. Van Eygen disclosed honoraria from Janssen-Cilag. Mooney has disclosed no relevant financial relationships.
JCO Glob Oncol. 2021 Sep;7:1564-1571. Full text