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Research
A randomised crossover trial of chemotherapy in the home: patient
preferences and cost analysis
Danny Rischin, Michelle A White, Jane P Matthews, Guy C Toner,
Kathryn
Watty, Anthony J Sulkowski, Jan L Clarke and Lois Buchanan
MJA 2000; 173: 125-127
Abstract -
Methods -
Results -
Discussion -
References -
Authors' details
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Abstract | |
Objectives: To determine patient preferences and
cost differences between home-based and hospital-based
chemotherapy.
Design: Randomised crossover trial.
Setting: A tertiary cancer hospital in Melbourne,
Victoria.
Participants: 20 patients who required chemotherapy
suitable for administration at home.
Interventions: Patients were assigned at random to
receive their first chemotherapy treatment in either the home or the
hospital and the second treatment in the alternative setting.
Main outcome measures: Patient preference, costs.
Results: There was universal agreement by the 20 patients
in the randomised trial that home-based chemotherapy was the
preferred option (P < 0.0001). No problems were nominated
by the patients as being associated with home-based chemotherapy.
Home-based treatment was estimated to result in an increased cost of
$83 (P = 0.0002) for each chemotherapy treatment compared
with hospital-based treatment. Reported advantages for
chemotherapy in the home included the elimination of travel,
reduction in treatment-associated anxiety, reduction in the burden
on carers and family, and the ability to continue other duties. There
were no significant complications associated with administration
of chemotherapy in the home.
Conclusions: Patients prefer home-based chemotherapy
to hospital-based treatment. The future of
chemotherapy-in-the-home programs in Australia will depend on
whether patient preferences are deemed to offset any potential
increase in costs.
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Patients with cancer who require treatment with chemotherapy will
experience major changes in lifestyle and overall well-being. Some
intravenous chemotherapy regimens require frequent visits to
hospital to receive treatment. This may be time-consuming and
inconvenient for a patient, and may also disrupt the lives of other
family members and carers.
The concept of home-based therapy is not new,1-3 but there have been few
reports on chemotherapy-in-the-home programs, and these have had a
different emphasis from our study (eg, costs [in a US paediatric
population];4 costs and safety [in a
retrospective review of an Australian adult population]5). We performed a
randomised crossover trial, the aim of which was to compare (i)
patient preference for hospital-based versus home-based
chemotherapy; and (ii) the cost of therapy administered in hospital
versus that in the home.
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| | Methods |
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Patient eligibility | |
Patients were considered eligible if they met the following
criteria: they were to receive chemotherapy that was suitable to be
given at home; their first two treatments were planned to be
identical; they had not received chemotherapy in the preceding 12
months; they lived in an area that was geographically suitable for
treatment at home; and they were aged 18 years or over.
Patients gave written informed consent and the study was approved by
the ethics committee of the Peter MacCallum Cancer Institute.
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Study design |
At enrolment, patients were randomly assigned to receive their first
chemotherapy treatment in hospital and the second at home, or their
first treatment at home and the second in hospital. They were assigned
according to a computer-generated randomisation chart, using an
allocation scheme based on a biased coin design.6Chemotherapy treatment refers to the first two administrations
of chemotherapy.
Following completion of the first two treatments, patients filled
out a questionnaire regarding the two different locations of
therapy. Questions focused on (i) patients' preference for where to
receive their remaining chemotherapy after completing their two
study treatments; and (ii) any perceived difficulties or advantages
of treatment in hospital or in the home. Chemotherapy nurse
specialists who also worked in the chemotherapy day ward at the
hospital administered all home chemotherapy treatments. Patients
were reviewed by a doctor before each chemotherapy cycle.
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Cost assessment | |
Cost comparisons for hospital-based versus home-based therapy were
made specifically from the perspective of the treating hospital, not
the patient or society in general. Costs were estimated using
Transition software (Eclipsys Transition Systems, Boston,
MA), which distributes direct
and indirect costs for an entire financial year between patient
episodes on the basis of the services received. It was decided to
compare only those components of the cost for which there could be a
genuine difference to the hospital attributable to the site of
delivery of the chemotherapy. Thus, costs related to patient
records, allied health, medical staff and pharmacy were excluded.
All overheads associated with the chemotherapy-in-the-home
program, including vehicle costs and travelling time, were
apportioned by Transition to nursing costs on the basis of time spent
with each patient. Similarly, hospital overheads were apportioned
on the basis of nursing times. The cost of providing a single meal was
included in the hospital costs.
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Statistical methods | |
A target sample size of 20 eligible patients with identical
chemotherapy for their first two treatments was chosen, to provide
84% power to test the null hypothesis that no one setting is preferred
versus the alternative hypothesis that at least 85% of patients
prefer one setting over the other, using a two-sided test of
significance at a significance level of 0.05.
To determine if significantly more patients preferred treatment at
home rather than in hospital, or vice versa, the proportion of
patients preferring to have their third treatment in the same
location as their first treatment was compared between the two
randomisation arms using Fisher's exact test for 2 x 2 contingency
tables. This test is valid even if there are "period" effects -- that
is, if patients tolerate their second chemotherapy treatment better
than their first, or vice versa.7
Standard methods for a 2 x 2 crossover trial7 were used to compare costs of
chemotherapy in hospital with costs in the home, and costs between the
first and second chemotherapy given ("period" effects), after
ensuring there were no significant carryover effects. (Carryover
effects were tested by comparing the sum of the costs in the home and
hospital for patients in the "hospital first" arm with patients in the
"home first" arm.) Statistical significance and 95% confidence
intervals (CIs) were estimated from the means and standard errors
assuming a Student's t-distribution. Two-sided
P-values have been given throughout. All statistical tests
were carried out using Stat Xact 4
(CYTEL Software Corporation, Cambridge, MA, 1998)
and Microsoft Excel (Microsoft
Corporation, Redmond, WA, 1996) software.
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| | Results |
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Patient selection and profile | |
The trial accrued the target 20 patients, out of a total of 64
registered on the chemotherapy-in-the-home program, between
February 1996 and March 1997 (see Box 1). Patient
demographics are shown in Box 2.
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Patient preferences | |
When asked where they would have preferred to receive their first two
treatments if they had had their time again, 70% of patients expressed
a preference for having both treatments at home, while none said they
would have preferred to have both treatments in hospital (Box 3).
Patients were then asked to nominate their preferred site for the
remaining treatments (the primary endpoint of the trial). All 20
patients (100%; 95% CI, 83%-100%) preferred to have their remaining
therapy given at home (P < 0.0001).
None of the patients in the trial reported concerns with chemotherapy
being given in their home; however, four (20%) reported concerns with
treatment in hospital, relating to transport difficulties and
waiting times.
Eighteen (90%) of the patients felt there were advantages with
treatment in the home. The reasons given included convenience;
avoidance of travel and parking problems (particularly not having to
travel while feeling unwell); reduction in treatment-associated
anxiety; not burdening their carers and family; and being able to
continue other duties, such as caring for their dependants. Only one
patient felt there were specific advantages to chemotherapy in the
hospital. This patient felt it was good to see other people who were
worse off. No major complications of chemotherapy administration
(eg, hypersensitivity reactions or extravasation) were reported.
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Costing |
Overall, chemotherapy in the home was associated with an estimated
average increased cost of $83 (95% CI, $46-$120; P = 0.0002)
relative to the cost of chemotherapy in the hospital. The average cost
of the first treatment was estimated to be $57 more than the cost of the
second (95% CI, $20-$94; P = 0.0044). There was no
carryover effect (P = 0.16).
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| | Discussion |
This study has demonstrated that patients have an overwhelming
preference for home-based therapy.
Clearly, home-based therapy is not possible, or indeed appropriate,
for all patients. Patients living outside designated geographical
areas or having special needs that can be met in the hospital setting
(eg, need for an interpreter) would be more easily treated at the
hospital.8 Complex or prolonged
chemotherapy regimens or those associated with a risk of an immediate
serious complication are more appropriately administered in the
hospital day ward setting. Nevertheless, many commonly
administered chemotherapy regimens are suitable for
administration in the home, and this study clearly demonstrates
that, given the choice, patients prefer to have such treatments at
home.
While in our study the cost of home-based treatment was on average $83
higher than the cost of hospital-based therapy, this estimate did not
include costs to the patient (such as travelling costs, lost time for
the patient or carers, and childcare costs). These could all have made
the hospital episode more costly relative to the home episode.
Furthermore, given that the cost per visit for any
chemotherapy-in-the-home program is dependent on the throughput of
patients and the geographical spread of the patients, an increase in
the frequency of home visits or a more limited geographical spread of
patients might further reduce the difference between home and
hospital costs.
Unlike some other hospital-in-the-home programs, chemotherapy in
the home does not necessarily result in cost savings to the
administering hospital, as treatment in the hospital does not
require overnight admission.
The future of chemotherapy-in-the-home programs in Australia will
depend on how governments, hospital administrators, oncologists
and nurses balance the overwhelming patient preference for
treatment at home with any potential increase in costs.
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| | References |
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therapy. A safe and cost effective alternative to inpatient care.
Med J Aust 1995; 162: 249-253.
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Koopman MMW, Prandoni P, Piovella F, et al. Treatment of venous
thrombosis with intravenous unfractionated heparin administered
in the hospital as compared with subcutaneous low molecular weight
heparin administered at home. N Engl J Med 1996; 334: 682-687.
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Bielory L, Long GC. Home health care costs: intravenous
immunoglobulin home infusion therapy. Ann Allergy Asthma
Immunol 1995; 74(3): 265-268.
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Close P, Burkey E, Kazak A, et al. A prospective, controlled
evaluation of home chemotherapy for children with cancer.
Pediatrics 1995; 95: 896-900.
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Lowenthal RM, Piaszczyk A, Arthur GE, et al. Home chemotherapy for
cancer patients: cost analysis and safety. Med J Aust 1996;
165: 184-187.
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Wei LJ, Lachin JM. Properties of the urn randomization
in clinical trials. Control Clin Trials 1988; 9:
345-364.
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Jones B, Kenward MG. Design and analysis of cross-over trials.
London: Chapman and Hall Ltd, 1989.
-
Zalcberg JR, Siderov J, Petty M. Outpatient chemotherapy: there's
no place like home - sometimes. Med J Aust 1996; 165: 182.
(Received 11 Oct 1999, accepted 24 May, 2000)
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Authors' details | |
Peter MacCallum Cancer Institute, Melbourne, VIC.
Danny Rischin, MB BS(Hons), FRACP, Consultant Medical
Oncologist, Division of Haematology and Medical Oncology;
Michelle A White, MB BS(Hons), FRACP, Clinical Fellow,
Division of Haematology and Medical Oncology;
Jane P
Matthews, BSc(Hons), PhD, AStat, Director, Statistical
Centre;
Guy C Toner, MD, BS, FRACP, Head of Medical Oncology,
Division of Haematology and Medical Oncology;
Kathryn
Watty, RN, RM, Clinical Nurse Consultant, Division of Nursing;
Anthony J Sulkowski, RN, BEd, Clinical Nurse Consultant,
Division of Nursing;
Jan L Clarke, RN, Clinical Nurse
Consultant, Division of Nursing;
Lois Buchanan, RN, RM,
Clinical Nurse Consultant, Division of Nursing.
Reprints will not be available from the authors.
Correspondence: Dr D
Rischin, Division of Hematology and Medical Oncology, Peter
MacCallum Cancer Institute, Locked Bag 1, A'Beckett Street,
Melbourne, VIC 8006.
drischinATpetermac.unimelb.edu.au
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