Fifteen Years' Experience of Home Care During the Pancytopenic Phase After Allogeneic Hematopoietic Stem Cell Transplantation

We have used home care as an option to hospital-care during the pancytopenic phase after hematopoietic allogeneic stem cell transplantation (HSCT) for 15 years at Karolinska University Hospital . This is now an opportunity for children as well as for adults. A nurse from the unit visited and checked the patient regularly.

After treating 146 patients at home we compared them to hospital controls matched for sex, age, diagnosis, stage of disease, type of donor, source of stem cells and conditioning. Oral intake was intensified from September 2006 and improved (p=0.002). More calories per day was associated with less GVHD in an univariate analysis (p=0.02). In multivariate analysis grades 0–I GVHD was associated with home care (HR=2.46, p=0.02) and with days spent at home (HR=0.92, p=0.005), but not with oral nutrition (HR=0.98, p=0.13). Transplant-related mortality, chronic GVHD and relapse were similar in the groups. Five-year survival was 61% in the home care group as compared to 49% in the controls (p=0.07).

When we analyzed outcome of HSCT for the past two decades, we found that low transplant-related mortality (TRM) was associated with age (p<0.001), acute leukemia (p=0.002), HLA-identical related donor (p<0.001), reduced intensity conditioning (p=0.007) and home care (p=0.02).

We collected all in- and outpatient costs during two years at our unit. Costs during the initial transplant period until day 76 were significantly lower with home care in multivariate analysis (RH 0.8, p=0.035). Increased costs were associated with a second transplant, T-cell depletion, adults, G-CSF and complications.

To show Quality of life we used The Sympathy- Acceptance-Understanding-Competence-questionnaire (SAUC) instrument developed from the SAUC-model. This study aim to describe patients’ experiences of care and support from healthcare staff while treated in hospital or at home during the early post transplantation phase after HSCT. The study showed home care to be as satisfactory as hospital-care. Also 24 relatives staying at home together with the patients gave their opinion regarding quality of life. Eleven questions were asked in a survey with a scale from 1-5 where 1 was very satisfactory and 5 was the opposite.  21 rated 1-2 very satisfactory and three rated 2-3.

Conclusion: Home care is safe and cheaper than hospital care. Home care and many days spent at home were correlated with a low risk of acute GVHD. Home care was also associated with a lower TRM and a trend for better survival.