Safety and Financial Analysis of Outpatient Hypercvad Arm a Administration for Acute Lymphoblastic Leukemia
Authors: Sun Yujiao , Denson Ariel , Tobon Katherine , Nelson Rebecca Jean , Lubas Amber , Shah Bijal D. , Kubal Timothy , Salamanca Christopher Rodriguez , Chahoud Jad , Pinilla-Ibarz Javier , Isenalumhe Leidy Lismeris 
Published: December 2023

The hyperCVAD chemotherapy regimen for acute lymphoblastic leukemia (ALL) traditionally requires patients to be admitted inpatient for administration due to the need for coordinating infusion times and managing toxicities. This may cause significant financial burden to the healthcare system and an emotional burden to patients and caregivers. Our institution established an Inpatient/Outpatient (IPOP) program in 2014 which specializes in outpatient administration of various high-risk chemotherapies, including hyperCVAD arm A. This study aims to evaluate the safety and financial impact of administering hyperCVAD arm A in the outpatient setting.

A retrospective chart review was conducted on patients ≥18 years of age who received hyperCVAD arm A between January 2019 to July 2020 for treatment of B- or T-cell ALL at an National Cancer Institute-Designated Cancer Center in Florida. The primary endpoint of the study was the overall incidence of hospital admissions during outpatient chemotherapy administration during days 1 through 4 of hyperCVAD arms 2A, 3A, and 4A. Secondary endpoints included number of hospitalizations between cycles, number of hospital days saved by outpatient administration, infectious complications, adherence to institutional hematology/infectious diseases guidelines, and drug-related adverse events. Financial analysis was conducted based on reimbursement data and impact of hospital bed backfill to determine the overall financial impact outpatient hyperCVAD arm A administration. Direct margin was calculated by subtracting direct expense from reimbursement.

Out of 83 patients who received hyperCVAD arm A during the examined time period, 42 (50%) met inclusion criteria. Majority of patients were excluded due to receiving hyperCVAD arm A for non-ALL indications (n=31) or receiving hyperCVAD for delayed intensification (n=3). A total of 103 cycles of hyperCVAD arm A were administered, with 56 cycles given in the outpatient setting to 26 patients. Based on an approximated 5 days of hospital admission required for administration of hyperCVAD arm A, administering the regimen via the IPOP service resulted in an estimated 280 days of avoided hospitalization for 26 patients. No patients were removed from the IPOP program due to adverse effects. One (4%) patient required hospitalization during days 1 through 4 of outpatient chemotherapy administration due to a non-ST-Elevation Myocardial Infarction. This patient was subsequently switched to blinatumomab treatment administered via the IPOP service. Eight (31%) patients were hospitalized after completing day 4 of each cycle for reasons not directly related to hyperCVAD arm A (table 2).

Our reimbursement data found each outpatient cycle was associated with a 60% increase in margin compared to inpatient administration. Additionally, we expect a positive financial gain from backfilling of inpatient beds that would otherwise be occupied for approximately 5 days of hospitalization from hyperCVAD arm A administration. Considering the combined effect from these two factors, the administration of hyperCVAD arm A under the IPOP service resulted in a significant positive financial impact for our institution.

Our findings provide evidence to support the administration of hyperCVAD arm A under the IPOP service is safe and feasible. Although there may be upfront costs associated with implementing an ambulatory program for administration of traditionally inpatient chemotherapy regimens, the outpatient approach demonstrated favorable financial implications and alleviated bed shortages.