Home-based Autologous Hematopoietic Stem Cell Transplantation to Improve Outcomes and Decrease Costs

对于正在接受治疗的老年癌症患者来说，身体、情感和经济负担尤其繁重。 自体造血干细胞移植(HCT)，这需要延长住院时间或在 门诊期为3-4周，照顾者全天候服务。家庭HCT是一种新策略，可提供 集中支持、综合护理管理和个性化干预，专注于帮助患者和 护理者在家中管理护理，有可能提高患者的生活质量，减轻护理者的压力，以及 降低医疗保健利用率和成本。 在我们成功的第一阶段家庭HCT试验的基础上，我们建议进行一项家庭与 标准的自体红细胞移植。与标准的基于医院的护理不同，家庭HCT的提供者每天都在家里 呼叫，与患者和护理人员合作，形成个体化治疗计划，以促进管理 在家中出现了HCT并发症。以家庭为基础的护理可能有许多优势，特别是对老年人来说，而且 家庭HCT可能会改善患者的生活质量(保持在正常环境中)，更好的活动(更容易 在家里或附近走动比拥挤的医院走廊更好)，更好的营养(家与医院 食物)、更好的睡眠(家庭与医院病床)等。此外，后勤工作大大简化了照顾者 不需要每天来回开车，这可以减少照顾者的压力、焦虑和疲劳，从而 提高护理者的生活质量；此外，这可能会解放护理者为患者提供更多支持， 进一步改善患者的预后。此外，增加了在家照顾病人的信心和能力 可能会减少急诊室就诊和再入院。尽管前期人力成本可能会更高，但总体来说 通过减少并发症和让患者远离医院，医疗系统的成本可能会降低。 我们的第一个目标是确定家庭HCT对患者健康、生活质量和功能的影响， 包括总体生活质量(FACT-BMT，主要终点)、症状、身体功能、认知功能、 疲劳、睡眠、营养状况、心理健康、社会支持、自我效能、自付费用和回归 工作。我们的第二个目标是确定家庭HCT对照顾者福祉的影响，包括许多 以上测量以及照顾者压力(照顾者压力指数，主要终点)、负担和满意度。 定性研究是这两个目标的一部分，目的是更好地了解家庭HCT的哪些方面最具影响力 并可应用于其他疾病；这对于规划未来的研究和实施尤其重要。 第三个目标是确定家庭HCT对医疗保健利用结果的影响，如再次住院， 停留时间和总费用。长期目标是改善患者和照顾者的结果 通过支持他们在家中的护理；让患者在家和不在医院里，反过来可能会降低成本。这个 这项研究的成功可能会为其他减轻照顾者负担和留住患者的策略提供借鉴 走出医院，在家中提供高质量的护理。

Physical, emotional, and financial burdens are especially demanding for older cancer patients undergoing autologous hematopoietic stem cell transplant (HCT), which requires prolonged hospitalizations or daily visits in outpatient clinics for 3-4 weeks and caregivers to be available 24/7. Home HCT is a novel strategy that provides intensive support, integrated care management, and individualized interventions focused on helping patients and caregivers manage care at home, with the potential to improve patient quality of life, reduce caregiver strain, and decrease healthcare utilization and costs. Building on our successful phase 1 home HCT pilot, we propose a randomized phase 2 trial of home vs. standard autologous HCT. In contrast to standard hospital-based care, providers of home HCT make daily house calls, working with patients and caregivers to form individualized treatment plans that facilitate management of HCT complications at home. Home-based care may have many advantages, particularly for older adults, and home HCT may result in better patient quality of life (remaining in their normal environment), better activity (easier to walk around the home or neighborhood than crowded hospital corridors), better nutrition (home vs. hospital food), better sleep (home vs. hospital bed), etc. Additionally, logistics are vastly simplified for caregivers who don’t need to drive back-and-forth daily, which could decrease caregiver strain, anxiety, and fatigue, thereby improving caregiver quality of life; in addition, this may free caregivers to provide more support for patients, further improving patient outcomes. In addition, increased confidence and ability to take care of patients at home may reduce emergency room visits and readmissions. Though upfront staffing costs may be higher, overall health system costs may be lowered by reducing complications and keeping patients out of the hospital. Our first aim is to determine the impact of home HCT on patient health, quality of life and function, including overall quality of life (FACT-BMT, primary endpoint), symptoms, physical function, cognitive function, fatigue, sleep, nutritional status, mental health, social support, self-efficacy, out-of-pocket costs, and return to work. Our second aim is to determine the impact of home HCT on caregiver well-being, including many of the above measures as well as caregiver strain (caregiver strain index, primary endpoint), burden, and satisfaction. Qualitative studies are part of both aims to better understand which aspects of home HCT are most impactful and may be applied to other diseases; this is especially important for planning future studies and implementation. The third aim is to determine the effect home HCT on healthcare utilization outcomes such as readmissions, length of stay, and overall costs. The long-term objectives are to improve outcomes for patients and caregivers by supporting their care at home; keeping patients at home and out of the hospital may in turn reduce costs. The success of this study may serve as a model for other strategies to reduce caregiver burden and keep patients out of the hospital by delivering quality care at home.