Developing a pediatric outpatient transplantation program. The Children's Memorial Hospital experience

We describe the development of a pediatric outpatient transplant program an d our initial experience with autologous and allogeneic transplants perform ed partially or completely in the outpatient setting. Forty-eight autologou s and seven allogeneic transplants have been performed in our institution i n the outpatient setting between June 1994 and July 2000. The ablation used for the autologous outpatient transplants was VP-16 1000 mg/m(2)/ day as a continuous infusion for 2 days and Carboplatinum 667mg/m(2)/day for 2 days . The autologous inpatient transplants received Thio-tepa 300-mg/m(2) per d ay x 3 days and cyclophosphamide 60 mg/kg/day for 4 days. For those patient s who received an immune-ablative allogeneic outpatient transplant, the reg imen consisted of Fludarabine 30 mg/m(2)/day for 6 days, followed by busulf an for children less than five years of age 1 mg/kg/dose x 8 doses and for those five years and older 0.8 mg/kg/dose x 8 doses, followed by ATG 40mg/k g/day x 4 days. Engraftment was complete in all transplants achieving an AN C >500 for the outpatient transplant in 15 days (10-35) vs. the inpatient i n 15 days (14-58). This was not statistically significant. They achieved un -sustained platelets >20.0 by day 19(14-58) for the outpatients and day 32 10-64) for the inpatient. The allogeneic immune ablative transplants were c onsidered engrafted when their VNTRs were greater that 30% which was achiev ed at a median of 13 days (10-27). The economic data showed a statistically significant decrease in charges and direct costs between the outpatient (m edian charges $30775, direct costs $8389) and the inpatient (median charges $99838, direct costs $42757) transplants (p0.001). There was no difference in morbidity and mortality between the two groups but the use of empiric a mphotericin B was markedly decreased in the outpatient transplants. In conc lusion it is feasible and less costly to perform autologous hematopoietic s tem cell transplants in the outpatient setting with no increase in morbidit y and mortality. For the allogeneic transplants there is not yet enough dat a to establish a similar conclusion.