Quick Case Study

An Alternative to In-Hospital Bone Marrow Transplant Recovery

A middle-aged patient who lived about an hour away from Duke Medicine was diagnosed with multiple myeloma and referred to Duke for a bone marrow transplant. At Duke, hematologist Nelson Chao, MD, chief of the Division of Cellular Therapy, performed the myeloablative treatment and autologous stem cell transplant in the outpatient setting.

During the neutropenic post-transplant phase, patients must typically be isolated in the hospital or rent an apartment close to the center for approximately 4 to 8 weeks to prevent infection. Although this is necessary, having to remain close to the hospital can be a significant inconvenience or financial burden for many patients.

Question: What alternative approach was Chao able to offer this patient during the transplant recovery period?

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Answer: Chao offered the patient at-home transplant recovery.

Because the patient lived within an hour of Duke, Chao was able to offer him a unique opportunity: to spend the post-transplant recovery period in his own home.

Duke is the first center in the United States to offer at-home transplant recovery, but Sweden’s Karolinska Institute has been successfully treating patients at home for more than 15 years. Several small retrospective studies from that center have found that patients allowed to remain at home during the post-transplant pancytopenic phase have less acute graft-versus-host disease (in allogenic transplantation), improved oral nutrition, and significantly lower short-term and long-term mortality rates.

Chao and his colleagues are currently recruiting patients with multiple myeloma or lymphoma for a study to evaluate at-home treatment after autologous stem cell transplantation. Results from the first phase of the study demonstrate that living at home is feasible, so the researchers are now offering this option to patients undergoing allogenic stem cell transplants as well.

The patient was happy to have the opportunity to remain at home and successfully recovered during a 4-week period. The logistics of at-home post-transplant recovery require that health care professionals think outside of traditional point-of-care boundaries. Chao said that 2 nurses are sent on an initial visit to evaluate the patient’s home to ensure that no sources exist for possible infection, such as the presence of mold or pets. After the transplant, when the patient returns home, a nurse practitioner or physician assistant visits the patient in the morning and performs a physical examination and blood tests, while a clinic nurse visits in the afternoon to deliver necessary daily medical supplies or therapies such as electrolytes, blood, or platelets. A physician is also in daily contact with the patient via online video. Arrangements are made with a local emergency department in case the patient should need acute treatment for serious infection.

There is another possible benefit to remaining at home that Chao is investigating. “We know that the gut microbiome is specific to a person’s environment, and if patients stay in the hospital or rented housing for a number of weeks, the gut microbiome changes pretty dramatically,” he said. “The question we are asking is: If you stay home during the recovery phase, does that individual microbiome diversity improve outcomes with less toxicity and less graft-versus-host disease?”

In addition, there might be other ancillary benefits to remaining at home, Chao said, such as better nutrition, being able to be physically active, get better sleep, and potentially lower medical costs in the long run. Risks associated with being treated at home are primarily related to the patient being removed from medical personnel. “Theoretically, if something were to happen, people can’t get to you quite as rapidly or there may be important events that happen that aren’t recognized,” Chao said. For this reason, it is critical to educate patients and their families to ensure that they receive appropriate care.