Duke First in Nation to Offer Post-HSCT At-Home Care

Clinical trial assesses patient outcomes

When a 62-year-old man’s chronic myelomonocytic leukemia (CMML) progressed to acute myeloid leukemia, his Duke hematologist started him on chemotherapy and referred him to the Duke Adult Bone Marrow Transplant Clinic. Given the patient’s disease progression, allogeneic hematopoietic stem cell transplant (HSCT) was his best option for long-term disease-free survival.

At the clinic, the patient was offered an unusual option: post-transplant care at home. Rather than staying at the hospital for several months, because he lived less than an hour from Duke, he could recover at home, with clinicians coming to his house for follow up. He elected to try it.

The patient was enrolled in a randomized phase 2 clinical trial comparing outcomes for patients receiving post-transplant at-home care versus those receiving standard hospital care. Led by Duke HSCT specialists Nelson Chao, MD, MBA, Anthony Sung, MD, and Krista Rowe, MSN, RN, the trial is the first of its kind in the United States.

In addition to being an attractive option for many patients, Sung says, at-home care may offer medical benefits. A study at the Karolinska Institutet in Sweden demonstrated that, compared with standard hospital care, at-home transplant care is associated with less graft versus host disease (GVHD) and infection—two common complications of HSCT.

Outcome measures of the Duke study include incidence of grade II-IV acute GVHD, rate of infection, disease-free survival, and overall survival. Patients’ gut microbiota will also be compared to assess whether the lower incidence of complications in patients receiving at-home care results from better maintenance of their microbiomes.

A year after undergoing HSCT, the patient is doing well. Although it is too early to comment on the clinical trial, Sung is excited about its potential: “GVHD is one of the main causes of treatment-related mortality in these patients, so anything we can do to reduce GVHD would save lives.”

He adds that at-home transplant has the potential to significantly reduce health care resource utilization and costs by preventing GVHD and keeping patients out of the hospital. Transferring the locus of care from the hospital to the home also has less tangible benefits, he says: “Being invited into patients’ homes allows us to develop a more intimate bond with our patients and helps us understand how we can better care for them. I think there’s a reason historically physicians would make house calls.”