Home delivery: chemotherapy and pizza?

The past century has seen hospitals become the focus of the healthcare system despite attempts to shift the emphasis of care to the community. Most attempts to move complex and invasive procedures out of hospital completely and into patients' homes remain marginal. One example of this is home chemotherapy, the subject of a randomised trial in this week's issue (p 826).¹

Home chemotherapy is a service that provides a package of care to support the administration of chemotherapy to patients in their homes by specialist healthcare professionals (usually nurses). It may be distinguished from ambulatory chemotherapy, where patients visit the outpatient department to be connected to portable disposable pumps prefilled with cytotoxic drugs, which are then administered via a central venous catheter for 48 to 168 hours, and from day hospital chemotherapy, where patients visit the hospital daily to have their chemotherapy administered.

In the United Kingdom home chemotherapy is chiefly the domain of a few private “intravenous access” companies, whereas the NHS service is limited to a handful of nurse led projects being piloted in both urban and rural areas. In north America, however, home intravenous therapy was recently the fastest growing segment of the healthcare system.²

The most obvious shift in chemotherapy practice in the UK has been from inpatient to outpatient ambulatory therapy, with evident cost savings and enhanced patient satisfaction. If the next logical evolution in service delivery is establishing home chemotherapy, then there are three issues that must be resolved: Is it safe? Given a choice, do patients prefer it? And is it cost effective?

In their article in this week's issue Borras et al have investigated compliance, satisfaction, and quality of life in patients with colorectal cancer assigned at random to either home based or outpatient chemotherapy.¹ This trial contributes to a small body of literature on home chemotherapy, including three randomised trials.^3–10 Overall, these studies have shown some psychological benefit to patients (and sometimes carers, including parents) mainly from their active participation in the treatment (“helped me to cope,” “I felt in control,” and “home was less stressful”).⁸ They also show that the success of any home service depends on the clarity of communication between the multidisciplinary teams in the hospital and community. However, many studies are flawed by their small scale and lack of economic analysis and have failed to show consistent outcomes.

The selection of appropriate patients and chemotherapy regimens for home delivery is crucial to its success. The chemotherapy delivery team, patients, and carers must acquire the necessary skills, knowledge, and back up protocols to ensure patient safety at home.⁹,¹⁰ In their study of 179 patients undergoing home chemotherapy Lowenthal et al found the service to be safe.⁶ Borras et al used fairly conventional chemotherapy regimens, which appeared to be well tolerated in both arms of the trial. Interestingly, patients were less likely to withdraw voluntarily from chemotherapy when it was delivered at home (1/45 v 6/42).

Two recent Australian randomised trials show inconsistent results regarding patient preference for home or hospital chemotherapy.⁴,⁵ We therefore need more information to define the profile of patients who should be offered home delivery.

Like Lowenthal et al⁶ in Tasmania, Close et al³ and Holdsworth et al⁷ in the US found that a home chemotherapy programme (compared with outpatient care in the first study and inpatient care in the US studies) resulted in monetary savings, whereas the other two Australian groups⁴,⁵found home delivery to be consistently more expensive.

This week's study by Borras et al contributes to this home versus hospital debate by showing that home chemotherapy for patients with colorectal cancer was safe and highly acceptable to patients (they did not seek the opinion of the carers). They measured the unplanned use of health resources and found no difference in either group in use of primary care or emergency services. The authors claim, “It was fairly obvious that a home programme would require additional resources” but fail to substantiate this with any data on cost effectiveness.

Thus there is a growing body of evidence showing the safety and acceptability of selected, protocol-driven chemotherapy when administered at home by a team of trained nurse specialists supported by hospital based oncologists. Before this approach becomes more widely available, however, more work needs to be performed on patient selection and the cost effectiveness of such a service.

Paper p 826