Agence d’Evaluation des Technologies et des Modes d’Intervention en Sante (AETMIS) (2004)

Agence d’Evaluation des Technologies et des Modes d’Intervention en Sante (AETMIS) (2004)
Design: Systematic review evidence level: 2++
Country: Canada
Inclusion criteria:
None stated
Exclusion criteria:
Excluded studies:
Studies focused on terminally ill patients receiving chemotherapy as palliative care
Studies of home-based, high dose chemotherapy and stem cell rescue for MBC and other cancers
Population:
Number of patients = N/K
Interventions:
Home chemotherapy, including any type of administration of chemotherapeutic agents (intravenous, subcutaneous, oral etc) at home with or without the supervision of a nurse.
Outcomes:
Outcomes that might be relevant: clinical benefit, cost reduction, safety and patient quality of life.

Outcomes that are probably not relevant and are not included here: organisational implications for the healthcare system (of Canada), ethical, legal and social implications (for Canada), and influence of patient and regional characteristics on viability as a service.
Follow up:
N/A
Results:
Clinical benefit:
The authors found a lack of evidence for the effect of home chemotherapy on clinical outcomes since most of the eight identified studies related to specific protocols rather than to the treatment settings e.g. oral (in the home) vs intravenous (in a hospital) chemotherapy as opposed to the same therapy administered at hospital or in the home.

Cost reduction:
The authors found only one study that provided convincing evidence in support of cost savings for home chemotherapy compared with in-patient therapy. However, this study was a US paediatric crossover trial with just 14 participants. Two studies found home chemotherapy to be more expensive than in-patient treatment. The additional cost was attributed mainly to nursing labour (care and co-ordination), travel time, transportation and special equipment. Because of these variable results the authors concluded that home chemotherapy has a cost shifting effect, from in-patient to out-patient facilities or from there to home care agencies and visiting nurse organisations. The evidence for the financial effect on patients was lacking.

Safety:
The authors summarised the results from seventeen papers in a table, a modified version of which (excluding paediatric studies or studies not involving iv therapy), is shown below. The conclusion was that, notwithstanding the generally small sample size of most included studies, home chemotherapy can be provided safely. However, they add that the strict selection criteria used to determine patient eligibility might make this conclusion unsurprising and also that rare adverse reactions might not be observed in small patient number studies.

The authors point out that for half of the studies involving intravenous chemotherapy a nurse either administered the treatment or daily visits by a nurse were provided, which presumably would have reduced the risk to the patient.

Quality of life:
The authors concluded that the evidence for this issue was limited by the small number of controlled studies and participants. The evidence that was identified in controlled studies did not demonstrate an improved quality of life in favour of home treatment, except for paediatric patients and their parents. Uncontrolled studies had generally positive findings in favour of home treatment

Patient preference:
The authors presented results from studies reporting on patient preference with home care, satisfaction and other psychosocial issues such as independence, concerns, needs and levels of stress. Nine out of eleven studies reporting on patient preference and choice presented strong evidence in favour of home treatment. Seven out of the nine studies which reported patient satisfaction presented results which favoured home therapy or some part of thereof.
General comments:
This is a thorough systematic review which is only partly relevant to the topic question e.g. studies recruiting patients with metastatic disease were excluded but all studies of all types of chemotherapy (e.g. subcutaneous, oral administration etc) are included. Some of the outcomes are specific to Canada and were the results of semi-structured qualitative interviews with service providers or administrators from the Canadian health system. However, some outcomes of this review are relevant and have been included in this evidence base. The review was presented in narrative form and there were no data analyses.

The overall conclusions were that there was insufficient evidence on the clinical benefit or cost effectiveness of home chemotherapy compared to non-home settings but more evidence to show that home treatment could be delivered safely with few serious complications or accidents, providing patients were carefully selected and trained. Evidence in favour of improved quality of life is anecdotal but preference for, and satisfaction with, home chemotherapy is strongly supported with the proviso that study participants may have been required to be accepting of the methodology in order to be recruited thus introducing an element of selection bias.

From: Chapter 5, Community-based treatment and supportive care

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Advanced Breast Cancer: Diagnosis and Treatment.
NICE Clinical Guidelines, No. 81.
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