Development and Health Economic Evaluation of a Novel Ambulatory

Haematological Cancer Service.

Dr Christopher DalleyDepartment of Haematology

Sheffield Teaching Hospitals NHS Foundation Trust

Overview

• Background

• Developing ambulatory care

• Outcomes

• Future plans

The Royal Hallamshire;Clinical Haematology

• Bone marrow transplant programme

• Largest treatment centre for blood cancer in S.Yorkshire

• Two inpatient wards and large day care ward

The problem;blood cancer care

• Intensive chemotherapy

• Side effects

• Lengthy inpatient stay

• Increasing demand

• Treatment closer to home

The solution

• Ambulatory care

– Deliver key parts of patient care in day case or home environment

– Reduce or avoid inpatient stays where possible

– Deliver care safely

What we aimed to do

• Introduce new ambulatory care treatments– Patients with acute leukaemia (AML)– Patients with lymphoma needing high-dose therapy

• Clinical microsystems

• Evaluate – Economic impact– Patient experience

Implementing ambulatory pathwaysClinical microsystems

• Microsystems team– Patients, nurses, doctors, pharmacist, hotel services,

managers, health economist

• Training

• Weekly meetings

• Tools– PDSA, questionnaires, news clips,– Process mapping

Process mapping

Chemo

Support

28 days

Patient stays in flat/home

Ambulatory pathway

Chemo Support

Patient stays in ward

Normal inpatient pathway

28 days

Supporting the ambulatory pathways• New protocols and guidelines

• Patient & carer education programme

• Patient information booklets

• Patient alert card

• Ambulatory flats and hotel services

• Longer day ward opening hours including weekends

OutcomesAmbulatory patients with AML

Patient Age Days ambulatory

Days inpatient

Reason for readmission

1 23 38 3 Nausea and vomiting

2 65 23 10 Not applicable

3 35 419

176

InfectionNot applicable

4 58 14 7 Not applicable

Ambulatory Care Patients

Outcomes Ambulatory patients with lymphoma

Patient Age Days ambulatory

Days inpatient

Reason for readmission

5 28 11 9 Sore mouth

6 42 16 4 Infection

7 63 12 24 Sore mouth

8 66 14 10 Sore mouth

Ambulatory Care Patients

OutcomesHealth-economic

• School of Health and Related Research (ScHARR)

• Computer simulation used to assess impact of introducing new ambulatory care pathways alongside standard care pathways in a clinical unit.

• Various simulations used to measure effect of different degrees of ambulatory care

• Unit costs for ambulatory and standard pathways provided by RHH management team

Effect of ambulatory care provision on bed days and care costs

1 flat 2 flats 1 flat & home care

2 flats & home care

Reduction in bed days per

year

342 453 521 521

Reduction in costs

£54,210 £65,185 £81,823 £74,409

Percentage reduction in

costs

7.1% 8.6% 10.8% 9.8%

OutcomesPatient experience

Establishing ambulatory care

• Department to write full business case to support ambulatory care:– Second ambulatory flat refurbished– Ambulatory co-ordinator post to be appointed

• Presenting our findings:– Local (Cancer Board Haemato-oncology group)– Nationally (Shelford group)– International-(EBMT Geneva, April 2012)