Contextual analysis of hematopoietic stem cell transplantation in outpatientsABSTRACT
Objectives: to analyze and map the contextual aspects of hematopoietic stem cell transplantation in outpatients in the literature.
Methods: a scoping review was conducted from October 2023 to June 2024 in databases, portals, and thesis and dissertation libraries. Data collection and analysis were based on the framework proposed by Hinds, Chaves, and Cypress, according to the contextual layers: metacontext, general, specific, and immediate.
Results: the final sample consisted of 30 studies. Regarding the contextual layers, metacontext addressed outpatient hematopoietic stem cell transplantation worldwide; general, advantages and weaknesses; specific, effects of these care models; and immediate, characteristics of patients undergoing outpatient transplantation.
Final Considerations: it was observed that outpatient transplantation is a healthcare trend that offers benefits for improving patients’ health, but faces challenges in its implementation.
Descriptors:
Outpatients; Ambulatory Care; Transplantation; Hematopoietic Stem Cell Transplantation; Bone Marrow Transplantation.
RESUMO
Objetivos: analisar e mapear na literatura os aspectos contextuais do transplante de células-tronco hematopoéticas em pacientes ambulatoriais.
Métodos: scoping review realizada no período de outubro de 2023 a junho de 2024 em bases de dados, portais e biblioteca de teses e dissertações. A coleta e análise de dados ocorreram a partir do referencial de Hinds, Chaves e Cypress, segundo as camadas contextuais metacontexto, geral, específico e imediato.
Resultados: a amostra final foi composta por 30 estudos. Quanto às camadas contextuais, no metacontexto, foi abordado o transplante ambulatorial de células-tronco hematopoéticas no âmbito mundial; no geral, as vantagens e fragilidades; no específico, os efeitos desses modelos assistenciais; e no imediato, a caracterização dos pacientes submetidos ao transplante ambulatorial.
Considerações Finais: observou-se que transplante ambulatorial é uma tendência assistencial que apresenta benefícios para melhoria da saúde dos pacientes, mas que enfrenta desafios para sua implementação.
Descritores:
Pacientes Ambulatoriais; Assistência Ambulatorial; Transplante; Transplante de Células-Tronco Hematopoéticas; Transplante de Medula Óssea.
RESUMEN
Objetivos: analizar y mapear los aspectos contextuales del trasplante de células madre hematopoyéticas en pacientes ambulatorios en la literatura.
Métodos: se realizó una revisión exploratoria entre octubre de 2023 y junio de 2024 en bases de datos, portales y bibliotecas de tesis y disertaciones. La recopilación y el análisis de datos se basaron en el marco de Hinds, Chaves y Cypress, según los niveles contextuales: metacontexto, general, específico e inmediato.
Resultados: la muestra final constó de 30 estudios. En cuanto a los niveles contextuales, el metacontexto abordó el trasplante ambulatorio de células madre hematopoyéticas a nivel mundial; a general, las ventajas y debilidades; a específico, los efectos de estos modelos de atención; y a inmediato, la caracterización de los pacientes sometidos a trasplante ambulatorio.
Consideraciones Finales: se observó que el trasplante ambulatorio es una tendencia de atención médica que ofrece beneficios para mejorar la salud de los pacientes, pero enfrenta desafíos en su implementación.
Descriptores:
Pacientes Ambulatorios; Atención Ambulatoria; Trasplante; Trasplante de Células Madre Hematopoyéticas; Trasplante de Médula Ósea.
INTRODUCTION
Hematopoietic stem cell transplantation (HSCT) is a therapy indicated for various types of oncohematological diseases, consisting of the infusion of hematopoietic stem cells (HSCs) to reestablish bone marrow function so that it produces new healthy cells(1).
Traditionally, this treatment was usually performed entirely in a hospital setting, as there was the infrastructure and equipment necessary to care for these patients(2). However, with advances in scientific research in the field, the development of outpatient HSCT has been considered a new, safe, and viable therapeutic option compared to transplants performed entirely during hospitalization(2,3).
In outpatient HSCT, patients do not need to be hospitalized, returning daily to the clinic where they receive care in all phases of treatment, namely pre-HSCT, Day Zero, and post-HSCT(4,5). Thus, patients experience a daily routine of chemotherapy, transfusions, central venous catheter care, and multidisciplinary assessment until bone marrow transplantation and discharge(5).
This model requires that the patient and caregiver be trained to identify warning signs, such as fever, bleeding, or changes in general condition, in order to allow for early and safe interventions, ensuring continuity of treatment until engraftment, which occurs between ten and 30 days after the infusion of HSCs. After confirmation of engraftment and clinical stabilization, patients undergo periodic outpatient follow-up to control long-term complications and ensure transplant success(6).
It is also important to highlight that, for the success of outpatient HSCT, a joint, harmonious, and cohesive action is necessary from a multidisciplinary team that works daily providing guidance on nutrition, hygiene, and medication administration at home, in addition to offering psychological and pharmaceutical support, reinforcing the importance of adherence to treatment and protective home isolation(3,6).
As members of this team, nurses are present throughout the patients’ entire treatment. Therefore, these professionals must possess scientific knowledge that enables them to apply care methods appropriately, demonstrating mastery over transplant patients’ actions and needs, which will contribute to their recovery(6).
Nurses have the responsibility to intensify care, maintain constant attention to risks and other complications, adopt strategies that promote patient self-care, guide family members regarding the needs involved in this process, and ensure effective communication with the interdisciplinary and multidisciplinary team(7).
However, even with the benefits for healthcare institutions and patients, this care model is not yet a reality practiced by healthcare services in Brazil and worldwide, as it has a low adoption rate, such as in the United States of America (USA), which has 45% of outpatient HSCT clinics, and the United Kingdom, where only 19% of oncohematological treatment units are outpatient clinics(8).
Given the above, this study is justified because outpatient HSCT is a relatively new healthcare practice that needs to be better elucidated: in what contexts does it occur, what are the reasons that favor its development, and what are the challenges for its implementation? These factors are crucial for the overall interpretation of the phenomenon investigated so that it can be replicated by other countries.
To this end, context analysis is a theoretical and methodological framework that favors this investigation, as it helps healthcare professionals understand human beings, assisting in the development of conditions for health promotion and meaningful experiences. Through a purposeful, systematic, and analytical relationship with the phenomenon, the aim is to understand its meaning in its totality and to conduct a global analysis. Therefore, elucidating a context will enable the prediction, explanation, and comprehension of the investigated phenomenon(9).
Thus, context can be defined as a set of interconnected relationships related to an event or scenario. To analyze it, it is necessary to understand this phenomenon at four interrelated interactive levels: metacontext, general context, specific context, and immediate context(9).
From this perspective, it is important to conduct research that identifies and analyzes the contextual aspects of this type of outpatient treatment in order to present its main characteristics, benefits, challenges, and to elucidate how it is carried out worldwide.
Therefore, the following guiding question was defined: what are the contextual aspects of HSCT in outpatients?
OBJECTIVES
To analyze and map the contextual aspects of HSCT in outpatient settings within the literature.
METHODS
Ethical aspects
Approval from the Research Ethics Committee was waived, as this was a review of data available in the literature and did not involve human subjects. However, it should be noted that all citations of the mapped studies were duly carried out and respected.
Study design
A scoping review was developed, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews(10) guidelines and JBI recommendations(11).
This type of review aims to identify, map, and synthesize the evidence and gaps in knowledge surrounding a particular phenomenon. The process follows a rigorous methodological approach outlined in the following stages: defining the objective and research question; aligning inclusion and exclusion criteria with the study objective and research question; describing the search for evidence, selection, data extraction, and presentation of findings; searching for evidence; and selection, extraction, analysis, synthesis, and presentation of evidence(11).
It is worth noting that the method proposed by JBI(11) was applied to develop the study protocol, define the objective, research question, eligibility criteria, search different data sources and map evidence aligned with the object of study in an organized and systematic way. The protocol was developed and duly registered in the Open Science Framework (OSF) (DOI: https://doi.org/10.17605/OSF.IO/8GSZN).
Study period and location
The search in databases and grey literature was conducted between October 2023 and updated in June 2024. Data collection took place in databases (U.S. National Library of Medicine (PubMed), Scopus, Web of Science, Science Direct, Latin American and Caribbean Literature in Health Sciences (LILACS), Cochrane), in thesis and dissertation catalogs (Academic Archive Online (DIVA), Education Resources Information Center (ERIC), DART-Europe E-Theses Portal, Electronic Theses Online Service, National ETD Portal, Teses e Dissertações da América Latina, Coordination for the Improvement of Higher Education Personnel (In Portuguese, Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES) Thesis and Dissertation Portal), and in a digital library (National Library of Australia’s (Trove)).
Inclusion and exclusion criteria
Eligibility criteria were defined based on the expertise and experience of the members and researchers of the research group, who, through consensus, decided to include scientific articles indexed in health journals, theses and dissertations, since evidence is produced from robust scientific methods, well-defined with theoretical depth and that have a substantial innovative contribution to the scientific field under study.
These studies should address the study’s objective and guiding question, be available in full electronically, without temporal or language restrictions, accessible through the Federated Academic Community via the CAPES Journals Portal of the Ministry of Education. Studies in the form of editorials, letters to the editor, books, book chapters, abstracts, and opinion articles were excluded. Duplicate documents were considered only once.
Study protocol
Before initiating the protocol development process, an open literature search and an open search of the OSF were conducted to verify the existence of previously published studies or any similar study protocols under development, which were not found.
Formulating research questions to investigate or assess a clinical problem aims to understand the complexity of care and disseminate this knowledge among the scientific community and patients(9). Therefore, to formulate the guiding question, the PCC strategy was used (Population: patients; Concept: HSCT; Context: outpatient clinic). Thus, the guiding question determined for the search for evidence was: what are the contextual aspects of HSCT in outpatients?
Subsequently, a search for studies was conducted in PubMed and Cochrane to identify the descriptors and keywords that best suited the object of study. Descriptors were selected in English using Medical Subject Headings, and in Portuguese using the Health Sciences Descriptors. Additionally, the Boolean operators AND and OR were used. Thus, the following search strategy was defined in English, as presented in Chart 1, which was adapted according to the specificities of each data source.
The searches were initiated, and the results were exported to Rayyan® software(12), which assisted in the pre-analysis stage of the titles and abstracts. Subsequently, the selected studies were read in full and subjected to the eligibility criteria listed. The stages were carried out by pairs of reviewers with expertise in HSCT, and in cases of disagreement, the opinion of a third reviewer was requested.
Data analysis
After selecting the studies, the reviewers used a protocol developed to extract the following information: data sources; title; authors; year of publication; country where the study was conducted; methodological design; objective; type of HSCT; and contextual layers (metacontext, general context, specific context, and immediate context). The collected data were organized in a spreadsheet using Microsoft Excel® 2017 software.
To identify the contexts and analyze the evidence, the theoretical-methodological framework of contextual analysis proposed by Hinds, Chaves and Cypress(9) was followed, which allows examining the relationships that constitute a phenomenon to make its occurrence and extent more understandable in four contextual layers: metacontext, general context, specific context, and immediate context(9).
Metacontext incorporates socially constructed knowledge, highlighting the present and emphasizing the conditions and lessons learned as a model for the future, with direct explanation and influence on the behaviors and events of that particular phenomenon(9). Therefore, at this level, information was sought regarding existing guidelines, policies, or other documents concerning the implementation of outpatient HSCT.
General perspective encompasses interpretations conceived through past and present interactions of the phenomenon over time(9). Therefore, the aim was to highlight the advantages and weaknesses of these models for healthcare services. Specific encompasses the immediate past and the circumstances that influence the present moment, such as time, people, location, among others(9). Thus, the aim was to map the positive effects of these outpatient HSCT models.
Immediate context focuses on the present and expresses the phenomenon in question, and can be defined by relevant aspects of the phenomenon, such as space, action, and protagonists, which will delimit the pattern of behavior(9). In this layer, the main characteristics related to outpatient HSCT were identified.
Evidence was grouped into the corresponding contextual layers in accordance with the method proposed by Hinds, Chaves and Cypress(9), and presented by means of an image that illustrates the relationship between them.
RESULTS
Originally, the search in data sources and catalogs of theses and dissertations identified 9,185 studies, but 5,254 were not available in full. After that, 2,908 underwent screening of titles and abstracts. Of these, only 41 were submitted to a thorough full-text reading, but, at the end of this process, the study sample consisted of 30 studies. Study selection is presented in the flowchart below (Figure 1).
The final sample characterization consisted of 30 studies. As for the country of publication, 12 countries that perform outpatient HSCT were identified, with the highest concentration in the USA, published between 1998 and 2024, with 2019 being the most prominent year, as illustrated in Figure 2. Study characterization regarding the outpatient model and the type of HSCT most frequently performed is described in Chart 2.
Study characterization regarding the identification of the type of publication, study title, authorship, year of publication, country where the research was conducted, and type of hematopoietic stem cell transplant performed, Natal, Rio Grande do Norte, Brazil, 2024 (N=30)
Countries of publications that addressed outpatient hematopoietic stem cell transplantation, 2025
With regard to contextual layers, Figure 3 presents the main aspects related to metacontext, general context, specific context, and immediate context.
In metacontext, outpatient HSCT was explored in the global context, along with guidelines regulating its implementation in Asian, European, and North American countries. It was observed that each country has its own policies and diverse healthcare organizations.
In the overall context, the advantages and weaknesses of these models for healthcare services were highlighted. Among the advantages, a decrease in the total length of hospital stay, patients’ early return to their family environment, and reduced exposure to antibiotics and other cytotoxic drugs were cited. Among the weaknesses, hospital readmissions and screening based on social criteria for patient admission to outpatient care were mentioned.
In this specific context, the positive effects of these outpatient HSCT models were mentioned, such as reduced costs, lower infection rates, reduction in neutropenic fever, mucositis and positive blood culture results, decreased morbidity and mortality, improved patient physical and emotional well-being, excellent hematopoietic recovery, and accelerated neutrophil and platelet graft engraftment.
In immediate context, the main characteristics were addressed, such as the transition of oncohematological treatment from hospital inpatient care to outpatient care, existing models, and safe practices, such as the administration of high-dose chemotherapy and antimicrobial prophylaxis in HSCT.
DISCUSSION
HSCT was first performed in 1957 in the USA(41), but its development on an outpatient basis only actually occurred in 1993 among North American countries(2). Such evidence supports the findings of this study.
The results from the contextual analysis proposed by Hinds, Chaves and Cypress(9) are arranged in subtopics organized in each corresponding layer, in order to facilitate understanding of the context in which outpatient HSCT is found.
Metacontext - outpatient hematopoietic stem cell transplantation in a global context
A significant milestone in oncohematology was the HSCT care transition, which was previously performed in a hospital setting, but can now be safely and economically viable performed on an outpatient basis, adaptable to the realities of various countries around the world(40).
In the meantime, HSCT regulation at the outpatient level is of paramount importance for countries to manage their healthcare services in terms of logistical and financial resources so that they can offer qualified, universal, and safe care that provides good clinical outcomes for patients undergoing this therapy(42).
The use of outpatient HSCT has increased exponentially in recent years in high-income countries compared to middleand low-income countries, and there has also been a greater number of guidelines to guide and regulate this procedure(38). Given this, these countries can foster a model and provide guidelines to encourage the development of HSCT in an outpatient setting in other countries, especially those with limited human and financial resources so that they can create similar standards, but adapted to their particularities and realities(42).
Clinical practice guidelines for outpatient HSCT in Canada and the USA are quite similar regarding patient eligibility and the definition of patient selection criteria(43). In the USA, the American Society for Transplantation and Cellular Therapy has developed a best practice guideline for outpatient management that provides guidance on the responsibilities of the professionals involved, patients, and caregivers, as well as offering recommendations based on scientific evidence(44).
Considering the effectiveness of treatments and the advantages for healthcare services, in Europe, although there is still a predominance of inpatient HSCT, there is already a shift towards home-based complex treatments, such as autologous HSCT. Therefore, Italian consensus guidelines published in 2016 establish rigorous guidelines for screening eligible patients for the outpatient model and clinical management, which include assessment of functional and psychological status and caregiver support(35).
Still within the European context, for the performance of allogeneic HSCT in outpatient centers, accreditation by the European Society for Blood and Marrow Transplantation is necessary as a way to establish professional responsibility towards patients and public healthcare services(45).
HSCT has grown considerably in Asia, according to reports published by the Asia-Pacific Blood and Marrow Transplant Group. Unlike other regions, these countries have seen a higher number of allogeneic transplants compared to autologous transplants in recent years, particularly in countries with larger populations and higher incomes, such as Japan, South Korea, Singapore, and China, compared to those with lower-middle incomes, such as India, Pakistan, and Sri Lanka(46).
In Brazil, no guidelines, laws, or regulations were found in the literature that provide instructions regarding HSCT in an outpatient setting. However, Ordinance 44 of January 2001, from the Ministry of Health, establishes the standards for day-hospital or outpatient care for healthcare services that offer intermediate-level assistance with a maximum patient stay of 12 hours, in addition to providing technical, logistical, and human resources support(47).
It is worth highlighting that, in the Brazilian context, the nursing team plays a fundamental role in outpatient HSCT, as their presence in outpatient clinics and their role in the direct care of oncohematological patients are supported by Resolution 629 of March 2020 from the Federal Nursing Council, which approves and assigns to nurses the provision of more technically complex care that requires specific scientific knowledge for decision-making(48).
General context - advantages and weaknesses of hematopoietic stem cell transplantation in outpatients
Outpatient HSCT can be considered a less costly treatment, as hospitalization is only indicated if complications need to be treated for both autologous and allogeneic cases. Reduced hospitalization time is beneficial, as it provides a better quality of life for patients, promoting an early return to their family environment(26,35).
Furthermore, the safe administration of high-dose chemotherapy, such as cyclophosphamide, thiotepa, carboplatin, and melphalan, on an outpatient basis stands out, eliminating the need for patient isolation and demonstrating scientifically proven efficacy and safety. This was considered one of the main factors driving the development of outpatient HSCT, and its development has since been encouraged and replicated among HSCT centers(26).
It is worth noting that these chemotherapeutic agents are frequently used in the conditioning of outpatient HSCT, a care procedure performed by nurses in the pre-HSCT period, especially in autologous cases(5). It should be noted that, previously, this stage was performed in a hospital setting, as drugs were administered to promote bone marrow aplasia in order to subsequently infuse HSCs. However, today it is considered a safe procedure in an outpatient setting(49).
Administering high doses of chemotherapy is a task assigned to nursing professionals, as it is considered a technically complex procedure requiring specific knowledge of each medication to be administered, double-checking of medical prescription, patient data, drug information, and dosage. Furthermore, nurses administer the medication and must be able to intervene in possible adverse reactions, as well as provide comfort and guidance regarding the stage of treatment patients are undergoing(50).
Given this milestone, logistical arrangements are essential to ensure adequate care during outpatient treatment. In addition to having a qualified service and a skilled multidisciplinary team, it is crucial that caregivers are available to provide the necessary care, and should be instructed on their responsibilities and how to detect signs of complications in a timely manner(5,51).
Another advantage presented in the results of this study was the lower occurrence of graft-versus-host disease (GVHD) in outpatient allogeneic transplants. This complication leads to impaired functional status, decreased health-related quality of life, financial impacts due to job loss, and the continuous need for immunosuppressive therapy(52).
GVHD commonly occurs in 30 to 60% of patients undergoing allogeneic HSCT, and is associated with a higher number of readmissions, hospitalizations, and outpatient visits, especially among those undergoing multiple lines of chemotherapy and immunosuppressants, such as corticosteroids(53). However, with prophylaxis for GVHD, periodic outpatient follow-up, and reduced exposure to multidrug-resistant microorganisms, a decrease in the occurrence rate of this phenomenon has been observed in patients treated under this new care modality(51).
During nursing care in outpatient HSCT, nurses can utilize educational technologies, such as guides or booklets, to empower patients and family members/caregivers regarding HSCT prevention and the early identification of signs and symptoms of this complication. In addition to providing guidance in a playful and understandable way, these resources are also essential for improving service and optimizing the nursing team’s workflow(54).
Although there are advantages to this therapy, such as reduced hospitalizations and mortality rates, there are also weaknesses, such as hospital readmission. The causes for this phenomenon are related to hemodynamic instability, fever, altered level of consciousness, nausea/vomiting, or unavailability of a caregiver(55).
Specific context - effects of outpatient hematopoietic stem cell transplantation models
The outpatient HSCT model provides a better quality of life, fewer hospital stays, reduced nosocomial infections, and lower financial costs for healthcare services. Therefore, studies encourage this type of transplant and the dissemination of results demonstrating its effectiveness worldwide(33).
In addition to presenting financial and economic benefits for patients and institutions, it has been observed that patients undergoing HSCT performed entirely during hospitalization experience dissatisfaction with the care provided and a reduction in their quality of life, as the required social isolation leads to high levels of stress(56). However, patients undergoing outpatient HSCT had a significantly lower risk of developing febrile neutropenia and septicemia, greater satisfaction with the care provided, and better quality of life than those admitted for inpatient HSCT(2,39).
However, with healthcare professionals’ improvement, enhancements in chemotherapy infusion devices, verification of the effectiveness of chemotherapy protocols, support in the use of medications, and advances in research, these factors have propelled the transition of onco-hematological treatment from inpatient hospital settings to outpatient settings(56).
From this perspective, it is noteworthy that outpatient transplantation can be considered a feasible option due to its low morbidity and mortality rates(35,57). Furthermore, it was also observed that the time for neutrophil and platelet transplantation is shorter in the outpatient group than in the hospital group(34).
The engraftment period corresponds to a neutrophil count above 500/µL for three consecutive days and a platelet recovery greater than 20,000/µL, without blood transfusion for at least seven days. It is a critical period that requires continuous monitoring to prevent the occurrence of febrile neutropenia(58).
Neutropenia is considered a serious complication that can result in sepsis and even death if not detected and treated promptly. Therefore, nurses should train patients and caregivers to identify signs and symptoms related to this condition for early treatment(17).
Therefore, outpatient HSCT can lead to increased caregiver burden, as this person assumes the responsibility of continuing some of the care provided in healthcare institutions in home environments, periodic follow-up appointments, administration of oral medications, measurement and monitoring of vital signs, and identification of complications(51).
Immediate context - characterization of hematopoietic stem cell transplantation in outpatients
The most commonly performed transplant in the total outpatient setting is the autologous transplant. In this type of transplant, patientss own HSCs are used, and it is indicated for various oncohematological diseases, such as multiple myeloma, Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, multiple and systemic sclerosis, and some solid tumors(41). It was the first type of HSCT to be performed on an outpatient basis in 1993 in North American countries(2).
In this new care approach, patients undergo all phases of treatment (pre-, Day Zero, and post-) or some of them in an outpatient setting(5,33). In autologous cases, procedures such as HSC mobilization and collection, chemotherapy conditioning, HSC infusion, and post-HSCT care can be performed safely and entirely on an outpatient basis, without causing harm to individuals. These procedures result in greater engraftment success, improved survival, and increased life expectancy(5).
However, for these new services to succeed, a qualified and well-coordinated multidisciplinary team is necessary, composed of hematologists, general practitioners, physiotherapists, pharmacists, psychologists, social workers, and nurses(57). However, the nursing team’s performance stands out, as they follow patients up throughout their entire treatment.
In this context, the nursing team develops specific skills and knowledge that must be constantly updated through continuing health education, involving various teaching activities and knowledge expansion. It is important to highlight that it is essential to articulate the new knowledge acquired with the general strategies applied, in order to promote organizational change focused on the nursing team and the groups of collaborators in the HSCT unit(59).
Healthcare services offering this assistance should operate five to seven days a week for 12 hours a day. They must be linked to the hematology network and have access to laboratories, blood banks, emergency rooms, and inpatient units. In terms of physical structure, they need to include consulting rooms, a procedure room, an infusion room, and a multidisciplinary team specialized in the area(5,35).
Regarding the selection criteria for patients eligible for outpatient HSCT, they must be under 65 years of age, have good vital functions, live near the clinic or in support homes less than 60 minutes away, have regular blood tests, be free of infections, and have a caregiver throughout the treatment(28,34).
It is worth highlighting that the increasing number of outpatient HSCTs has expanded the capacity to provide care for people who need this type of treatment, in a more accessible and low-cost way, but with qualified and safe care(35).
Study limitations
This study presented limitations regarding the unavailability of fully published studies freely available, which may result in the loss of relevant data. Furthermore, concerning the levels of evidence of the studies, especially those demonstrating the effectiveness of outpatient HSCT in preventing infections and assessing the improvement in survival and quality of life of patients undergoing this type of care, there is a lack of information. Moreover, no studies were found that presented regulations and guidelines for outpatient HSCT implementation.
Contributions to nursing, health, or public policy
Contributions to the health field included disseminating knowledge about the modalities in which outpatient HSCT occurs and its impacts on patients’ quality of life and on improving the care offered by healthcare services, aiming to consolidate these outpatient models in a more systematic and comprehensive manner.
With regard to nursing, these contributions are geared towards nurses’ practice, since this type of care demands a fundamental role from these professionals for the success of treatment, the execution of complex care, and the provision of more complex care. Therefore, it represents a new field of practice to be explored, capable of demonstrating the importance and value of nursing in this environment.
Therefore, it is necessary to develop new studies that promote discussion about current legislation and guidelines on this topic as a way to encourage the implementation of outpatient HSCT in lowand middle-income countries.
-
FUNDING
To CAPES for the scholarships granted.
AVAILABILITY OF DATA AND MATERIAL
The research data are available in a repository: https://doi.org/10.17605/OSF.IO/8GSZN.
REFERENCES
-
1 Azevedo IC, Ferreira Junior MA, Nascimento AAA, Vitor AF, Teston EF, Frota OP, et al. Analysis of factors associated with hematopoietic stem-cell retransplantation: a case-control study. Rev Latino-Am Enfermagem. 2022;30(1):e3569. https://doi.org/10.1590/1518-8345.5794.3569
» https://doi.org/10.1590/1518-8345.5794.3569 -
2 Gómez-Almaguer D, Gómez-De León A, Colunga-Pedraza PR, Cantú-Rodríguez OG, Gutierrez-Aguirre CH, Ruíz-Arguelles G. Outpatient allogeneic hematopoietic stem-cell transplantation: a review. Ther Adv Hematol. 2022;13(1):1-11. https://doi.org/10.1177/20406207221080739
» https://doi.org/10.1177/20406207221080739 -
3 Thong E, Poon M, Lim P, Kumari S, Yelly, Lim HL et al. Safety, feasibility and healthcare cost differences between inpatient and outpatient mobilization chemotherapy for autologous hematopoietic stem cell transplantation in multiple myeloma: a single center experience. Blood. 2021 138(1):1921-2. https://doi.org/10.1182/blood-2021-152882
» https://doi.org/10.1182/blood-2021-152882 -
4 Barban A. Análise da mobilização e resultados do transplante de células-tronco hematopoiéticas autogênico (TCTHa) com alta hospitalar precoce nos portadores de doenças hematológicas [Dissertação]. São Paulo: Universidade de São Paulo; 2013. https://doi.org/10.11606/D.5.2013.tde-09102013-155104
» https://doi.org/10.11606/D.5.2013.tde-09102013-155104 - 5 Azevedo VD. Desenvolvimento de um fluxograma para o cuidado de enfermagem no transplante autólogo ambulatorial de células-tronco hematopoiéticas [Dissertação]. Natal: Universidade Federal do Rio Grande do Norte; 2023.
-
6 Couto F, Silva M, Santos A, Oliveira R, Lima P. Enfermagem em Transplante de Células Tronco Hematopoiéticas: estudo bibliométrico. Rev Praxis. 2022 Nov;24(1):29-46. https://doi.org/10.47385/praxis.v14.n28.3942
» https://doi.org/10.47385/praxis.v14.n28.3942 -
7 Silva BS, Nascimento MIS, Ramos EMFC, Paixão EFS, Ronconi FS. Transplante de medula óssea e os cuidados de enfermagem. Rev Científ Fac Educ Meio Ambiente [Internet]. 2020[cited 2025 Apr 2];10(Esp):124-30. Available from: https://revista.faema.edu.br/index.php/Revista-FAEMA/article/view/1133
» https://revista.faema.edu.br/index.php/Revista-FAEMA/article/view/1133 -
8 Opstal JV, Zhao AT, Kaplan SJ, Cantado AD, Schoemans H. eHealth-generated patient data in an outpatient setting after hematopoietic stem cell transplantation: A scoping review. Transplant Cell Ther. 2022;28(8):463-71. https://doi.org/10.1016/j.jtct.2022.05.016
» https://doi.org/10.1016/j.jtct.2022.05.016 -
9 Hinds PS, Chaves DE, Cypress SM. Context as a source of meaning and understanding. Qualitative Health Research. 1992;2(1):61-74. https://doi.org/10.1177/104973239200200105
» https://doi.org/10.1177/104973239200200105 -
10 Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372(71):1-36. https://doi.org/10.1136/bmj.n71
» https://doi.org/10.1136/bmj.n71 -
11 The Joanna Briggs Institute. Joanna Briggs Institute reviewers’ manual: 2020 edition. Adelaide, Australia: Author, 2020. https://doi.org/10.7326/M18-0850
» https://doi.org/10.7326/M18-0850 -
12 Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan: a web and mobile app for systematic reviews. Syst Rev. 2016;5(210):1-10. https://doi.org/10.1186/s13643-016-0384-4
» https://doi.org/10.1186/s13643-016-0384-4 -
13 Meisenberg, BR, Ferran K, Hollenbach K, Brehm T, Jollon J, Piro LD. Reduced charges and costs associated with outpatient autologous stem cell transplantation. Bone Marrow Transplant. 1998;21(9):927-32. https://doi.org/10.1038/sj.bmt.1701191
» https://doi.org/10.1038/sj.bmt.1701191 -
14 Ruiz-Argüelles GJ, Ruiz-Argüelles A, Pérez-Romano B, Marín-López A, Delgado-Lamas JL. Non-cryopreserved peripheral blood stem cells autotransplants for hematological malignancies can be performed entirely on an outpatient basis. Am J Hematol. 1998;58(3):161-164. https://doi.org/10.1002/(sici)1096-8652(199807)58:3<161::aid-ajh1>3.0.co;2-p
» https://doi.org/10.1002/(sici)1096-8652(199807)58:3<161::aid-ajh1>3.0.co;2-p -
15 Schulmeister L, Quiett K, Mayer K. Quality of life, quality of care, and patient satisfaction: perceptions of patients undergoing outpatient autologous stem cell transplantation. Oncol Nurs Forum. 2005;32(1):57-67. https://doi.org/10.1188/05.ONF.57-67
» https://doi.org/10.1188/05.ONF.57-67 -
16 Atmar JS, Xá HB, Nash V. Impact of multidisciplinary care in improving outcomes in multiple myeloma patients receiving outpatient autologous peripheral blood stem cell transplantation. Transplant Nurs. 2005;11(2):1. https://doi.org/10.1016/j.bbmt.2004.12.281
» https://doi.org/10.1016/j.bbmt.2004.12.281 -
17 Faucher C, Le Corroller Soriano AG, Esterni B, Vey N, Stoppa AM , Chabannon C, et al. Randomized study of early hospital discharge following autologous blood SCT: medical outcomes and hospital costs. Bone Marrow Transplant. 2012;47(4):549-55. https://doi.org/10.1038/bmt.2011.126
» https://doi.org/10.1038/bmt.2011.126 -
18 Martino M, Montanari M, Bruno B, Console G, Irrera G, Messina G, et al. Autologous hematopoietic progenitor cell transplantation for multiple myeloma through an outpatient program. Expert Opin Biol Ther. 2012;12(11):1449-62. https://doi.org/10.1517/14712598.2012.707185
» https://doi.org/10.1517/14712598.2012.707185 -
19 Holbro A, Ahmad I, Cohen S, Roy J, Lachance S, Chagnon M, et al. Safety and cost-effectiveness of outpatient autologous stem cell transplantation in patients with multiple myeloma. Biol Blood Marrow Transplant. 2013;19(4):547-51. https://doi.org/10.1016/j.bbmt.2012.12.006
» https://doi.org/10.1016/j.bbmt.2012.12.006 -
20 Martino M, Montanari M, Ferrara F, Ciceri F, Scortechini I, Palmieri S, et al. Very low rate of readmission after an early discharge outpatient model for autografting in multiple myeloma patients: an Italian multicenter retrospective study. Biol Blood Marrow Transplant. 2014;20(7):1026-32. https://doi.org/10.1016/j.bbmt.2014.03.027
» https://doi.org/10.1016/j.bbmt.2014.03.027 -
21 Campbell P, Walker P, Avery S, Patil S, Curtis D, Schwarer A, et al. Safe and effective use of outpatient non-myeloablative allogeneic stem cell transplantation for myeloma. Blood Cancer J. 2014;4(5):e213. https://doi.org/10.1038/bcj.2014.33
» https://doi.org/10.1038/bcj.2014.33 -
22 Graff TM, Singavi AK, Schmidt W, Eastwood D, Drobyski WR, Horowitz M, et al. Safety of outpatient autologous hematopoietic cell transplantation for multiple myeloma and lymphoma. Bone Marrow Transplant. 2015;50(7):947-53. https://doi.org/10.1038/bmt.2015.46
» https://doi.org/10.1038/bmt.2015.46 -
23 Paul TM, Liu SV, Chong EA, Luger SM, Porter DL, Schuster SJ, et al. Outpatient autologous stem cell transplantation for patients with myeloma. Clin Lymphoma Myeloma Leuk. 2015;15(9):536-40. https://doi.org/10.1016/j.clml.2015.05.006
» https://doi.org/10.1016/j.clml.2015.05.006 -
24 Abid MB, Christopher D, Abid MA, Poon ML, Tan LK, Koh LP, et al. Safety and cost-effectiveness of outpatient autologous transplantation for multiple myeloma in Asia: single-center perspective from Singapore. Bone Marrow Transplant. 2017;52(7):1044-6. https://doi.org/10.1038/bmt.2017.77
» https://doi.org/10.1038/bmt.2017.77 -
25 Shah N, Cornelison AM, Saliba R, Ahmed S, Nieto YL, Bashir Q, et al. Inpatient vs outpatient autologous hematopoietic stem cell transplantation for multiple myeloma. European journal of haematology. 2017;99(6):5352-535. https://doi.org/10.1111/ejh.12970
» https://doi.org/10.1111/ejh.12970 -
26 Lisenko K, Sauer S, Bruckner T, Egerer G, Goldschmidt H, Hillengass J, et al. High-dose chemotherapy and autologous stem cell transplantation of patients with multiple myeloma in an outpatient setting. BMC Cancer. 2017;17(151):1-10. https://doi.org/10.1186/s12885-017-3137-4
» https://doi.org/10.1186/s12885-017-3137-4 -
27 Martino M, Ciavarella S, De Summa S, Russo L, Meliambro N, Imbalzano L, et al. A comparative assessment of quality of life in patients with multiple myeloma undergoing autologous stem cell transplantation through an outpatient and inpatient model. Biol Blood Marrow Transplant. 2018;24(3):608-13. https://doi.org/10.1016/j.bbmt.2017.09.021
» https://doi.org/10.1016/j.bbmt.2017.09.021 -
28 Owattanapanich W, Suphadirekkul K, Kunacheewa C, Ungprasert P, Prayongratana K. Risk of febrile neutropenia among patients with multiple myeloma or lymphoma who undergo inpatient versus outpatient autologous stem cell transplantation: a systematic review and meta-analysis. BMC Cancer. 2018;18(1):1126. https://doi.org/10.1186/s12885-018-5054-6
» https://doi.org/10.1186/s12885-018-5054-6 -
29 Granot N, Storer BE, Cooper JP, Flowers ME, Sandmaier BM, Storb R. Allogeneic hematopoietic cell transplantation in the outpatient setting. Biol Blood Marrow Transplant. 2019;25(11):2152-9. https://doi.org/10.1016/j.bbmt.2019.06.025
» https://doi.org/10.1016/j.bbmt.2019.06.025 -
30 Koo J, Silverman S, Nuechterlein B, Keating AK, Verneris MR, Foreman NK, et al. Safety and feasibility of outpatient autologous stem cell transplantation in pediatric patients with primary central nervous system tumors. Bone Marrow Transplant. 2019;54(10):1605-13. https://doi.org/10.1038/s41409-019-0479-3
» https://doi.org/10.1038/s41409-019-0479-3 -
31 Kodad SG, Sutherland H, Limvorapitak W, Abou Mourad Y, Barnett MJ, Forrest D, et al. Outpatient autologous stem cell transplants for multiple myeloma: analysis of safety and outcomes in a tertiary care center. Clin Lymphoma Myeloma Leuk. 2019;19(12):784-90. https://doi.org/10.1016/j.clml.2019.09.619
» https://doi.org/10.1016/j.clml.2019.09.619 -
32 Dhir V, Zibdawi L, Paul HK, Espin-Garcia O, Chen CI, Crump M, et al. Quality of life and caregiver burden in patients and their caregivers undergoing outpatient autologous stem cell transplantation compared to inpatient transplantation. Blood. 2021;138(4):1-10. https://doi.org/10.1182/blood-2019-131281
» https://doi.org/10.1182/blood-2019-131281 -
33 Dytfeld D, Lojiko-Dankowska A, Nowicki A, Matuszak M, Wache A, Gil L. Safety and cost effectiveness of outpatient autologous hematopoietic stem cell transplantation for multiple myeloma - single-center experience of a pilot Early Discharge Program. Acta Haematol Pol. 2021;52(3):178-81. https://doi.org/10.5603/ahp.a2021.0029
» https://doi.org/10.5603/ahp.a2021.0029 -
34 Martino M, Paviglianiti A, Memoli M, Martinelli G, Cerchione C. Multiple myeloma outpatient transplant program in the era of novel agents: state-of-the-art. Front Immunol. 2020;10:592487. https://doi.org/10.3389/fonc.2020.592487
» https://doi.org/10.3389/fonc.2020.592487 -
35 González MJ, Urizar E, Urtaran-Laresgoiti M, Nuño-Solinís R, Lázaro-Pérez E, Vázquez L, et al. Hospital and outpatient models for hematopoietic stem cell transplantation: a systematic review of comparative studies for health outcomes, experience of care and costs. PLoS One. 2021;16(8):e0254135. https://doi.org/10.1371/journal.pone.0254135
» https://doi.org/10.1371/journal.pone.0254135 -
36 Martino M, Pitino A, Tripepi G, Paviglianiti A, Russo L, Cusumano G, et al. The burden in caregivers of multiple myeloma patients undergoing outpatient autologous stem-cell transplantation compared to inpatient transplantation. Clin Lymphoma Myeloma Leuk. 2021;21(4):e402-9. https://doi.org/10.1016/j.clml.2020.11.011
» https://doi.org/10.1016/j.clml.2020.11.011 -
37 Tan XN, Yew CY, Ragg SJ, Harrup RA, Johnston AM. Outpatient autologous stem cell transplantation in Royal Hobart Hospital, Tasmania: a single-centre, retrospective review in the Australian setting. Intern Med J. 2022;52(7):1242-50. https://doi.org/10.1111/imj.15334
» https://doi.org/10.1111/imj.15334 -
38 Jaime-Pérez JC, Meléndez-Flores JD, Ramos-Dávila EM, Hernandez-Coronado M, González-Treviño M, Tarín-Arzaga L, et al. Outpatient hematopoietic cell transplantation for older adults with hematologic malignancies: results at an academic tertiary-care center. J Geriatr Oncol. 2022;13(2):190-3. https://doi.org/10.1016/j.jgo.2021.08.007
» https://doi.org/10.1016/j.jgo.2021.08.007 -
39 Marini J, Maldonado A, Weeda E, Neppalli A, Hashmi H, Edwards K. Effectiveness, safety, and cost implications of outpatient autologous hematopoietic stem cell transplant for multiple myeloma: a single center experience. Hematol Oncol Stem Cell Ther. 2023;16(4):351-7. https://doi.org/10.56875/2589-0646.1038
» https://doi.org/10.56875/2589-0646.1038 -
40 Garcés-Carrasco AM, Santacatalina-Roig E, Carretero-Márquez C, Chover-Sierra, Martínez-Sabater A, Balaguer-López E. Post-transplant complications in patients undergoing autologous hematopoietic cell transplantation (HCT): a comparative analysis of home care versus hospitalized patients. Medicina (Kaunas). 2024;60(1):44. https://doi.org/10.3390/medicina60010044
» https://doi.org/10.3390/medicina60010044 -
41 Khaddour K, Hana CK, Mewawalla P. Hematopoietic stem cell transplantation. StatPearls. 2021;1(1):1-15. https://doi.org/10.7326/M18-0850
» https://doi.org/10.7326/M18-0850 -
42 Rocha V, Fatobene G, Niederwieser D. Transplantation and the worldwide network for blood and marrow transplantation: increasing access to allogeneic hematopoietic cell transplant - an international perspective. Hematol Am Soc Hematol Educ Program. 2021;2021(1):264-74. https://doi.org/10.1182/hematology.2021000258
» https://doi.org/10.1182/hematology.2021000258 -
43 Hershenfeld SA, Matelski J, Ling V, Paterson M, Cheung M, Cram P. Utilisation and outcomes of allogeneic hematopoietic cell transplantation in Ontario, Canada, and New York State, USA: a population-based retrospective cohort study. BMJ Open. 2020;10(10):e039293. https://doi.org/10.1136/bmjopen-2020-039293
» https://doi.org/10.1136/bmjopen-2020-039293 -
44 Goldsmith SR, San-Rozano M, Katindoy J, Rattanapichetkul J, Rosenzweig M. Policy and perspective on outpatient programs for autologous hematopoietic cell transplantation and immune-effector cell therapy administration. Front Immunol. 2024;15:1423959. https://doi.org/10.3389/fimmu.2024.1423959
» https://doi.org/10.3389/fimmu.2024.1423959 -
45 EBMT. JACIE accreditation Activity Report 2024[Internet]. 2024[cited 2025 Apr 2]. https://www.ebmt.org/annual-report-2024/jacie-activity-report-2024
» https://www.ebmt.org/annual-report-2024/jacie-activity-report-2024 -
46 Iida M, Kodera Y, Dodds A, Ho AYL, Nivison-Smith I, Akter MR, et al. Advances in hematopoietic stem cell transplantation in the Asia-Pacific region: the second report from APBMT 2005-2015. Bone Marrow Transplant. 2019;54(12):1973-86. https://doi.org/10.1038/s41409-019-0554-9
» https://doi.org/10.1038/s41409-019-0554-9 -
47 Ministério da Saúde (BR), Conselho Nacional de Saúde (CNS). Resolução nº 44, de 10 de janeiro de 2001. Aprovar no âmbito do Sistema Único de Saúde a modalidade de assistência Hospital Dia [Internet]. Brasília: Ministério da Saúde; 2001[cited 2025 Apr 2]. https://bvsms.saude.gov.br/bvs/saudelegis/gm/2001/prt0044_10_01_2001.html
» https://bvsms.saude.gov.br/bvs/saudelegis/gm/2001/prt0044_10_01_2001.html - 48 Conselho Federal de Enfermagem (Cofen). Resolução COFEN nº 629/2020. Aprova e atualiza a norma técnica que dispõe sobre a atuação de enfermeiro e de técnico de enfermagem em hemoterapia. Brasília: COFEN; 2020.
-
49 Cazeau N, Cavlier K, Bhatt V, McElrath C, Lestrange N, Lachaud-Richard M, et al. Outpatient BEAM using daily etoposide and cytarabine with autologous hematopoietic stem cell transplantation for lymphoma is feasible and decreases inpatient length of stay. Blood. 2019;134(1):5830-1. https://doi.org/10.1182/blood-2019-127402
» https://doi.org/10.1182/blood-2019-127402 -
50 Costa CO, Monteiro IBS, Rodrigues GLO, Monteles AO, Gomes AF, Souza SBF, et al. Atuação do enfermeiro na administração segura de quimioterapia antineoplásica endovenosa: relato de experiência. Hematol Transfus Cell Ther. 2020;42(2):455-6. https://doi.org/10.1016/j.htct.2020.10.767
» https://doi.org/10.1016/j.htct.2020.10.767 -
51 Singhal S, Saadeh SS, Durani U, Kansagra A, Alkhateeb HB, Shah MV, et al. Allogeneic hematopoietic stem cell transplantation in the outpatient setting: the Mayo Clinic experience. Transplant Cell Ther. 2023;29(3):180-6. https://doi.org/10.1016/j.jtct.2022.12.016
» https://doi.org/10.1016/j.jtct.2022.12.016 -
52 Bachier CR, Aggarwal SK, Hennegan K, Milgroom A, Francis K, Dehipawala S, et al. Epidemiology and treatment of chronic graft-versus-host disease post-allogeneic hematopoietic cell transplantation: a US claims analysis. Transplant Cell Ther. 2021;27(6):504-10. https://doi.org/10.1016/j.jtct.2020.12.027
» https://doi.org/10.1016/j.jtct.2020.12.027 -
53 Sabatelli L, Keranen M, Viayna E, Roset M, Lara N, Thunstrom D, et al. Burden of hospitalizations and outpatient visits associated with moderate and severe acute graft-versus-host disease in Finland and Sweden: a real-world data study. Support Care Cancer. 2022;30(6):5125-35. https://doi.org/10.1007/s00520-022-06915-9
» https://doi.org/10.1007/s00520-022-06915-9 -
54 Niero AC, Rodrigues JAP, Piubello SMN. Construction of an educational booklet for guidance on care in graft-versus-host disease. Enferm Foco[Internet]. 2021[cited 2025 Apr 2];12(4):753-9 Available from: https://enfermfoco.org/wp-content/uploads/articles_xml/2357-707X-enfoco-12-04-0753/2357-707X-enfoco-12-04-0753.pdf
» https://enfermfoco.org/wp-content/uploads/articles_xml/2357-707X-enfoco-12-04-0753/2357-707X-enfoco-12-04-0753.pdf -
55 Prieto del Prado MA, Fernández Avilés F. Ambulatory models for autologous stem-cell transplantation: a systematic review of the health impact. Front Immunol. 2024;15:1419186. https://doi.org/10.3389/fimmu.2024.1419186
» https://doi.org/10.3389/fimmu.2024.1419186 -
56 Applebaum AJ, Bevans M, DuHamel K, Tuminello S, Scherber R, Amonoo HL, et al. Fit for duty: lessons learned from outpatient and homebound hematopoietic cell transplantation to prepare family caregivers for home-based care. Transplant Cell Ther. 2023;29(3):143-50. https://doi.org/10.1016/j.jtct.2022.12.014
» https://doi.org/10.1016/j.jtct.2022.12.014 -
57 Crowe J, Edbrooke L, Khot A, Dnehy L, Francis JJ. Enablers and barriers to referral and delivery of multidisciplinary prehabilitation in the autologous stem cell transplant population: a theory-based interview study. Support Care Cancer. 2022. https://doi.org/10.1007/s00520-023-08234-z
» https://doi.org/10.1007/s00520-023-08234-z -
58 Nascimento AAA. Construção e validação de tecnologia educacional para formação de enfermeiros do transplante de células-tronco hematopoéticas sobre o Programa Paciente Experto [Dissertação] [Internet]. Natal: Universidade Federal do Rio Grande do Norte; 2022[cited 2025 Apr 2]. https://repositorio.ufrn.br/handle/123456789/51181
» https://repositorio.ufrn.br/handle/123456789/51181 -
59 Rodrigues JAP, Lacerda MR, Galvão MC, Gomes IM, Meier MJ, Caceres NTG. Cuidados de enfermagem aos pacientes em pós-transplante de células-tronco hematopoiéticas: revisão integrativa. Rev Bras Enferm. 2021;74(3):1-11. https://doi.org/10.1590/0034-7167-2020-0097
» https://doi.org/10.1590/0034-7167-2020-0097
Edited by
-
EDITOR IN CHIEF:
Dulce Barbosa
-
ASSOCIATE EDITOR:
Rafael Silva
