Inpatient versus Outpatient Chemotherapy—Benefits, Risks, and Costs

A set of guidelines came out in 1996 which codified the conventional wisdom of practicing oncologists, and made recommendations regarding hospital administration of chemotherapy. These circumstances are specified in Table 1.²

A body of literature over the last decade has informed the oncology community as to safe methods of administering chemotherapy, especially in the outpatient setting in which most 21^st century care is delivered.^12-14 Prior to November 2009, when the first set of safety standards for chemotherapy administration were published, oncologists and fellow team members were informed by guidelines, recommendations, and position statements.  The November 2009 set of standards addressed the following areas: education, training, and job functions of clinical staff administering chemotherapy; chart documentation; general chemotherapy practice; chemotherapy orders; drug preparation standards; chemotherapy administration standards; and monitoring and assessment.  These 2009 standards were considered applicable only to outpatient hematology/oncology practices in which most care is delivered.¹² 

These standards were reviewed, revised, and published in 2011 to include inpatient chemotherapy.   Agreement was obtained that all the original standards approved for outpatient treatment also applied to inpatient therapy, including the standard that a licensed practitioner must be on-site during delivery.  Wording changes were, of course, needed to expand the coverage from practice to practice/institution.  A few changes were also made in the following: 2 of the psychosocial assessment standards; a standard concerning verification of orders by a second person; another standard for labeling of chemotherapy drugs; a standard dealing with informed consent issues; a standard on error-free reporting.  The standard requiring CPR training for all staff remained unchanged.¹⁵    

The future is likely to see the development of much needed standards for oral chemotherapy, noncancer medication reconciliation, and home chemotherapy administration.¹⁵  To some extent the future is already here, and a new set of standards that includes oral chemotherapy is out for public comment.¹⁶   The role of the oncology physician or skilled allied health professional will be to help patients, other members of the oncology team, caregivers, and third-party payers learn to balance standards for safe chemotherapy administration with payment/reimbursement cost issues.