Decreasing Cost and Decreasing Length of Stay After Implementation of Updated High-Dose Methotrexate Discharge Criteria

PURPOSE: High-dose methotrexate (HD-MTX) is commonly used for the treatment of osteosarcoma or for CNS involvement in lymphoproliferative neoplasms. It is often given in the inpatient setting because of monitoring requirements after administration. We conducted a process improvement initiative to change our institutional discharge criteria for HD-MTX from 0.05 µmol/L to ≤ 0.1 µmol/L to reduce cost and length of stay (LOS) for this patient population.METHODS: After an assessment of drivers of LOS among patients receiving HD-MTX, we identified discharge criteria as an actionable factor. We developed a workflow to discharge patients with 3 days of oral leucovorin and sodium bicarbonate when the methotrexate level reached ≤ 0.1 µmol/L. Patient demographics, chemotherapy regimen, cycle, dose, and LOS data were collected for a 7-month period before and a 4-month period after the intervention. Cost savings were estimated on the basis of the daily cost of a hospital bed at the institution.RESULTS: Mean LOS for the pre-intervention and postintervention group was 4.84 days (n = 49) and 3.67 days (n = 42), respectively, resulting in a 24.4% reduction in LOS, with a mean ratio of 0.756 (95% CI, 0.615 to 0.927; P = .007). Reduced LOS resulted in a decrease in cost of $1,828.73 per admission, with a 4-month savings of $76, 806.56 and projected annualized savings of $230,419.67. No patient experienced complications because of the change in discharge criteria.CONCLUSION: Liberalizing discharge criteria for HD-MTX was feasible and safe and reduced cost. Additional efforts to reduce LOS for elective chemotherapy admissions or to safely transition some of these complex regimens to the home setting are currently underway at our institution.