ASCT is the primary treatment for MM, with MM accounting for 55–70% of all ASCT procedures performed annually in Europe and the United States[16, 17]. ASCT in patients with MM typically has low toxicity with a mortality rate under 3%, which has prompted the exploration of various outpatient models—total outpatient care, early discharge, and delayed admission—since 1995[7, 9]. They have shown significant advantages, such as reduced infection rates, improved mental health, and enhanced quality of life due to family support, with a therapy-related mortality rate consistently below 1%[10–13, 15]. These benefits have been confirmed by meta-analysis[14]. Additionally, outpatient ASCT has been shown to enhance healthcare cost-effectiveness by up to 60%[19–22].
Nonetheless, outcomes are influenced by multiple factors, with febrile neutropenia being the most common reason for re-admission, occurring in 30–70% of patients. Factors associated with re-admission include Grade 3–4 mucositis, fever, delayed transplantation, low albumin levels, and female sex[9, 12]. Socioeconomic considerations, such as the need for 24-hour caregiver availability, proximity to healthcare facilities, and a comprehensive understanding of clinical urgencies by patients, also play a crucial role in determining the feasibility of outpatient ASCT[23].
In Thailand, several challenges hinder the implementation of outpatient ASCT. First, the tropical climate increases the risk of microbial infections. Outpatient care is also complicated by a lack of specialized units for routine and emergency patient follow-up. Significant geographic and socioeconomic obstacles, such as long travel distances to healthcare facilities and insufficient self-care knowledge among patients and caregivers, pose significant barriers. Additionally, the high demand for positive pressure rooms needed for stem cell transplantation exceeds the availability of HEPA-filtered rooms. To mitigate these issues, our institution implemented an early SD ward approach for patients with MM after ASCT.
Our study’s findings confirm the effectiveness of the early SD ward following ASCT in patients with MM. The infection rates were similar between the groups, with septicemia occurring in 13% of the SD group and 12% of the HEPA-filtered group (OR 1.18, 95% CI 0.55–2.5). Re-admission rates were also comparable, with 6% in the SD group versus 9% in the HEPA-filtered group (OR 0.64, 95% CI 0.55–1.66). There were no cases of therapy-related mortality within the first 100 days following ASCT in either group. Additionally, the early SD ward significantly reduced the duration of stay in HEPA-filtered rooms, with median durations of 4 days (range: 1–11) versus 18 days (range: 10–43, p < 0.001).
The implementation of this strategy led to a significant increase in the number of ASCT procedures at our center, which has only four HEPA-filtered rooms. Prior to the early SD ward, our annual volume was 30–40 ASCTs. After its implementation, from 2020 to 2023, we performed 85–100 ASCTs annually, even during the COVID-19 pandemic. This substantial increase underscores the role of the early SD ward in enhancing the accessibility of ASCT in resource-constrained settings without increasing morbidity and mortality rates. Furthermore, these results suggest that ASCT can be effectively performed in hospitals lacking HEPA-filtered rooms, contingent upon rigorous early septic workup and prompt administration of antibiotics to manage complications.
The next phase at our institute will focus on training nurses in the SD ward to administer chemotherapy for ASCT in patients with MM. ASCT will be conducted primarily in the SD ward, reserving HEPA-filtered rooms predominantly for allogeneic stem cell transplantations.
The limitations of this study include its single-center design, which may impede the generalizability of the results to other healthcare environments. The retrospective nature of the research introduces the potential for selection bias and incomplete data collection, which could compromise the accuracy of our findings. Furthermore, the absence of a comprehensive cost analysis diminishes our ability to evaluate the economic impact of the early SD ward approach. Additionally, as this study was conducted in Thailand, its findings may not be directly applicable to other geographical or ethnic populations.
To overcome these limitations and bolster the validity and applicability of our results, future research should expand to multicenter studies with larger sample sizes and extended follow-up periods. Such studies would help validate our findings and facilitate the adoption of the early SD ward model in diverse healthcare environments globally.