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| | Author (year) | Country of origin | Study methodology and design | Study population | Outcomes measured | Key findings reported |
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| Primary research | Mcmonagle (2015) [24] | UK | Qualitative interview, three-time intervals, and phenomenological approach | 8 adult participants with a mean age of 58 (range 35–67) undergoing melphalan or LEAM (lomustine, etoposide, cytarabine, and melphalan) autograft in an ambulatory care
Lymphoma (n = 5) and multiple myeloma (n = 3) | Patient experience | Patients appreciated the privacy that ambulatory care afforded. Initially, most unaccompanied patients were content to stay on their own, but their need for companionship increased as they became more unwell. Often patients could recognise when they required hospital admission to complete treatment |
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| Primary research | Nissim et al. (2014) [25] | Canada | Qualitative interview and grounded theory | 35 adult participants with a median age of 49 (range 26–71)
Acute myeloid leukaemia
Consolidation chemotherapy delivered on an ambulatory basis | Perceptions of experience during the transition from inpatient to ambulatory care | Participants described adjusting to the intensity of ambulatory care and the need to assume greater responsibility for their own care. They reported a focus on understanding their longer-term care plan, compared to a focus on the present time as an inpatient |
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| Primary research | Morrison (2010) [26] | USA | Qualitative interview | 21 registered nurse participants
Cancer population | Adult nurses’ experiences of delivering ambulatory care | Identified five themes reflecting expert ambulatory nursing practice: being a content expert, creating positive relationships, listening with attuned skill, advocating for the patient, and developing long-term patient/family relationships |
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| Primary research | Statham (2005) [12] | UK | Interpretive phenomenology and qualitative interview | 7 adult participants with a mean age of 50 (range 40–63)
Lymphoma
BEAM (BCNU, etoposide, cytarabine, and melphalan) autograft | Patient experience | Treatment in an ambulatory care is an empowering experience, which facilitates the implementation of various coping mechanisms such as an increased level of patient control, greater normality, and privacy.
Results revealed that the importance of relationships was the most dominant theme, in particular, family and friends.
A supportive social network, personal commitment, and motivation were found to be essential prerequisites for a positive ambulatory experience |
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| Primary research | Grimm et al. (2000) [27] | USA | A longitudinal, descriptive study comparing the emotional responses and needs of caregivers of patients who underwent bone marrow transplantation in an inpatient-outpatient setting compared with those in an inpatient setting. Data were collected at six points across the BMT trajectory (before the procedure to 12 months after) | 43 caregivers were selected, n = 26 from the inpatient unit and n = 17 from the ambulatory setting
Haematological malignancy
Patients undergoing either autologous or allogeneic bone marrow transplantation | Emotional responses were measured by the profile of Mood states. The importance and satisfaction of information, patient care, and psychological needs were assessed by a caregiver needs survey | Findings support the inpatient-outpatient model of care as being less emotionally distressing and for better meeting the needs of family caregivers. Specific implications for practice include the importance of caregiver education |
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| Primary research | Tighe et al. (1985) [28] | USA | A conceptual framework of ambulatory care nursing activities was used to help describe the role of the oncology and non-oncology nurse at a large federal hospital | 84 questionnaires were given to nurses with a 60% response rate
26% of participants were oncology nurses and, the remaining 74% were classified as “non-oncology”
Type of cancer treatment not stated | A self-report questionnaire based on the conceptual framework was developed to obtain information about nursing practice. Respondents indicated the frequency they had engaged in individual activities | Oncology nurses had a greater involvement in therapeutic care and communication activities within the ambulatory cancer setting compared with non-oncology nurses |
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| Retrospective studies | Li et al. (2022) [29] | USA | A retrospective chart review of 253 cycles of high-dose and intermediate-dose cytarabine is given at a shorter time interval to facilitate the administration as an outpatient | 118 adult patients
Acute myeloid leukaemia
Cytarabine given in a shorter interval of every 10 hr instead of 12 hrs | Safety, feasibility, and bed days saved along with the need for hospitalisation | No patients required hospitalisation during chemotherapy. 43 (36%) patients required hospitalisation most commonly due to neutropenia. Report shows that 1265 bed days were saved, and a significant income was generated |
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| Retrospective studies | Li et al. (2021) [30] | USA | A retrospective chart review of 193 cycles of dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) given via an ambulatory infusion pump on an outpatient basis | 219 cycles of dose-adjusted EPOCH were given to 56 patients with a diagnosis of B-cell lymphoma with 193 cycles administered in the outpatient setting | Safety, financial analysis, and bed days saved | No patients required hospitalisation during outpatient administration resulting in 965 saved hospital days.
There were 26 inpatient cycles administered with the most common reason for inpatient administration being close monitoring required for tumour lysis syndrome. 23 patients required 40 hospital admissions between cycles, most commonly due to neutropenia. Safety reported, alongside financial gains |
| Retrospective studies | Fridtjof et al. (2018) [31] | Denmark | A retrospective review of 177 ambulatory care chemotherapy courses. Service coordinated by a hospital with patients residing at home | 84 patients aged 20–74 years (median age = 46–58)
Acute myeloid leukaemia, acute lymphoblastic leukaemia, non-Hodgkin lymphoma, and Hodgkin lymphoma
Induction and consolidation chemotherapy | Safety and ability to undertake self-care requirements using a portable programmable infusion pump | Homebased ambulatory care is safe and frees up hospital beds for patients in need. Safe use of portable programmable infusion pumps was demonstrated, and improved patient experience was suggested. Authors indicated that a national implementation study in six regional centres in Denmark to investigate the feasibility of portable infusion pumps and homecare-based advanced chemotherapy in AML was planned |
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| Retrospective studies | Villegas et al. (2017) [32] | Argentina | A retrospective analysis of ambulatory high-dose methotrexate (HDMX) from April 2007 to December 2010. 150 of 447 courses of HDMTX (31.4%) were given on an outpatient basis among 24 patients | Children aged 7 to 17 years (mean age = 12.6)
High grade osteosarcoma
HDMTX administration with oral hydration, alkalinisation, and leucovorin rescue | Feasibility, safety | Successful ambulatory administration was defined as the lack of need for hospital admission within the first 24 hours after HDMTX administration. 91.2% of treatments were successfully completed on an ambulatory basis demonstrating feasibility and safety in a less well-resourced population |
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| Retrospective studies | Reid et al. (2016) [33] | USA | A retrospective chart review of 58 patients who received BCNU, etoposide, cytarabine, and melphalan (BEAM) conditioning on an outpatient basis, compared to a prior cohort of 49 patients who received inpatient BEAM conditioning | Outpatient cohort’s mean age = 58 years. Inpatient cohort’s mean age = 59 years
Hodgkin or non-Hodgkin lymphoma
BEAM chemotherapy before autologous haematopoietic stem cell transplantation | Feasibility, cost, complications, and clinical outcomes | Length of hospital stay reduced by 6 days for the outpatient (OP) cohort resulting in cost savings.
Fewer complications, infections, and toxicities occurred in the OP cohort.
Authors conclude a likely improvement in patient satisfaction and quality of life associated with the AC pathway |
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| Retrospective studies | Graff et al. (2015) [34] | USA | A retrospective cohort study of 230 patients who underwent autologous haematopoietic cell transplantation for myeloma or lymphoma (135 inpatients and 95 outpatients) | In the outpatient cohort, aged 21–76 years, 66.3% had myeloma and 33.7% had lymphoma. (median age = 59 yrs) | Toxicities and adverse events; transplant outcomes | With daily evaluation and supportive care, outpatient transplantation can result in acceptable toxicities and good clinical outcomes. The impact of outpatient on quality of life requires further study and it acknowledges the requirement for a companion to take responsibility for the patient |
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| Retrospective studies | Sive et al. (2012) [3] | UK | A retrospective analysis of data from 1443 AC patient episodes across a 6-year period (2005–2011) | Patients aged 18–79 years (median age = 41 years)
Haematological malignancies (82%) and sarcoma (17%)
Among the 1443 admissions to ambulatory care, 1203 were for the administration of chemotherapy, haematopoietic stem cell transplant, or monitoring of neutropenia | Safety, feasibility, and hospital capacity management | Creation of bed capacity is described as a driver. Safety and efficiencies of pathway are demonstrated. Report shows that anecdotal patient feedback had been generally positive, with an appreciation for less time spent on the ward and more with family members |
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| Retrospective studies | Solomon et al. (2010) [35] | USA | A retrospective review of 100 consecutive patients who underwent a matched-related donor myeloablative allogeneic haematopoietic stem cell transplant (HSCT) on an ambulatory basis between January 2000 and February 2006. Patients were required to have a caregiver with them available on a 24-hr basis | Patients aged 21–64 years (median age = 44 years)
Haematological malignancies
Haemopoietic stem cell transplant | Safety, need for hospitalisation, and clinical outcomes | Outpatient myeloablative allogeneic HSCT with expectant inpatient management can be accomplished safely. Advances in supportive care medications have made transplants possible on an outpatient basis. Safety and efficiencies of pathway are demonstrated. Authors suggest efforts to decrease hospital utilisation that may translate to improved patient satisfaction and quality of life, reduced exposure to nosocomial pathogens, lower costs, and reduced pressure on available beds |
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| Retrospective studies | Mahadeo et al. (2010) [36] | USA | A retrospective analysis of 97 ambulatory HDMTX administrations amongst 12 patients | Patients aged 7 to 22 years with a mean age of 15 years
High grade osteosarcoma
HDMTX | Safety, feasibility, and cost of outpatient administration | 99% of AC admissions (n = 97) were successfully completed demonstrating safety, feasibility, and cost-effectiveness, whilst improved quality of life was suggested |
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| Retrospective studies | Bakhshi, et al. (2009) [2] | India | A retrospective review to assess the outcomes of 90 cycles of acute myeloid leukaemia consolidation given to 30 patients between July 2003 and July 2007 | Children aged 1.5–15 years (mean age = 8 years)
Acute myeloid leukaemia
High-dose cytosine arabinoside consolidation | Safety and feasibility | Among 69 cycles given on an outpatient basis, 44 cycles were managed entirely on an AC basis, and 25 cycles required readmission to the hospital (36.2%) associated with febrile neutropenic episodes or documented infections.
Increasing attention to the quality of life and to healthcare costs, bigger demand for existing inpatient resources, and high risk of severe multiresistant infections are seen as a driver for the service. Avoiding delays in treatment due to bed capacity is regarded as a benefit.
Outpatient ambulatory chemotherapy was reported as safe, and resulted in a shorter duration of febrile neutropenia |
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| Retrospective studies | Zelcer et al. (2008) [37] | USA | A retrospective review of 708 chemotherapy cycles during a 6-year period (1996–2002) | 82 children and young people aged 6–32 (median age = 16 years)
High grade osteosarcoma
HDMTX | Safety and feasibility | 82% were successfully completed as an outpatient demonstrating that the ambulatory pathway is safe and feasible |
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| Retrospective studies | Rosen and Nirenberg (1982) [38] | USA | Review of experience delivering HDMTX on an ambulatory basis among 5000 treatments during a 5-year period (1977–1982) | Adult and adolescent oncology
High-grade osteosarcoma
HDMTX | Safety and feasibility | Asserting that outpatient administration of high-dose methotrexate (HDMTX) is safe, and often safer if delivered in an outpatient setting as patient and family members can be often more diligent in undertaking the monitoring required. Reduced cost of treatment is a benefit of the service |
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| Quality improvement and service evaluation | Ranney et al. (2020) [39] | USA | Quality improvement project: Home ambulation following high-dose methotrexate delivered in hospital for acute lymphoblastic leukaemia amongst 10 patients who completed a total of 38 chemotherapy cycles. A quality of life (QOL) mixed-methods survey was administered to patients and their caregivers to measure concepts related to QOL | Age range: 2 to 16 years with a mean age of 7 years
Acute lymphoblastic leukaemia
HDMTX | Outcomes measured: Laboratory results of renal function and medication clearance, length of hospitalisation, and family-reported quality of life | Project sought to improve the QOL for patients and their families during the period post HDMTX infusion without compromising safety. Families reported that measured quality of life improved in most domains with family time and sleep having the largest improvement, while the level of stress remained the same (completion rate 50% = 5 families). The opportunity to use families’ developed support system, coping skills, and connection to friends and family was reported |
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| Quality improvement and service evaluation | Beaty et al. (2015) [40] | USA | A quality improvement project to establish a process for the administration of vincristine, dactinomycin, and cyclophosphamide (VAC) chemotherapy in the outpatient setting to improve patient satisfaction and to reduce costs | 7 patients aged 1–16 years (median age of 8.5 years) who received 31 cycles of outpatient VAC
Most patients were male (n = 6)
Rhabdomyosarcoma
Vincristine, dactinomycin, and cyclophosphamide (VAC) chemotherapy | Caregiver satisfaction and cost | Alongside clinical outcomes, patient and caregiver satisfaction was measured via a modified Likert scale survey (parental proxy reporting). 100% of patients reported that they prefer outpatient over inpatient administration. Reduced costs are seen as a driver for the pathway alongside the release of inpatient beds for other patients |
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| Quality improvement and service evaluation | Brown and Walker (2016) [41] | UK | A service evaluation exploring the different stakeholder perspectives of AYA ambulatory care via focus group, claims, concerns, and issues exercise with nurse specialists (n = unknown), questionnaires to nursing staff (n = 14) and doctors (n = 5) | Age range 13–24 years (age of participants not stated)
Adolescent and young adult cancer
Focus group participants: patients n = 3 and carers n = 2
Type of treatment not stated | Experience | Stakeholders identified opportunities for ambulatory care to empower TYA patients enabling young people to get involved and take more responsibility for their care whilst living as normal a life as possible. A potential for anxiety associated with the pathway was acknowledged |
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| Literature review | Richie (2005) [42] | UK | Described as a “mini-review,” the aim of the literature search was to assess whether outpatient autologous haematopoietic stem cell transplant (AHSCT) was as effective as inpatient | Four databases were searched, 10 references were screened by abstract, and four studies were included in the review | Bed occupancy and morbidity | A perception that ambulatory AHSCT offers a better quality of life but there was little evidence available to support this |
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