In a study reported in a research letter in JAMA Oncology, Tang et al found that the use of the subcutaneous route for administering medications and fluids in patients with cancer was highly predominant in a Canadian center, whereas use of the intravenous (IV) route was nearly universal in a U.S. center.
As stated by the investigators, “Subcutaneous administration of medications and fluids is underutilized in the U.S. despite reported benefits. It is easier to access and maintain compared with IV placement. The site may be used for 7 days or more. Patients are free of the burden of IV pumps, allowing for greater mobility. There are also cost-saving benefits….”
Study Details
The frequency of subcutaneous use was assessed at two sites that practice similar care for patients with cancer at the end of life: the acute palliative care units at The University of Texas MD Anderson Cancer Center in Houston, and at Princess Margaret Cancer Centre in Toronto. A total of 200 consecutive patient admissions with a diagnosis of advanced cancer (locally advanced, recurrent, or metastatic) at each site were reviewed in reverse chronological order from October 30 to July 1, 2020.
Key Findings
A total of 398 patients were included in the analysis, 200 from Princess Margaret and 198 from MD Anderson; 2 patients at MD Anderson had two admissions, with only the first admission for each used in the analysis. Values were missing for nine patients in the Princess Margaret cohort (analysis set = 191 patients).
For Princess Margaret vs MD Anderson: subcutaneous only was used in 106 (55.5%) of 191 patients vs 0 (0%) of 198 patients (P < .001); IV only was used in 9 (4.7%) vs 197 (99.5%) patients (P < .001); and both subcutaneous and IV were used in 76 patients (39.8%) vs 1 (0.5%) patient (P < .001).
The investigators stated, “The findings showed a substantial difference in use of subcutaneous administration between locations, with 99.5% of patients in the U.S. only using IV routes and 95.3% of Canadian patients using a subcutaneous route at some point.”
They continued, “Lack of familiarity may be a factor limiting subcutaneous use in the [United States]…. Reimbursement models may also play a role. The ‘buy-and-bill’ model may promote IV use, since payers reimburse for the cost of IV drugs given in clinical settings. This incentivizes practices to use more expensive therapies. Also, subcutaneous administration of fluids does not increase the acuity level of patients in the same manner as IV hydration, also affecting reimbursement. Length of stay was significantly shorter in the U.S. acute palliative care unit. This finding likely reflects the pressure exerted by private insurance companies for hospital discharge in the U.S. health-care system. More research is necessary to explain this finding.”
The authors concluded, “The subcutaneous route can deliver safe, effective, and more comfortable care…. More research is needed to better understand the role of subcutaneous administration in the [United States].”
Michael Tang, MD, of the Department of Palliative, Rehabilitation & Integrative Medicine, The University of Texas MD Anderson Cancer Center, is the corresponding author for the JAMA Oncology article.
Disclosure: For full disclosures of the study authors, visit jamanetwork.com.
