Deviations from guideline-based therapy for febrile neutropenia in cancer patients and their effect on outcomes

Abstract

Importance: Although febrile neutropenia (FN) is a major source of morbidity and mortality for patients with solid tumors, little is known about the use of guideline-based care.

Objectives: To examine compliance with guideline-based recommendations for FN treatment, explore the factors that influence adherence to consensus guidelines, and analyze how the use of guideline-based care affects the outcomes.

Design: The Perspective database was used to examine the treatment of cancer patients with FN from January 1, 2000, through March 31, 2010. To capture initial decision making, we examined treatment within 48 hours of hospital admission. We determined use of guideline-based antibiotics and nonguideline-based treatments, vancomycin, and granulocyte colony-stimulating factors (GCSF). Hierarchical models were developed to examine the factors associated with treatment. Patients were stratified into low- and high-risk groups, and the effect of the initial treatment on outcome (nonroutine hospital discharge and death) was examined.

Setting and participants: Twenty-five thousand two hundred thirty-one patients with solid tumors hospitalized for neutropenia.

Main outcome measure: Use of guideline-based antibiotics, vancomycin, and GCSF and their affect on outcome.

Results: Among 25 231 patients admitted with FN, guideline-based antibiotics were administered to 79%, vancomycin to 37%, and GCSF to 63%. Patients treated at high FN-volume hospitals (odds ratio [OR], 1.56; 95% CI, 1.34-1.81) by high FN-volume physicians (OR, 1.19; 95% CI, 1.03-1.38) and patients managed by hospitalists (OR, 1.49; 95% CI, 1.18-1.88) were more likely to receive guideline-based antibiotics (P < .05). Vancomycin use increased from 17% in 2000 to 55% in 2010, while GCSF use only decreased from 73% to 55%. Among low-risk patients with FN, prompt initiation of guideline-based antibiotics decreased discharge to a nursing facility (OR, 0.77; 95% CI, 0.65-0.92) and death (OR, 0.63; 95% CI, 0.42-0.95).

Conclusions and relevance: While use of guideline-based antibiotics is high, use of the nonguideline-based treatments, vancomycin, and GCSF is also high. Physician and hospital factors are the strongest predictors of both guideline- and nonguideline-based treatment.

Figure 1

Use of guideline and non-guideline based therapy for patients with febrile neutropenia stratified into low and high-risk groups. A. Guideline-base antibiotics. B. Vancomycin. C. Granulocyte colony stimulating factor. The black line represents the overall mean for each treatment.

Figure 1

Use of guideline and non-guideline based therapy for patients with febrile neutropenia stratified into low and high-risk groups. A. Guideline-base antibiotics. B. Vancomycin. C. Granulocyte colony stimulating factor. The black line represents the overall mean for each treatment.

Figure 2

Use of filgrastim in patients with febrile neutropenia. A. Number of days of filgrastim use. B. Percentage of hospital days in which filgrastim was used in patients who received the drug.