Abstract P5-08-06: Impact of a decision-support tool on the utilization of colony-stimulating factors and incidence of febrile neutropenia among patients with breast cancer

Abstract

Abstract Background: Following the 2012 American Society of Clinical Oncology's Choosing Wisely campaign recommendation against the routine use of colony-stimulating factors (CSFs) for the primary prevention of febrile neutropenia (FN) in patients with ≤ 20% risk, an evidence-based clinical decision-support tool (CSF decision tool) was implemented to promote risk-appropriate CSF use in breast cancer patients receiving chemotherapy by a national payer in the United States (US). We hypothesized that there should be no change in pre- and post-implementation FN rates if the CSF decision tool had promoted appropriate FN risk stratification among breast cancer patients. Methods: A retrospective observational cohort study design was used to analyze data from a national payer administrative claims database of nearly 40 million lives geographically spread across the US. The CSF decision tool was first implemented in 2014, with a staggered implementation across states (July 1, 2014 - November 1, 2014). Study subjects were female patients, aged ≥ 18 years, who initiated chemotherapy for breast cancer in the time periods before or after the implementation of the decision tool (July 1, 2014 through March 30, 2015). Patients were assigned to case (defined as patients in the states where the CSF decision tool had been implemented) or control (defined as patients in states where the CSF decision tool had yet to be implemented) cohort. Patients in each cohort were followed up to 6 months after the first chemotherapy dose in the pre- and post-implementation periods. The outcomes were changes in the incidence of FN and CSF use rates, respectively. Rates of FN and CSF use were compared between the cohorts using difference-in-differences models; generalized estimating equations were used to adjust for differences in baseline risk factors including age, history of neutropenia or infections. Results: The final study population comprised 7,224 patients: 4,001 and 3,223 in the case and control cohorts, respectively. There was a higher proportion of patients who were 65 years or older in the case cohort compared to the control (22% vs 18%, p: <0.001). Otherwise, the cohorts were comparable in FN risk factors at baseline in pre- and post-implementation periods. In adjusted regression results, pre- and post-implementation FN rates were not significantly different for both case (5.38% to 5.65%) and control (5.07% to 5.13%) cohorts, [p=0.778]. Use of CSF in the pre- and post-implementation periods decreased from 75% to 69% in the case cohort compared with a reduction from 72% to 71% in the control cohort: an absolute difference of 5.4% decrease in CSF use associated with the implementation of the decision support tool [p= 0.006]. Conclusion: Despite a modest reduction in CSF use, we found no evidence of an increase in FN rates after the implementation of the CSF decision tool. Given the lack of impact of the Choosing Wisely campaign on inappropriate CSF use; our findings suggest that beyond the educational efforts and media campaigns, a greater reduction in unnecessary CSF use can be achieved through the use of clinical decision algorithms to reduce practice variation and improve adherence to national guideline recommendations. Citation Format: Adeboyeje G, Agiro A, Goodwin A, DeVries A, Malin J. Impact of a decision-support tool on the utilization of colony-stimulating factors and incidence of febrile neutropenia among patients with breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-08-06.