Deviations from guideline-based therapy for febrile neutropenia in cancer patients.

Abstract

6078 Background: Febrile neutropenia (FN) is a common cause of morbidity in cancer patients. We examined guideline and non-guideline based care for cancer patients hospitalized with FN and examined how treatment influenced outcomes. Methods: The Perspective database was used to examine the treatment of solid tumor patients with FN from 2000-2010. To capture initial decision-making, we examined treatment within 48 hrs of admission. Based on evidence-based guidelines we determined the appropriate use of guideline-based antibiotics as well as use of treatments not routinely recommended, vancomycin and granulocyte-colony stimulating factors (GCSF). Hierarchical mixed effects models were developed to examine the influence of patient, physician, and hospital characteristics on the quality of treatment. Patients were stratified into low and high-risk groups and the effect of initial treatment on outcome (nursing home discharge and death) examined. Results: Among 25,231 patients with FN, within 48 hours of admission blood cultures were obtained in 90%, guideline-based antibiotic administered to 79%, vancomycin to 37%, and GCSF to 63%. Patients treated at high-volume hospitals, by high-volume physicians and patients managed by hospitalists were more likely to receive guideline-based antibiotics (p<0.05). Vancomycin use increased with time from 17% in 2000 to 55% in 2010 while GCSF use only decreased from 73% to 55%. Patients treated by internists and hospitalists were more likely to receive vancomycin; high-volume physicians were less likely to treat with both vancomycin and GCSF (p<0.05). Among patients who received GCSF, 15% received only one dose and 22% received 2 doses of filgrastim. Among low-risk patients prompt initiation of guideline-based antibiotics decreased the risk of discharge to a nursing facility (OR=0.78; 95% CI, 0.66-0.91) and death (OR=0.65; 95% CI, 0.50-0.85). Conclusions: There is substantial variability in the initial treatment for FN in cancer patients. While use of appropriate empiric antibiotics is high, use of non guideline-based treatments such as vancomycin and GCSF are common. Physician and hospital factors are the most important predictors of both guideline and non guideline-based treatment.