Impact of Decision-Support On Clinicians' Assessment of Febrile Neutropenia Risk.

Background: FN is a dose-limiting toxicity of chemotherapy which can affect patient (pt) outcomes. EORTC guidelines recommend G-CSF primary prophylaxis when the overall FN risk assessment is ≥20%. We evaluated risk assessment and guideline adherence (prophylaxis in high-risk pts) in clinical practice among breast cancer patients. Methods: Eligible pts were enrolled consecutively at centres selected based on experience and geographical spread. Key inclusion criteria were diagnosis of solid tumour or lymphoma, physician-assessed overall FN risk ≥10% (chemotherapy risk plus individual risk factors per EORTC guidelines), and planned primary (PPP) or secondary (PSP) prophylaxis with pegfilgrastim. Pegfilgrastim administered >3 days after chemotherapy completion was classified as therapeutic use. The primary objective was to describe the proportion of pts with an investigator-assessed overall FN risk of >20% or 10–20% receiving PPP or PSP. Secondary objectives included evaluating FN incidence and chemotherapy dose reductions/delays. Data from breast cancer patients only are reported, and prophylaxis in high-risk patients was determined to evaluate guideline adherence. Results: 1003 pts were enrolled from Nov 2007 to Sept 2010. Mean (±SD) age was 54.4 (±11.2) years, almost all pts (99%) were female. Treatment intent was deemed curative by the investigator in 91% of pts. The investigator-assessed FN risk was >20% in 505 (50%) pts and 10–20% in 414 (41%) pts. Despite eligibility criteria, 84 (8%) pts were assessed by investigators as <10% risk; reasons for inclusion of low-risk pts were not documented. Measured baseline patient risk factors were similar between PPP and PSP pts, and PPP and PSP pts were equally likely to receive chemotherapy with curative intent (92% vs 89%) and less likely to have received prior chemotherapy (11% vs 20%). 100 pts (10%) experienced FN, 43/680 (6%) in the PPP and 53/254 (21%) in the PSP group. 45 (4%) pts experienced FN-related dose reductions or dose delays, with 22/680 (3%) in the PPP group and 22/254 (9%) in the PSP group. In the subgroup of pts assessed as high FN risk, PPP was administered to fewer pts than planned and PSP to more pts than planned (Table). Conclusion: Adherence to G-CSF guidelines, and reasons for differences between planned and administered prophylaxis warrants further investigation. Comparison of outcomes between prophylaxis groups should be interpreted with caution; however, FN incidence remained low with pegfilgrastim PP among breast cancer pts in German clinical practice. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-15-02.

Febrile Neutropenia Risk Assessment and Granulocyte-Colony Stimulating Factor Support in Patients with Diffuse Large B Cell Lymphoma Receiving R-CHOP Regimens.

Aim of the studyThe first aim was to investigate the knowledge and awareness of oncologists concerning febrile neutropenia (FN) risk assessment and indications for granulocyte colony-stimulating factor (G-CSF) primary prophylaxis (PP), based on current therapeutic guidelines (PTOK and EORTC). The second aim was to educate the oncologists on best practices for risk assessment and neutropenia management.Material and methodsThe project participants included 169 oncologists from 7 regions working in large specialist oncological centres, university hospitals, regional and city hospitals, specialist outpatient clinics, and oncological wards in small local hospitals. The participants completed a questionnaire based on seven prepared clinical cases of patients with different tumour types and patient characteristics, receiving chemotherapy (CT), and with different levels of FN risk. Participants answered questions related to FN risk assessment and G-CSF use. After completing the questionnaire, the participants proceeded to an educational module in which they were provided with an analysis of correct diagnostic and therapeutic procedures according to the PTOK and EORTC guidelines.Results and ConclusionsFebrile neutropenia risk assessment was found to be a routine procedure performed for over 90% of the clinical cases by the participant oncologists. However, the FN risk assessment of clinical cases was correct and consistent with therapeutic guidelines in only 65% of responses. Indications for G-CSF PP were properly identified in 76% of responses and it appeared that indications for G-CSF PP were more likely to be correctly identified in patients receiving high-risk or low-risk regimens than in those receiving intermediate-risk regimens, where the decision to give G-CSF PP is based on additional assessment of patient risk factors. The vast majority of participants who correctly identified the need for PP administered G-CSF in accordance with the dose and schedule recommended by PTOK and EORTC.

Predictors of Febrile Neutropenia Among Cancer Patients Receiving Myelosuppressive Chemotherapy in US Clinical Practice

Pegfilgrastim Use and Outcomes In Non-Hodgkin-Lymphoma Patients Receiving Chemotherapy In Clinical Practice: Combined Analysis Of The Austrian and Swiss E-Avare Studies

Background: A prediction model was previously developed to estimate the risk of SN or FN during the first cycle of chemotherapy, taking into account both the myelotoxicity of the chemotherapy regimen and the interplay of specific tumor and patient characteristics (Lyman, 2011). This model may potentially be useful for predicting which patients are at greatest risk for developing neutropenic complications, particularly among those patients receiving intermediate FN risk chemotherapy regimens, where the influence of patient characteristics becomes a critical consideration. To assess the clinical utility of this model, physicians assessed FN risk in patients with non-myeloid malignancies, and then physician-assessed FN risk was compared to prediction model risk. Methods: This was a prospective, multicenter, observational study (124 community-based oncologists, 944 patients). Analysis of a breast cancer subgroup (93 oncologists, 364 patients) is reported here. Patients were eligible if they were: ≥18 years old, newly diagnosed, and candidates for initiating a new course of chemotherapy using an NCCN intermediate (10-20%) FN risk chemotherapy regimen. Oncologists entered clinical data about the patient into the model; they also made a clinical prediction of FN risk. Oncologists were blinded to both the data elements collected by the model and the risk predicted by the model. Data were only collected until the chemotherapy order was written; no outcome data were collected. The primary objective was to investigate the relationship between physician-assessed FN risk and prediction model SN or FN risk. As an exploratory endpoint, physicians were asked to estimate FN risk on the same set of four hypothetical case studies with varying FN risk factors. The correlation between risk probability scores was estimated as well as a 95% confidence interval accounting for intra-physician correlation. A smooth spline curve was fit to show the average relationship between physician-assessed and prediction model risk probability scores. Results: Most patients were planning to receive TC (54%) and most had stage I-II disease (71%). Median (min, max) age was 58 years (23, 83). Physician-assessed FN risk correlated weakly with prediction model FN or SN risk: correlation 0.166 (95% CI: 0.027, 0.298). There was wide variability among all 124 physicians in their assessment of FN risk for the four case studies (Q1, Q3 case study 1: 20%, 40%; case study 2: 10%, 18%; case study 3: 20%, 40%; case study 4: 25%, 60%). Conclusions: This study suggests that community oncologists would benefit from the use of an automated system for assessing FN risk among those receiving intermediate risk chemotherapy regimens. Such a system would help oncologists identify the patients who would benefit most from clinical intervention and help improve practice efficiency and quality of care. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-15-08.

Clinicians in Emergency Medicine (EM) are increasingly exposed to guidelines and treatment recommendations. To help access and recall these recommendations, electronic Clinical Decision Support Systems (CDSS) have been developed. This study examined the use and sensibility of two CDSS designed for emergency physicians. CDDS for community acquired pneumonia (CAP) and neutropenic fever (NF) were developed by multidisciplinary teams and have been accessed via an intranet-based homepage (eCPG) for several years. Sensibility is a term coined by Feinstein that describes common sense aspects of a survey instrument. It was modified by emergency researchers to include four main headings: (1) Appropriateness; (2) Objectivity; (3) Content; and (4) Discriminative Power. Sensibility surveys were developed using an iterative approach for both the CAP and NF CDSS and distributed to all 25 emergency physicians at one Canadian site. The overall response rate was 88%. Respondents were 88% male and 83% were less than 40; all were attending EM physicians with specialty designations. A number reported never having used the CAP (21%) or NF (33%) CDSS; 54% (CAP) and 21% (NF) of respondents had used the respective CDSS less than 10 times. Overall, both CDSS were rated highly by users with a mean response of 4.95 (SD 0.56) for CAP and 5.62 (SD 0.62) for NF on a seven-point Likert scale. The majority or respondents (CAP 59%, NF 80%) felt that the NF CDSS was more likely than the CAP CDSS to decrease the chances of making a medical error in medication dose, antibiotic choice or patient disposition (4.61 vs. 5.81, p=0.008). Despite being in place for several years, CDSS for CAP and NF are not used by all EM clinicians. Users were generally satisfied with the CDSS and felt that the NF was more likely than the CAP CDSS to decrease medical errors. Additional research is required to determine the barriers to CDSS use.

Patterns of Granulocyte Colony-Stimulating Factor (G-CSF) Use in Elderly Patients with Non-Hodgkin's Lymphoma (NHL) Receiving Myelosuppressive Chemotherapy

Value of Incorporating Newly Identified Risk Factors into Risk Prediction for Chemotherapy-Induced Febrile Neutropenia (FN)

Incidence of Febrile Neutropenia Among Patients Receiving Chemotherapy Regimens Not Classified As High-Risk in Guidelines for Myeloid Growth Factor Use: Importance of “Risk Factor Stacking”

2010 update of EORTC guidelines for the use of granulocyte-colony stimulating factor to reduce the incidence of chemotherapy-induced febrile neutropenia in adult patients with lymphoproliferative disorders and solid tumours

Febrile neutropenia risk assessment tool: Improving clinical outcomes for oncology patients

This article evaluates the feasibility of developing and implementing a computer-based risk assessment tool (CBRAT) for febrile neutropenia and determines whether it could improve documentation of risk assessment in patients starting myelosuppressive chemotherapy regimens. The CBRAT was designed using a template creator in a commercial electronic medical records system. The effectiveness of the CBRAT was evaluated by comparing medical records data of patients with one or more risk factor for febrile neutropenia who were given prophylactic granulocyte-colony-stimulating factor before and after implementation. CBRAT usage significantly increased the likelihood of documented febrile neutropenia risk assessment from 13% before implementation to 100% after implementation (p < 0.001). No significant changes occurred in febrile neutropenia incidence rates, dose reductions, or dose delays. In addition, healthcare providers quickly learned how to operate the CBRAT and used it routinely, significantly improving the number of patients with documented febrile neutropenia risk assessment. Implementation of a computer-based tool can help nurses follow evidence-based guidelines that recommend routine febrile neutropenia risk assessment for patients initiating myelosuppressive chemotherapy.

Risk of Febrile Neutropenia (FN) in Select Myelosuppressive Chemotherapy Regimens

Trends in Neutropenia-Related Hospitalization in Older Patients with Non-Hodgkin Lymphoma (NHL) Receiving Myelosuppressive Chemotherapy in the United States: 1995-2015