Experience shows in febrile neutropenia treatment

By Eleanor McDermid, Senior medwireNews Reporter

The strongest predictors of guideline-compliant care of cancer patients with febrile neutropenia are the case volumes of the treating physicians and hospitals, a study shows.

The research, published in JAMA Internal Medicine, reveals that adherence to guideline-based treatment of febrile neutropenia is high, but so is the use of some treatments that lack solid evidence.

"While the association among volume, treatment, and outcome has received the most attention for surgical procedures, there is growing recognition that volume affects care for common medical conditions as well," comment lead researcher Jason Wright (Columbia University College of Physicians and Surgeons, New York, USA) and co-workers.

Their study involved 25,231 cancer patients hospitalized with febrile neutropenia between 2000 and 2010, 78.9% of whom received guideline-recommended antibiotics. After adjustment for confounding factors, physicians dealing with high annual volumes of febrile neutropenia (>2.7 cases) were 19% more likely to prescribe guideline antibiotics relative to those dealing with low volumes (<1.4 cases). In addition, high (≥14.6 cases) versus low (<8.4 cases) annual hospital volumes raised the likelihood for guideline care by 56%.

Physician specialty also influenced guideline adherence, with hospitalists the most likely to administer recommended antibiotics - 49% more likely than medical oncologists. On the other hand, hospitalists were the most likely to administer vancomycin, for which Wright et al say there is little evidence of benefit, but which was given to 36.9% of the patients over the study period.

Vancomycin was less likely to be used by physicians with high versus low febrile neutropenia volumes, but was more likely to be administered in hospitals with high case volumes.

Granulocyte colony-stimulating factors (GCSFs), which have no impact on mortality in febrile neutropenia and are not recommended, were given to 62.9% of patients. Physician and hospital febrile neutropenia volumes were not associated with use of GCSFs, but they were significantly less likely to be administered to patients in teaching, as opposed to nonteaching, hospitals.

Use of GCSFs fell over the time period of the study, but only from 72.5% to 55.0%, whereas vancomycin use increased, from 17.2% to 54.9%.

Ronald Chen (University of North Carolina at Chapel Hill, USA), the author of an invited commentary, agrees with the researchers' opinion that the overall guideline adherence rate is high, saying that expecting complete adherence would "fail to acknowledge the complexity of clinical scenarios and patient autonomy."

However, he highlights the finding that nonadherence is related to less experience on the part of physicians and hospitals, stressing that this is "fixable." He says: "These findings suggest that education and clinical decision support have the potential to increase guideline adherence."

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