September 22, 2011 — Discharging cancer patients with "low-risk" febrile neutropenia early from the hospital seems safe and definitely lowers the cost of care, according to a pair of studies published online September 19 in the Journal of Clinical Oncology — one dealing with safety and the other dealing with cost.
However, in a surprise finding from the safety study, patients treated at home were not significantly more comfortable, according to the authors of a multicenter, controlled randomized trial that compared hospital and home treatment. The trial involved 113 cancer patients who developed febrile neutropenia (temperature ≥100.5 °F; neutrophil count >500/uL) after chemotherapy.
"We found no evidence of adverse medical consequences from home care, despite a protocol designed to detect evidence of clinical deterioration," write the authors, led by James A. Talcott, MD, from Massachusetts General Hospital and Harvard Medical School in Boston.
There were 5 major medical complications (8%) in the hospital group (n = 66) and 4 (9%) in the home-care group (n = 47) (P = .56). No study patient died.
However, despite the study's findings and conclusion, it does not allow for a "definitive statement about comparable complication risk" because of low accrual, say the authors of an accompanying editorial, Alison Freifeld, MD, from the University of Nebraska Medical Center in Omaha, and Kent Sepkowitz, MD, from Memorial Sloan-Kettering Cancer Center in New York City.
But the new data add to the literature, which cumulatively provide "strong evidence" that outpatient management is "safe, effective, and comparable to standard hospital-based therapy," the pair note.
However, the editorialists and the study authors say it is "surprising" that there was only marginal evidence of quality of life being better at home.
The reason for that might be that the trial was started 17 years ago when intravenous antibiotics were the standard of treatment. Low-risk patients are now more commonly treated with less cumbersome oral antibiotics for febrile neutropenia, observe Dr. Freifeld and Dr. Sepkowitz.
Nevertheless, they found the quality-of-life findings somewhat troublesome.
"Perhaps outpatients felt more vulnerable or neglected without the safety net of around-the-clock medical care in the hospital. Clearly this aspect of home-based therapy needs to be more carefully studied," the editorialists write.
Early discharge is a common practice. A 2008 survey of practicing oncologists in the United States revealed that 82% used outpatient antibiotic management for selected patients with fever and neutropenia who were considered to be at low risk for complications.
The cost study found that discharging low-risk patients early was unequivocally less expensive. Mean total charges for the hospital group were 47% higher than for the home-care group ($16,341 vs $10,977; P > .01), report lead author Ann Hendricks, PhD, from the VA Boston Healthcare System, in Massachusetts, and colleagues.
Rules of Thumb for Home Care
In the safety study, the suggested broad-spectrum antibiotic regimens for patients without penicillin allergy included a semisynthetic penicillin plus aminoglycoside combination or ceftazidime alone; for penicillin- and cephalosporin-allergic patients, imipenem alone or an aztreonam-containing regimen was suggested.
The median presenting absolute neutrophil count was 100/uL, and the median neutropenia duration was 4 days. Hematopoietic growth factors were used in 38% of the episodes. Five outpatients were readmitted to the hospital.
With regard to quality of life, the investigators used the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) and found that self-reported pain decreased for home-care patients and slightly increased for hospitalized patients (P = .01). Emotional function scores increased for home-care patients and declined for hospitalized patients (P = .04). No other QLQ-C30 subscale differences were evident.
No differences were noted in consumer satisfaction or the general well-being questionnaire.
Patients were considered to be low risk, in general, if they had no indication for hospitalization other than fever and neutropenia and had adequately controlled cancer.
The investigators evaluated patients more precisely with a set of validated prediction rules, developed by Dr. Talcott and colleagues, to identify patients with febrile neutropenia who are at low risk. It is 1 of 2 such validated rules sets that incorporate the variables of patient history, age, acute clinical conditions, outpatient status, and severity of underlying disease, according to the editorialists. The other is from the Multinational Association for Supportive Care in Cancer.
The editorialists provided a list of "basic rules" that need to be observed when discharging febrile neutropenia patients early:
J Clin Oncol. Published online September 19, 2011. Abstract, Abstract, Editorial
However, in a surprise finding from the safety study, patients treated at home were not significantly more comfortable, according to the authors of a multicenter, controlled randomized trial that compared hospital and home treatment. The trial involved 113 cancer patients who developed febrile neutropenia (temperature ≥100.5 °F; neutrophil count >500/uL) after chemotherapy.
"We found no evidence of adverse medical consequences from home care, despite a protocol designed to detect evidence of clinical deterioration," write the authors, led by James A. Talcott, MD, from Massachusetts General Hospital and Harvard Medical School in Boston.
There were 5 major medical complications (8%) in the hospital group (n = 66) and 4 (9%) in the home-care group (n = 47) (P = .56). No study patient died.
However, despite the study's findings and conclusion, it does not allow for a "definitive statement about comparable complication risk" because of low accrual, say the authors of an accompanying editorial, Alison Freifeld, MD, from the University of Nebraska Medical Center in Omaha, and Kent Sepkowitz, MD, from Memorial Sloan-Kettering Cancer Center in New York City.
But the new data add to the literature, which cumulatively provide "strong evidence" that outpatient management is "safe, effective, and comparable to standard hospital-based therapy," the pair note.
However, the editorialists and the study authors say it is "surprising" that there was only marginal evidence of quality of life being better at home.
The reason for that might be that the trial was started 17 years ago when intravenous antibiotics were the standard of treatment. Low-risk patients are now more commonly treated with less cumbersome oral antibiotics for febrile neutropenia, observe Dr. Freifeld and Dr. Sepkowitz.
Nevertheless, they found the quality-of-life findings somewhat troublesome.
"Perhaps outpatients felt more vulnerable or neglected without the safety net of around-the-clock medical care in the hospital. Clearly this aspect of home-based therapy needs to be more carefully studied," the editorialists write.
Early discharge is a common practice. A 2008 survey of practicing oncologists in the United States revealed that 82% used outpatient antibiotic management for selected patients with fever and neutropenia who were considered to be at low risk for complications.
The cost study found that discharging low-risk patients early was unequivocally less expensive. Mean total charges for the hospital group were 47% higher than for the home-care group ($16,341 vs $10,977; P > .01), report lead author Ann Hendricks, PhD, from the VA Boston Healthcare System, in Massachusetts, and colleagues.
Rules of Thumb for Home Care
In the safety study, the suggested broad-spectrum antibiotic regimens for patients without penicillin allergy included a semisynthetic penicillin plus aminoglycoside combination or ceftazidime alone; for penicillin- and cephalosporin-allergic patients, imipenem alone or an aztreonam-containing regimen was suggested.
The median presenting absolute neutrophil count was 100/uL, and the median neutropenia duration was 4 days. Hematopoietic growth factors were used in 38% of the episodes. Five outpatients were readmitted to the hospital.
With regard to quality of life, the investigators used the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) and found that self-reported pain decreased for home-care patients and slightly increased for hospitalized patients (P = .01). Emotional function scores increased for home-care patients and declined for hospitalized patients (P = .04). No other QLQ-C30 subscale differences were evident.
No differences were noted in consumer satisfaction or the general well-being questionnaire.
Patients were considered to be low risk, in general, if they had no indication for hospitalization other than fever and neutropenia and had adequately controlled cancer.
The investigators evaluated patients more precisely with a set of validated prediction rules, developed by Dr. Talcott and colleagues, to identify patients with febrile neutropenia who are at low risk. It is 1 of 2 such validated rules sets that incorporate the variables of patient history, age, acute clinical conditions, outpatient status, and severity of underlying disease, according to the editorialists. The other is from the Multinational Association for Supportive Care in Cancer.
The editorialists provided a list of "basic rules" that need to be observed when discharging febrile neutropenia patients early:
- a minimum 24-hour in-hospital observation period before discharge
- the constant availability of a telephone, caregiver, and transportation to the hospital (although the 24-hour availability of the caregiver can be waived, depending on the "comfort level" of the physician and patient and the distance to the hospital)
- laboratory tests not less than 3 times weekly
- guidelines that describe specific clinical events or laboratory findings that would require hospital readmission.
J Clin Oncol. Published online September 19, 2011. Abstract, Abstract, Editorial
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