Safety and cost benefit of an ambulatory program for patients with low-risk neutropenic fever at an Australian centre

Teh, Benjamin W; Brown, Christine; Joyce, Trish; Worth, Leon J; Slavin, Monica A; Thursky, Karin

doi:10.1007/s00520-017-3921-3

Cited by 18 publications

(23 citation statements)

References 12 publications

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“…Similar to previous derivation and validation studies, the sensitivity and negative predictive value of this recalibrated rule for prediction of likely bacterial infection improved after a period of in-hospital observation [28,36]. When applying additional safety-net criteria, as described in adult and paediatric low-risk FN programs, 57% of FN episodes would have been eligible for home-based care with very few missed infections and only one severe adverse outcome [34,35]. A suggested approach to implementation of this rule is available, and includes a minimum inhospital observation period depending on the score [38].…”

Section: Discussionsupporting

confidence: 55%

“…Bacteraemia was defined as a recognised pathogen (including organisms associated with mucosal barrier injury in the setting of mucositis or neutropenia) from 1 blood culture set or common commensals from 2 blood culture sets drawn on separate occasions [33]. Eligibility for home based care was defined as no severe sepsis at presentation, no relapsed/refractory disease, not in induction chemotherapy, no acute myeloid leukaemia or infant leukaemia, no hematopoietic stem cell transplant and no-other complication requiring inpatient care [34,35].…”

Section: Definitionsmentioning

confidence: 99%

“…The proportion of episodes with a likely bacterial infection (including bacteraemia) was 107%, 164%, 232% and 381%, for risk-scores 0, 1, 2 and 3, respectively. Applying previously published eligibility criteria for home-based management of FN in children, the overall number of patients eligible for early transfer home would be 488 [34].…”

Section: Rule Recalibrationmentioning

confidence: 99%

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Re-evaluating and recalibrating predictors of bacterial infection in children with cancer and febrile neutropenia

et al. 2020

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Background: Numerous paediatric febrile neutropenia (FN) clinical decision rules (CDRs) have been derived. Validation studies show reduced performance in external settings. We evaluated the association between variables common across published FN CDRs and bacterial infection and recalibrated existing CDRs using these data. Methods: Prospective data from the Australian-PICNICC study which enrolled 858 FN episodes in children with cancer were used. Variables shown to be significant predictors of infection or adverse outcome in >1 CDR were analysed using multivariable logistic regression. Recalibration included re-evaluation of beta-coefficients (logistic model) or recursive-partition analysis (tree-based models). Findings: Twenty-five unique variables were identified across 17 FN CDRs. Fourteen were included in >1 CDR and 10 were analysed in our dataset. On univariate analysis, location, temperature, hypotension, rigors, severely unwell and decreasing platelets, white cell count, neutrophil count and monocyte count were significantly associated with bacterial infection. On multivariable analysis, decreasing platelets, increasing temperature and the appearance of being clinically unwell remained significantly associated. Five rules were recalibrated. Across all rules, recalibration increased the AUC-ROC and low-risk yield as compared to nonrecalibrated data. For the SPOG-adverse event CDR, recalibration also increased sensitivity and specificity and external validation showed reproducibility. Interpretation: Degree of marrow suppression (low platelets), features of inflammation (temperature) and clinical judgement (severely unwell) have been consistently shown to predict infection in children with FN.

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Section: Discussionsupporting

confidence: 55%

Section: Definitionsmentioning

confidence: 99%

Section: Rule Recalibrationmentioning

confidence: 99%

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Re-evaluating and recalibrating predictors of bacterial infection in children with cancer and febrile neutropenia

et al. 2020

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“…SPOG-AE, Alexander and Rackoff), albeit with a lower sensitivity, factoring in additional safe guards such as a period of overnight observation may make these more palatable [21,23,26]. Such a pragmatic approach has been successfully described in the adult FN population where patients stratified as low-risk must also have stable underlying disease, no active infection or medical complication requiring in-hospital care and suitably resourced follow up before being eligible for home-based care [45].…”

Section: Discussionmentioning

confidence: 99%

Risk stratification in children with cancer and febrile neutropenia: A national, prospective, multicentre validation of nine clinical decision rules

et al. 2020

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A B S T R A C TBackground: Reduced intensity treatment of low-risk febrile neutropenia (FN) in children with cancer is safe and improves quality of life. Identifying children with low-risk FN using a validated risk stratification strategy is recommended. This study prospectively validated nine FN clinical decision rules (CDRs) designed to predict infection or adverse outcome. Methods: Data were collected on consecutive FN episodes in this multicentre, prospective validation study. The reproducibility and discriminatory ability of each CDR in the validation cohort was compared to the derivation dataset and details of missed outcomes were reported. Findings: There were 858 FN episodes in 462 patients from eight hospitals included. Bacteraemia occurred in 111 (12¢9%) and a non-bacteraemia microbiological documented infection in 185 (21¢6%). Eight CDRs exhibited reproducibility and sensitivity ranged from 64% to 96%. Rules that had >85% sensitivity in predicting outcomes classified few patients (<20%) as low risk. For three CDRs predicting a composite outcome of any bacterial or viral infection, the sensitivity and discriminatory ability improved for prediction of bacterial infection alone. Across all CDRs designed to be implemented at FN presentation, the sensitivity improved at day 2 assessment. Interpretation: While reproducibility was observed in eight out of the nine CDRs, no rule perfectly differentiated between children with FN at high or low risk of infection. This is in keeping with other validation studies and highlights the need for additional safeguards against missed infections or adverse outcomes before implementation can be considered.

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“…[5][6][7] In addition to having a shorter length of hospital stay (LOS), the benefits of out-patient care include improved health-related quality of life, 8,9 reduced risk of hospital-acquired infections and lower costs. [10][11][12][13] There is consistent evidence demonstrating out-patient treatment of low-risk FN patients to be a cost-effective strategy compared with continued in-patient hospitalisation. 12,14 Although the advantages of ambulatory programs are evident, there remain inconsistencies in managing these patients.…”

Section: Introductionmentioning

confidence: 99%

National cost savings from an ambulatory program for low-risk febrile neutropenia patients in Australia

Tew

Förster²,

Teh

et al. 2019

Aust. Health Rev.

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Objective. The management of low-risk febrile neutropenia (FN) patients through ambulatory programs has demonstrated comparative safety and effectiveness to in-patient strategies. However, there is limited evidence of benefits of changing practice, particularly on a national scale. The aim of this study was to estimate costs and benefits of the program over a 10-year time horizon. Methods. A comparative cost analysis from a health system perspective was performed, comparing costs and length of stay (LOS) of patients enrolled in an ambulatory program to a historical cohort who did not receive the program. Generalised linear models were used for analysis and bootstrapped to account for uncertainty. National data of identified FN admissions were used to inform future projections, with varying proportions of low-risk patients and eligibility for the ambulatory program. Results. The overall LOS for patients in ambulatory cohort was 1.9 days shorter (95% confidence interval (CI) 1.0-2.8 days), a 50% reduction in in-patient bed-days. Although patients in the ambulatory cohort incurred additional costs due to care received outside hospital (mean (AE s.d.) A$828.03 AE 124.30), the mean total cost incurred remained substantially lower than that of the historical cohort (A$2979 lower; 95% CI A$772-5391). On a national scale, this could translate into A $62.7 million in costs averted and 41 347 bed-days saved over 10 years if the low-risk prediction rate and eligibility for ambulatory programs remained at currently observed rates. Conclusions. The wider implementation of a safe and effective ambulatory program to manage low-risk FN patients can result in significant return-on-investment for the healthcare system by eliminating avoidable costs due to unnecessary lengthy hospital admissions. What is known about the topic? There is strong evidence demonstrating outpatient treatment of low-risk FN patients to be an effective and cost-effective strategy compared with continued in-patient hospitalisation. What does this paper add? This study demonstrates the sustainability of the ambulatory program in ensuring cost benefits and in-patient beds through real-life implementation data. It also provides evidence of the substantial cost and bed-days potentially averted when the cost savings and difference in LOS are estimated on a national scale over a 10-year time horizon. What are the implications for practitioners? The management of low-risk FN patients through ambulatory or outpatient programs is a safe and effective approach. There is strong evidence demonstrating the likely cost savings and considerable bed-days saved, which can be reallocated to meet other medical demands.

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Safety and cost benefit of an ambulatory program for patients with low-risk neutropenic fever at an Australian centre

Abstract: Of relevance to hospitals providing cancer care, feasibility, safety, and cost benefits of an ambulatory program for low-risk NF patients have been demonstrated.

Cited by 18 publications

References 12 publications

Re-evaluating and recalibrating predictors of bacterial infection in children with cancer and febrile neutropenia

Re-evaluating and recalibrating predictors of bacterial infection in children with cancer and febrile neutropenia

Risk stratification in children with cancer and febrile neutropenia: A national, prospective, multicentre validation of nine clinical decision rules

National cost savings from an ambulatory program for low-risk febrile neutropenia patients in Australia

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