Decision Aid Improves Management of Febrile Neutropenia

Pam Harrison

August 13, 2019

A clinical decision aid developed by the Mayo Clinic helps improve adherence to best practice guidelines for the management of febrile neutropenia (FN) in patients with cancer, new research shows.

"Compliance with FN guidelines improves the effective use of antimicrobials but the suboptimal rate of adherence to guidelines at many institutions results in poor antimicrobial stewardship practices, larger pharmaceutical expenses, and negative patient care outcomes," observe the authors, led by John O'Horo MD, MPH, Mayo Clinic, Rochester, Minnesota.

"We successfully developed a consensus best practice standard for evaluating and treating patients with FN [and] showed that [it] can be used to modify clinician practices to better align with best practices," they conclude.

The study was published online July 19 in the Journal of Oncology Practice.

The team focused on creating a tool to help guide providers through empirical antimicrobial selection and diagnostic evaluation of patients with FN during the first 24 hours after their diagnosis.

To do this, they used AskMayoExpert (AME), an application for medical knowledge, to develop a care process model (CPM) that would standardize the management of FN.

"We evaluated the incidence of nonadherence to best practice before, during, and after rollout of a clinical decision aid in conjunction with an educational initiative," investigators note. The project itself took place during a year-long study interval.

Some 28 patients with possible FN were identified at baseline, 14 of whom had true FN.

When the project was over, the authors identified 26 patients with potential FN, 11 of whom had true FN.

Post-project assessments were made 3 months after dissemination of the decision aid, when 32 patients with possible FN were identified, 15 of whom had true FN.

At baseline, antimicrobial use consistent with the best-practice algorithm developed by the Mayo Clinic was only 42.9%, as study authors report.

At the end of the project, antimicrobial use that matched the clinic's best-practice algorithm had risen to 72.7%. Three months after completion of the project, antimicrobial use consistent with best practices was still higher than it was at baseline, at 66.6% (P = .19).

"In every instance of antimicrobial overuse, vancomycin was used inappropriately," researchers note, "either alone or in combination with other antimicrobials," they add.

Other instances of antimicrobial overuse included inappropriate selection of a drug or drugs for double coverage of gram-negative bacteria, use of anaerobic coverage when it was deemed unnecessary, and use of carbapenem when β-lactam or cephalosporin coverage would have been adequate.

Imaging Studies

Orders for radiographic studies were consistent with the best practice algorithm in 50% of patients at baseline, the researchers continue.

By project endpoint, and also at 3 months after the project had been rolled out, radiographic studies were 100% consistent with the best practice algorithm (P < .01).

Laboratory studies, in turn, matched the new algorithm rules 21.4% of the time at baseline. This increased to 54.6% at the end of the project and to 86.7% at the post-project follow-up assessment point.

Researchers also evaluated how frequently decisions deviated from the decision protocol since implementation and found "the proportion of patients having a critical deviation was 71% at baseline, 27.3% at project end, and 33.3% at post-project."

The authors also note that, since the fourth quarter of 2017, vancomycin use on the day of admission for patients with a hematologic malignancy has remained relatively stable at between 2.08% and 4.64%.

These statistics thus support the authors' suggestion that there has not been a drift toward increasing use of vancomycin and deviation from the protocol.

"Our project successfully implemented a complex algorithm for standardizing and optimizing care for patients with FN," O'Horo and colleagues conclude.

"And since its implementation, the care process model has been continually used within the Mayo Clinic," they indicate.

O'Horo has reported no relevant financial relationships.

J Oncol Pract. Published online July 19, 2019. Abstract

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