2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

dren treated with oral therapy compared with intravenous
therapy in the outpatient setting, although other outcomes,
including treatment failure and adverse events, were similar;
and there were no infection-related deaths among lowrisk
pediatric patients.
Consequently, if oral antibiotics can confidently be administered,
oral antibiotic therapy may be used in selected
low-risk children with FN, either in the outpatient or inpatient
settings. One approach to outpatient oral antibiotic
administration may be to administer one dose of oral antibiotics
during the initial health care encounter and only
discharge home with oral therapy if that dose can be
ingested. Costs, feasibility, and patient/family preferences
should influence the route of antibiotic administration for
children with low-risk FN in both the outpatient and inpatient
settings.
Costs
The adult literature has consistently demonstrated that
outpatient management is substantially cheaper than inpatient
management of FN, primarily related to the costs of
hospitalization. 19-21 Limited data are available on costs in
the pediatric setting. 16,17 However, the literature supports a
similar cost-saving associated with ambulatory management
in children. 22,23
A pediatric cost-utility model has been created that includes
event probabilities, costs, and QoL estimates. 24 Outpatient
management was the most cost-effective approach,
with outpatient intravenous antibiotic administration being
more cost-effective than outpatient oral antibiotic administration
because of the higher rate of readmission among
those who receive oral antibiotics and better QoL seen
with intravenous therapy (see below). However, within the
plausible range of some inputs into the model, outpatient
management with oral therapy could become the most
cost-effective strategy. Entire treatment in hospital with
intravenous antibiotics was the least cost-effective strategy;
it was more expensive and less effective than an early
discharge approach.
These data suggest that from a cost perspective, outpatient
management with either intravenous or oral antibiotics
should be used if the infrastructure is in place to support
this model of care, and, if the child, family, and system
factors permit an ambulatory approach.
QoL and Preferences
QoL considerations and preferences become more important
when strategies such as outpatient management of FN
have advantages and trade-offs. The advantages of outpatient
therapy include substantial cost-saving for the health
care system and reduction in nosocomial infections. However,
the trade-offs include increased responsibility and
burden for parents and other care providers, the need to
monitor children remotely from the health care center, and
the need for follow-up visits. It is important to evaluate QoL
and preferences for several reasons. First, this knowledge
allows strategies to be compared using approaches such as
cost-effectiveness analyses. Second, this information can
help to develop outpatient programs and may influence how
programs are structured. In other words, this information
may be used to determine whether or which outpatient FN
programs might be successful in a given context or practice
setting.
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QoL and preferences are two distinct constructs, although
QoL may influence preferences. QoL is complex in pediatric
medicine because QoL considerations may include the index
child, siblings, and parents/providers. Outpatient management
of children with FN may be associated with improved
QoL for children 25 although the effect on parents is unclear.
26 In a cross-sectional study in which we interviewed
parents of children with cancer and health care providers
who care for these children, we asked respondents to compare
just two options, namely oral outpatient management
compared with inpatient intravenous management. 26 Both
parents and health care professionals believed child QoL
would be better at home compared with the hospital setting.
However, health care professionals, when compared to parents,
overestimated QoL for children at home and underestimated
QoL for parents in the hospital setting.
In order to gain more insight, we asked parents of children
with cancer and the children themselves to anticipate child
QoL in four different scenarios, namely outpatient oral
therapy, outpatient intravenous therapy, early discharge,
and inpatient intravenous management. 27 The outpatient
regimen in these studies always included three times weekly
clinic visits as the standard scenario because almost all
published studies of outpatient management in pediatric
cancer include at least this frequency of clinic visits. Among
parent respondents, early discharge and outpatient management
with intravenous antibiotics were associated with
higher anticipated child QoL (score of 5.9 each on a 10-point
visual analog scale), whereas outpatient oral therapy was
associated with the lowest anticipated child QoL (score of
4.7). In other words, parents were concerned about the effect
of oral medication administration on the child’s QoL. For
child self-respondents, all of whom were 12 years or older,
early discharge was anticipated to be associated with the
highest child QoL. It is important to note that there are very
little data about child self-report of QoL in different FN
health states.
Preference will likely include QoL considerations but
also may include factors such as fear and anxiety, costs,
and logistics. We have taken several approaches to the
elicitation of preferences. The simplest approach is one in
which we have asked parents and children their preferred
management strategy. Using this approach, consistently,
approximately 50% of parents preferred outpatient management
compared with inpatient management. 26,27 When
asked to rank the most preferred strategy among the four
options, we found that the most common top-ranked choice
was inpatient intravenous management among both parents
and children. 27
We have also used other techniques to gain insight into
parent decision making in the context of management options
for low-risk FN. More specifically, we evaluated preferences
using a threshold technique and conjoint analysis.
With the threshold technique, one measures strength of
preference for a treatment option by systematically changing
one attribute of a treatment option (for example, increasing
or decreasing the number of clinic visits per week
associated with outpatient care) until the respondent gives
up their initially preferred option. Using this technique, we
described strength of preferences for inpatient parenteral
compared with outpatient oral management. 26 We found
that, in general, in order to accept outpatient oral management,
parents would not tolerate clinic visits more than