2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

TREATMENT APPROACHES IN CHILDREN
three times per week or a rate of readmission of more than
15%. We also found that stronger preference for outpatient
therapy was associated with higher anticipated QoL for the
parent and child at home relative to hospital. 26
We also used a conjoint analysis technique to assess
preferences and decision making for outpatient management
of low-risk FN. 28 Conjoint analysis is an emerging
approach to the measurement of preferences in the face of
multiple trade-offs in health care. In contrast to the threshold
technique, conjoint analysis allows evaluation of multiple
attributes concurrently or conjointly. 29 Using this
technique, we quantified the relative importance of attributes
associated with two treatment options—outpatient
oral compared with inpatient intravenous management.
Parents would be willing to accept only 2.1 (95% CI 1.1 to
3.2) clinic visits weekly in order to accept outpatient management.
With clinic visits three times weekly and a 7.5%
chance of readmission, the probability of parents accepting
an outpatient approach was only 43% (95% CI 39% to
48%). 28
Finally, we used a qualitative approach to better understand
parental perspectives and how this can influence
preferences. 30 The major themes identified when choosing
between outpatient oral and inpatient intravenous therapy
included convenience/disruptiveness for the family, concerns
related to physical health of the child, emotional well-being
for the child, and modifiers of parental decision making.
Thus, we demonstrated that many parents and children
prefer inpatient management, although anticipated QoL on
the aggregate level was higher with early discharge and
outpatient parenteral strategies. It is relatively straightforward
to explain these differences. Preferences for a treatment
option in this context incorporate considerations other
than child QoL, such as parent QoL, convenience, costs,
safety, and anxiety.
Implementation of Outpatient FN
We have used these findings to develop an outpatient
low-risk FN program in our own health care setting. We
have selected a very low-risk population, based on previ-
Author’s Disclosure of Potential Conflicts of Interest
Author
Lillian Sung*
*No relevant relationships to disclose.
Employment or
Leadership
Positions
Consultant or
Advisory Role
1. Bodey GP, Buckley M, Sathe YS, et al. Quantitative relationships
between circulating leukocytes and infection in patients with acute leukemia.
Ann Intern Med. 1966;64:328-340.
2. Schimpff S, Satterlee W, Young VM, et al. Empiric therapy with
carbenicillin and gentamicin for febrile patients with cancer and granulocytopenia.
N Engl J Med. 1971;284:1061-1065.
3. Pizzo PA. Management of fever in patients with cancer and treatmentinduced
neutropenia. N Engl J Med. 1993;328:1323-1332.
4. Rondinelli PI, Ribeiro Kde C, de Camargo B. A proposed score for
predicting severe infection complications in children with chemotherapyinduced
febrile neutropenia. J Pediatr Hematol Oncol. 2006;28:665-670.
5. Ammann RA, Bodmer N, Hirt A, et al. Predicting adverse events in
children with fever and chemotherapy-induced neutropenia: the prospective
multicenter SPOG 2003 FN study. J Clin Oncol. 2010;28:2008-2014.
6. Phillips B, Wade R, Stewart LA, et al. Systematic review and meta-
ously validated clinical prediction rules, to ensure that the
risk of readmission is very low and to build confidence in the
outpatient program among families and health care professionals.
We administer empiric antibiotics orally because we
have found it difficult to initiate empiric antibiotics intravenously
in a timely fashion. We administer a single dose of
oral antibiotic in the emergency room or clinic to ensure that
the child can ingest the oral antibiotic to be used in the
outpatient setting before discharge to home. The current
structure includes clinic visits two or three times weekly. A
system of home visits by nursing staff has not shown to be
feasible, and, consequently, the patients are monitored between
clinic visits with daily phone calls by a health care
professional. There are plans for evaluation of the program
on a regular basis, although it is too soon to provide such a
report.
Conclusion
In summary, a series of prospective observational studies
and RCTs have been conducted in pediatrics that support
the efficacy and safety of outpatient care and oral antibiotic
administration as initial treatment for children with lowrisk
FN. Costs are clearly lower with an ambulatory approach.
However, QoL is more complicated because child
and parent QoL considerations are important, and incremental
QoL at home compared with the hospital may not be
the same for both respondent types. Preferences are also
important to evaluate because this information may be used
to plan outpatient programs and to anticipate uptake of
these programs.
Future work may include the development of tools to ease
care in the outpatient setting and to measure caregiver
burden associated with this therapy. Additional work should
also focus on eliciting child QoL and preferences for outpatient
management of low-risk FN given that these may differ
substantially from parent-proxy responses. 31,32 Finally, the
study of the effectiveness of an ambulatory approach in the
real-world setting outside of clinical trials is important to
fully understand the effect of different management strategies
for initial treatment of low-risk pediatric FN.
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REFERENCES
Research
Funding
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