Effects of a Guideline-Informed Clinical Decision Support System Intervention to Improve Colony-Stimulating Factor Prescribing: A Cluster Randomized Clinical Trial.

Autor:	Ramsey SD; Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington., Bansal A; Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington.; The Comparative Health Outcomes, Policy, and Economics Institute, School of Pharmacy, University of Washington, Seattle., Sullivan SD; Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington.; The Comparative Health Outcomes, Policy, and Economics Institute, School of Pharmacy, University of Washington, Seattle., Lyman GH; Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington.; School of Medicine, University of Washington, Seattle., Barlow WE; Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington.; SWOG Statistics and Data Management Center, Seattle, Washington., Arnold KB; Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington.; SWOG Statistics and Data Management Center, Seattle, Washington., Watabayashi K; Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington., Bell-Brown A; Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington., Kreizenbeck K; Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington., Le-Lindqwister NA; Illinois CancerCare-Peoria (Heartland Cancer Research National Cancer Institute Community Oncology Research Program), Peoria., Dul CL; Ascension St John Hospital (Michigan Cancer Research Consortium National Cancer Institute Community Oncology Research Program), Detroit., Brown-Glaberman UA; University of New Mexico Cancer Center (New Mexico Minority Underserved National Cancer Institute Community Oncology Research Program, Albuquerque., Behrens RJ; Medical Oncology and Hematology Associates-Des Moines (Iowa-Wide Oncology Research Coalition National Cancer Institute Community Oncology Research Program), Des Moines., Vogel V; Geisinger Medical Center (Geisinger Cancer Institute National Cancer Institute Community Oncology Research Program), Danville, Pennsylvania., Alluri N; St Luke's Cancer Institute-Boise (Pacific Cancer Research Consortium National Cancer Institute Community Oncology Research Program), Boise, Idaho., Hershman DL; Department of Medicine and Epidemiology, Columbia University, New York, New York.
Jazyk:	angličtina
Zdroj:	JAMA network open [JAMA Netw Open] 2022 Oct 03; Vol. 5 (10), pp. e2238191. Date of Electronic Publication: 2022 Oct 03.
DOI:	10.1001/jamanetworkopen.2022.38191
Abstrakt:	Importance: Colony-stimulating factors are prescribed to patients undergoing chemotherapy to reduce the risk of febrile neutropenia. Research suggests that 55% to 95% of colony-stimulating factor prescribing is inconsistent with national guidelines. Objective: To examine whether a guideline-based standing order for primary prophylactic colony-stimulating factors improves use and reduces the incidence of febrile neutropenia. Design, Setting, and Participants: This cluster randomized clinical trial, the Trial Assessing CSF Prescribing Effectiveness and Risk (TrACER), involved 32 community oncology clinics in the US. Participants were adult patients with breast, colorectal, or non-small cell lung cancer initiating cancer therapy and enrolled between January 2016 and April 2020. Data analysis was performed from July to October 2021. Interventions: Sites were randomized 3:1 to implementation of a guideline-based primary prophylactic colony-stimulating factor standing order system or usual care. Automated orders were added for high-risk regimens, and an alert not to prescribe was included for low-risk regimens. Risk was based on National Comprehensive Cancer Network guidelines. Main Outcomes and Measures: The primary outcome was to find an increase in colony-stimulating factor use among high-risk patients from 40% to 75%, a reduction in use among low-risk patients from 17% to 7%, and a 50% reduction in febrile neutropenia rates in the intervention group. Mixed model logistic regression adjusted for correlation of outcomes within a clinic. Results: A total of 2946 patients (median [IQR] age, 59.0 [50.0-67.0] years; 2233 women [77.0%]; 2292 White [79.1%]) were enrolled; 2287 were randomized to the intervention, and 659 were randomized to usual care. Colony-stimulating factor use for patients receiving high-risk regimens was high and not significantly different between groups (847 of 950 patients [89.2%] in the intervention group vs 296 of 309 patients [95.8%] in the usual care group). Among high-risk patients, febrile neutropenia rates for the intervention (58 of 947 patients [6.1%]) and usual care (13 of 308 patients [4.2%]) groups were not significantly different. The febrile neutropenia rate for patients receiving high-risk regimens not receiving colony-stimulating factors was 14.9% (17 of 114 patients). Among the 585 patients receiving low-risk regimens, colony-stimulating factor use was low and did not differ between groups (29 of 457 patients [6.3%] in the intervention group vs 7 of 128 patients [5.5%] in the usual care group). Febrile neutropenia rates did not differ between usual care (1 of 127 patients [0.8%]) and the intervention (7 of 452 patients [1.5%]) groups. Conclusions and Relevance: In this cluster randomized clinical trial, implementation of a guideline-informed standing order did not affect colony-stimulating factor use or febrile neutropenia rates in high-risk and low-risk patients. Overall, use was generally appropriate for the level of risk. Standing order interventions do not appear to be necessary or effective in the setting of prophylactic colony-stimulating factor prescribing. Trial Registration: ClinicalTrials.gov Identifier: NCT02728596.
Databáze:	MEDLINE
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