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What was the research about?

Some patients with cancer who receive chemotherapy get a serious health condition called febrile neutropenia, or FN. FN puts patients at risk for illness and death. Patients may be at high or low risk of FN, depending on the type of chemotherapy they receive. National guidelines say that doctors should prescribe a medicine called colony-stimulating factor, or CSF, for patients at high risk, but not for patients at low risk.

In this study, the research team wanted to help doctors at community cancer centers prescribe CSF based on guidelines. The team tested whether alerts in the patients’ health records increased doctors’ prescribing CSF for patients at high risk and not for patients at low risk. The team also looked at how many patients got FN.

What were the results?

For patients at high risk and low risk of FN, clinics with and without the alert didn’t differ in how doctors prescribed CSF or how many patients got FN after six months.

Who was in the study?

This study included 2,898 adult patients with breast, lung, or colorectal cancer. All were receiving their first cycle of chemotherapy at one of 32 community cancer clinics. Among patients, 79 percent were White, 12 percent were Black, 3 percent were Asian, and 2 percent were of another race; 13 percent were Hispanic. The average age was 58, and 77 percent were women.

What did the research team do?

The research team assigned the clinics by chance to the alert system or usual care. In the alert system, doctors received an alert to prescribe CSF for patients at high risk. For patients at low risk, they received an alert not to prescribe CSF. In usual care, doctors did not receive an alert and ordered CSF as they usually would.

At the end of the patients’ first chemotherapy treatment cycle and again six months later, the research team looked at data from patients’ health records.

Patients, doctors, pharmacists, and others gave input on the design of the study.

What were the limits of the study?

The study included patients with breast, lung, or colorectal cancer. Results may differ for people with other types of cancer.

Future research could look at other ways to reduce FN among patients with cancer.

How can people use the results?

Health systems can use these results when considering how to support doctors in following national guidelines for prescribing CSF.

Objective

To compare the effectiveness of a standing order for prescribing primary prophylactic colony-stimulating factors (PP-CSF) versus usual care on improving adherence to clinical practice prescription guidelines and rates of febrile neutropenia (FN) in patients receiving chemotherapy

Study Design

This pragmatic cluster randomized trial compared the effectiveness of a standing order entry intervention with usual care on adherence to clinical practice guidelines for PP-CSF prescription and patient rates of FN.

Researchers randomly assigned 32 community oncology practices to provide the standing order entry intervention or usual care.

• Standing order entry. When doctors ordered high-risk chemotherapy, the electronic medical records order system alerted doctors that PP-CSF was recommended for the patient. When doctors ordered low-risk chemotherapy, the system alerted doctors not to prescribe PP-CSF. Doctors could override the orders.
• Usual care. Doctors decided if they would prescribe PP-CSF for high- and low-risk chemotherapy as they usually would.

The study included 2,898 adult patients receiving chemotherapy for breast, colorectal, or non-small cell lung cancer. Of these patients, 79% were White, 12% were Black, 3% were Asian, and 2% were of another race; 13% were Hispanic. The average age was 58, and 77% were female.

Researchers reviewed electronic medical records at the end of the first chemotherapy treatment cycle to assess guideline adherence and FN incidence rates within six months.

Patients, clinicians, pharmacists, and clinical practice guideline group representatives provided input on study design, participant recruitment, and sharing results.

Results

Among high-risk and low-risk chemotherapy regimens, sites with and without a standing order did not differ significantly on PP-CSF prescriptions. For high-risk regimens, doctors prescribed PP-CSF for 89% of patients at sites with a standing order compared with 96% at sites providing usual care. For low-risk regimens, doctors prescribed PP-CSF for 6.8% of patients at sites with a standing order compared with 5.5% of patients at sites providing usual care.

FN rates did not differ significantly between sites with and without a standing order. FN rates were 6% or lower for both high- and low-risk regimens, which was less than anticipated.

Limitations

The study included patients with breast, lung, or colorectal cancer. Results may differ for people with other types of cancer.

Conclusions and Relevance

In this study, guideline-informed standing orders did not increase PP-CSF use in high-risk patients, nor did it decrease use in low-risk patients. These findings suggest that order entry systems may not affect CSF prescribing in community settings.

Future Research Needs

Future studies could continue to examine ways to reduce FN among patients with cancer.