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© 1999 American Society for Clinical Oncology
Impact of American Society of Clinical Oncology Guidelines for Clinical Use of Colony-Stimulating FactorsTenon Hospital, Paris, France To the Editor: Guidelines for the use of colony-stimulating factors (CSFs) were established by the American Society of Clinical Oncology (ASCO) to assist physicians with decision making.1 However, there was limited evidence that they had any impact on clinical practice. To assess the impact of the ASCO guidelines on CSF prescription in a Paris university hospital involved in cancer care, a "before-after" study was performed in 1996 (the period before implementation of the guidelines) and in 1997 (the period after, when guidelines were implemented for 6 months). In accordance with the previously published guidelines for medical practice,2,3 they were implemented throughout the hospital with a specific form summarizing the guidelines used at the time of the prescription. All inpatients who received CSF in the oncology, radiotherapy, and lung departments were enrolled onto the study. The main outcome measure was physician compliance, which was considered to be the number of CSF prescriptions that conformed to the guidelines. ASCO guidelines supported CSF use for primary prophylaxis with chemotherapeutic regimens with at least a 40% risk of febrile neutropenia, secondary prophylaxis when dose reduction was undesirable, and therapy administration on a case-by-case basis when febrile neutropenia with complicating factors occurred. Use of CSF for peripheral-blood progenitor cell (PBPC) transplantation and PBPC mobilization was unquestionable.4 Physicians' compliance with the guidelines increased significantly, from 39% to 62%, between the two periods (P = .002) (Table 1). The increase in the number of patients treated with PBPC transplantation, considered to be unquestionable,4 the significant increase in physicians' compliance in secondary prophylaxis (P = .007), and the decrease in the number of CSF prescriptions in therapy explained the improvement in physician compliance with the guidelines after their implementation.
However, as previously reported,5 primary prophylaxis represented the most common reason for CSF administration, even after implementation of the guidelines. Furthermore, we did not observe a significant change in the prescription of CSF in primary prophylaxis between the two periods. Actually, before and after implementation, 88% and 94% of physicians, respectively, did not comply with the guidelines because the chemotherapy regimens did not induce 40% febrile neutropenia, as recommended by the ASCO guidelines. These results were confirmed in time as, in 1998, according to the same methodology, 94% of primary prophylaxis did not comply with the guidelines in our hospital. Furthermore, these results were in accordance with the preliminary results of a prospective study performed in 15 Paris university hospitals involved in cancer care in 1997. Implementation of guidelines might explain the 20% decrease in CSF use between the two periods. However, as in any uncontrolled study, others factors may be involved in the change in medical practice. Even though no significant change was noted in hospital activity between the two periods, we cannot assert that the patients' conditions before guideline implementation were similar to those observed afterward. Moreover, treatment procedures did not change between the two periods. In addition, CSF caused no serious adverse effects, and the cost of CSF decreased. Although physician compliance with the guidelines increased after their implementation in secondary prophylaxis and therapy, ASCO guidelines did not provide explicit guidance for the use of CSF in primary prophylaxis. Actually, the 40% incidence threshold in particular coincided with the results of cost analyses, showing that at the 40% incidence level, the estimated additional cost of CSF was equal to the estimated cost saving from avoiding hospitalization because of future neutropenia.6 In addition, although ASCO occasionally took into account risk factors for chemotherapy-induced infectious complications, criteria to precisely identify risk factors were still missing. To precisely identify risk factors, Blay et al7 proposed a predictive method to select patients who will experience febrile neutropenia. Although other factors may be involved, implementation of guidelines seems to have an impact on medical practice, although a causal relationship could not be demonstrated. Our study shows that primary prophylaxis was the major clinical situation in which physicians could benefit from guidance about whether or not to use a CSF. A better definition of patients who should receive CSF in primary prophylaxis would enhance the impact of the ASCO guidelines on medical practice. REFERENCES
1.
American Society of Clinical Oncology: Update of recommendations for the use of hematopoietic colony-stimulating factors: Evidence-based clinical practice guidelines. J Clin Oncol14:1957-1960, 1996 2. Grimshaw JM, Russel IT: Effect of clinical guidelines on medical practice: A systematic review of rigourous evaluations. Lancet342:1317-1322, 1993[Medline]
3.
Grimshaw JM, Russel IT: Achieving health gain though clinical guidelines: II. Ensuring guidelines change medical practice. Qual Health Care3:45-52, 1994 4. Klump PTR, Mangan KF, Goldberg SL, et al: Granulocyte colony-stimulating factor accelerates neutrophil engrafment following peripheral-blood stem-cell transplantation: A prospective, randomized trial. J Clin Oncol13:1323-1327, 1995[Abstract] 5. Gautié L, Canal P, Menguy F, et al: Analysis of hematopoietic growth factor prescriptions in 19 French cancer centers [in French]. Bull Cancer85:1043-1048, 1998[Medline]
6.
Lyman GH, Lyman GC, Sanderson RA, et al: Decision analysis of hematopoietic growth factor use in patients receiving cancer chemotherapy. J Natl Cancer Inst85:488-493, 1993
7.
Blay JY, Chauvin F, Le Cesne A, et al: Early lymphopenia after cytotoxic chemotherapy as a risk factor for febrile neutropenia. J Clin Oncol14:636-643, 1996
Response
Veterans Affairs Chicago Health Care System, Chicago, IL In Reply: The study by Debrix et al confirms the findings of two ASCO surveys of clinical oncologists that assessed the use of CSFs.1,2 In particular, use of CSFs in the setting of primary prophylaxis continues to be an area associated with overuse of these agents, while use of CSFs in the setting of secondary prophylaxis has decreased. Prior studies indicate that dissemination of guidelines in the form of written handouts to physicians, as done in the Debrix et al study, is unlikely to lead to meaningful changes in physician practice patterns, unless they are accompanied by discrete and targeted interventions.3,4 Local involvement in guideline development is especially important for improving adherence to recommended practices.5 Busy physicians, we suspect, rarely take the time to read forms such as those that summarize ASCO guidelines. Changes in CSF use, as described in this study, are more likely to reflect general temporal changes in physician practices rather than effects of publication and passive dissemination of written ASCO guidelines in the hospital setting. Other, more specific influences on CSF use might include increased experience with these agents, insurance denials, and widely publicized evidence.2 Nonetheless, targeted educational efforts that address patterns of CSF use in the setting of primary prophylaxis continue to be needed. These efforts should be carried out in the context of a randomized clinical trial of guidelines versus no guidelines. REFERENCES 1. Bennett CL, Smith TJ, Weeks JC, et al: Use of hematopoietic colony-stimulating factors: The American Society of Clinical Oncology Survey. J Clin Oncol14:2511-2520, 1997[Abstract] 2. Bennett CL, Weeks JC, Somerfield MR, et al: Use of hematopoietic colony-stimulating factors for solid tumors and lymphomas: Comparison of the 1994 and 1997 American Society of Clinical Oncology surveys. J Clin Oncol (in press) 3. Shortell SM, Bennett CL, Byck GR: Assessing the impact of continuous quality improvement on clinical practice: What will it take to accelerate progress. Milbank Q76:593-624, 1998[Medline] 4. Sarasin FP, Maschiangelo M, Schaller M, et al: Successful implementation of guidelines for encouraging the use of beta blockers in patients after acute myocardial infarction. Am J Med106:499-505, 1999[Medline] 5. Katterhagen G: Physician compliance with outcome-based guidelines and clinical pathways in oncology. Oncology10:113-121, 1996[Medline]
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Copyright © 1999 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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