Identifying low-risk febrile neutropenic cancer patients in the West of Scotland

2006 ◽  
Vol 24 (18_suppl) ◽  
pp. 18592-18592
Author(s):  
Y. C. Drew ◽  
R. Appleton ◽  
R. Jordan ◽  
J. White ◽  
J. Paul
Keyword(s):  
Cost Savings ◽  
Low Risk ◽  
Patient Treatment ◽  
Medical Complication ◽  
Oral Antibiotic ◽  
The West ◽  
Mascc Score ◽  
Co Morbidity ◽  
Risk Patients ◽  
Randomised Controlled

18592 Background: Febrile neutropenia (FN) is a potentially life threatening complication of chemotherapy. In-patient treatment using intravenous antibiotics reduces FN related mortality. However, most patients with FN are at low risk of complication. Identifying them could result in new strategies such as out-patient, oral antibiotic, based treatment resulting in improved quality of life and cost savings. The Multinational Association for Supportive Care in Cancer (MASCC) and the Talcott model were developed to identify such patients. Two randomised controlled trials have shown that oral antibiotics in low risk patients are safe and effective. However are such models appropriate in populations with a high incidence of co-morbidity such as the West of Scotland? This study reviews FN admissions to our cancer centre to determine the proportion of patients that would fall into a low risk group according to the MASCC and/or Talcott models and to identify other factors that might predict for low risk. Methods: Review of FN admissions between June–December 2002. Data included: patient demographics, MASCC score, Talcott group, co-morbidity, haematological and biochemical values, prior use of antibiotics and growth factors (GFs) and whether the fever resolved without serious medical complication (FRWMC). Results: 77 episodes of FN involving 68 patients. Mean age = 51 (range 16–79). 94% involved patients with solid malignancies. Commonest tumour type was breast (29%). Patients were classified as MASCC and Talcott low risk in 52% and 31% of episodes respectively. There was a significant association between low risk MASCC score and low risk Talcott score (χ2 28.665, d.f.3, p < 0.001). Low risk MASCC was associated with FRWMC (χ2 4.193, d.f.1, p < 0.05). Multiple logistic regression of risk factors showed that high bilirubin and low albumin were associated with a worse outcome. FN mortality rate was 7.8%. Conclusions: The use of clinical risk models to identify low risk patients can predict for an uncomplicated recovery in our patients. Bilirubin and albumin values at presentation added predicted value for low risk over and above the MASCC model. Future trials may validate this observation. No significant financial relationships to disclose.

scholarly journals Ambulatory Outpatient Management of patients with low risk febrile neutropaenia

2015 ◽  
Vol 14 (4) ◽  
pp. 178-181
Author(s):  
Timothy Cooksley ◽  
◽  
Mark Holland ◽  
Jean Klastersky ◽  
◽  
...  
Keyword(s):  
Febrile Neutropenia ◽  
Cost Savings ◽  
Scoring Systems ◽  
Low Risk ◽  
Ambulatory Setting ◽  
Medical Complications ◽  
Mascc Score ◽  
Risk Patients ◽  
Reduced Risk ◽  
Avoidance Cost

Patients with febrile neutropenia are a heterogeneous group with only a minority developing significant medical complications. Scoring systems, such as the Multinational Association for Supportive Care in Cancer (MASCC) score, have been developed and validated to identify low risk patients. Caring for patients with low risk febrile neutropenia in an ambulatory setting is proven to be safe and effective. Benefits include admission avoidance, cost savings and reduced risk of nosocomial infections, as well as improved patient experience and satisfaction. Implementation of an ambulatory pathway for low risk febrile neutropenia provides an excellent opportunity for Acute Physicians and Oncologists to collaborate in delivering care for this group of patients.

Abstract 137: Efficacy and Cost Savings Realized through Validation of a Tool to Identify Low Risk STEMI Patients not Requiring CCU Care

2012 ◽  
Vol 5 (suppl_1) ◽  
Author(s):  
William E Downey ◽  
Lara M Cassidy ◽  
Kerstin Liebner ◽  
Robyn Magyar ◽  
Angela D Humphrey ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Risk Score ◽  
New Technologies ◽  
Cost Savings ◽  
Low Risk ◽  
Hospital Death ◽  
Cardiac Care ◽  
Primary Pci ◽  
Risk Patients ◽  
Support Cost

Introduction In the early 1960s, the creation of Cardiac Care Units (CCUs) led to a 50% reduction in the in-hospital mortality of acute myocardial infarction (AMI). Prompt application of closed chest cardiac resuscitation and external defibrillation -- then new technologies -- served to reduce the consequences of the event. Over the ensuing four decades, therapeutic advances in the treatment of AMI (e.g. prompt reperfusion strategies) have favorably altered its natural history, potentially obviating the need for CCU care. Since such care is expensive, identification of a low risk cohort of patients in whom this care is not necessary could allow substantial improvements in the cost of cardiac care. Hypothesis Existing risk models can be used to accurately identify low risk STEMI patients who do not require CCU care after primary PCI. Methods We performed a retrospective chart review of all STEMI cases from 2010 at Carolinas Medical Center. We then assessed them using the TIMI STEMI risk score and a risk assessment algorithm for uncomplicated STEMI developed at Brigham and Women's Hospital (BWH). The BWH STEMI Care Redesign defines low risk STEMI patients as those who are promptly revascularized via successful single vessel PCI with (1) no evidence of ongoing ischemia, (2) EF>40%, (3) absence of CHF, hemodynamic or electrical instability, and (4) who are awake without need of respiratory support. Cost data (fixed and variable) from Quality Advisor™, a product by Premier, was abstracted for each STEMI case, examining specific resources used in CCU and non-CCU units. Results Among 310 consecutive STEMI patients, in-hospital mortality was 3.9%. The BWH risk score identified 46.4% of these patients as low-risk. Among these patients, in-hospital mortality was 0%. Only one of these 144 low-risk patients required subsequent CCU care. None required CPR or defibrillation after revascularization. The TIMI STEMI risk score <2 classified 26.1% of the patients as low-risk. Among these patients, in-hospital mortality was 0%. However, 3.7% of these "low-risk" patients had ventricular arrhythmias or respiratory decompensation during or shortly after PCI. None of the 3.7% were classified as "low-risk" by the BWH model. CCU care added $723 in fixed costs and $340 in variable costs per hospital day. Conclusion The BWH model, but not the TIMI STEMI risk score, accurately predicted a sizable cohort of STEMI patients at very low risk of in-hospital death and complications. These patients may be appropriate for admission to non-CCU level care immediately following primary PCI. Doing so would be projected to yield a cost savings of >$1000 per patient.

A cost analysis of inpatient compared with outpatient prostaglandin E2 cervical priming for induction of labour: results from the OPRA trial

2013 ◽  
Vol 37 (4) ◽  
pp. 467 ◽  
Author(s):  
Pamela L. Adelson ◽  
Garry R. Wedlock ◽  
Chris S. Wilkinson ◽  
Kirsten Howard ◽  
Robert L. Bryce ◽  
...  
Keyword(s):  
Outpatient Care ◽  
Inpatient Care ◽  
Controlled Trial ◽  
Hospital Costs ◽  
Cost Savings ◽  
Low Risk ◽  
Induction Of Labour ◽  
Cervical Priming ◽  
Randomised Controlled ◽  
The Cost

Objective To compare the costs of inpatient (usual care) with outpatient (intervention) care for cervical priming for induction of labour in women with healthy, low-risk pregnancies who are being induced for prolonged pregnancies or for social reasons. Methods Data from a randomised controlled trial at two hospitals in South Australia were matched with hospital financial data. A cost analysis comparing women randomised to inpatient care with those randomised to outpatient care was performed, with an additional analysis focusing on those who received the intervention. Results Overall, 48% of women randomised into the trial did not receive the intervention. Women randomised to outpatient care had an overall cost saving of $319 per woman (95% CI −$104 to $742) as compared with women randomised to usual care. When restricted to women who actually received the intervention, in-hospital cost savings of $433 (95% CI −$282 to $1148) were demonstrated in the outpatient group. However, these savings were partially offset by the cost of an outpatient priming clinic, reducing the overall cost savings to $156 per woman. Conclusions Overall cost savings were not statistically significant in women who were randomised to or received the intervention. However, the trend in cost savings favoured outpatient priming. What is known about the topic? Induction of labour is a common obstetric intervention. For women with low-risk, prolonged pregnancies who require cervical priming there has been increased interest in whether this period of waiting for the cervix to ‘ripen’ can be achieved at home. Outpatient priming has been reported to reduce hospital costs and improve maternal satisfaction. However, few studies have actually examined the cost of outpatient priming for induction of labour. What does this paper add? This is the first paper in Australia to both assess the full cost of outpatient cervical priming and to compare it with usual (inpatient) care. This is the first costing paper from a randomised controlled trial directly comparing inpatient and outpatient priming with prostaglandin E2. What are the implications for practitioners? For women with prolonged, low-risk pregnancies, a program of outpatient cervical priming can potentially reduce in-hospital costs and free up labour ward beds by avoiding an additional overnight hospitalisation.

scholarly journals Protocol for a multinational risk-stratified randomised controlled trial in paediatric Crohn’s disease: methotrexate versus azathioprine or adalimumab for maintaining remission in patients at low or high risk for aggressive disease course

BMJ Open ◽  
2020 ◽  
Vol 10 (7) ◽  
pp. e034892
Author(s):  
Rachel E Harris ◽  
Marina Aloi ◽  
Lissy de Ridder ◽  
Nicholas M Croft ◽  
Sibylle Koletzko ◽  
...  
Keyword(s):  
High Risk ◽  
Randomised Controlled Trial ◽  
Controlled Trial ◽  
Risk Groups ◽  
Low Risk ◽  
High Risk Patients ◽  
Link Type ◽  
Risk Patients ◽  
Randomised Controlled ◽  
Paediatric Crohn’S Disease

IntroductionImmunomodulators such as thiopurines (azathioprine (AZA)/6-mercaptopurine (6MP)), methotrexate (MTX) and biologics such as adalimumab (ADA) are well established for maintenance of remission within paediatric Crohn’s disease (CD). It remains unclear, however, which maintenance medication should be used first line in specific patient groups.AimsTo compare the efficacy of maintenance therapies in newly diagnosed CD based on stratification into high and low-risk groups for severe CD evolution; MTX versus AZA/6MP in low-risk and MTX versus ADA in high-risk patients. Primary end point: sustained remission at 12 months (weighted paediatric CD activity index ≤12.5 and C reactive protein ≤1.5 fold upper limit) without relapse or ongoing requirement for exclusive enteral nutrition (EEN)/steroids 12 weeks after treatment initiation.Methods and analysisREDUCE-RISK in CD is an international multicentre open-label prospective randomised controlled trial funded by EU within the Horizon2020 framework (grant number 668023). Eligible patients (aged 6–17 years, new-onset disease receiving steroids or EEN for induction of remission for luminal ± perianal CD are stratified into low and high-risk groups based on phenotype and response to induction therapy. Participants are randomised to one of two treatment arms within their risk group: low-risk patients to weekly subcutaneous MTX or daily oral AZA/6MP, and high-risk patients to weekly subcutaneous MTX or fortnightly ADA. Patients are followed up for 12 months at prespecified intervals. Electronic case report forms are completed prospectively. The study aims to recruit 312 participants (176 low risk; 136 high risk).Ethics and disseminationClinicalTrials.gov Identifier: (NCT02852694), authorisation and approval from local ethics committees have been obtained prior to recruitment. Individual informed consent will be obtained prior to participation in the study. Results will be published in a peer-reviewed journal with open access.Trial registration numberNCT02852694; Pre-results.

Membrane sweeping to induce labor in low-risk patients at term pregnancy: A randomised controlled trial

2009 ◽  
Vol 23 (7) ◽  
pp. 681-687 ◽  
Author(s):  
Gokhan Yildirim ◽  
Kemal Güngördük ◽  
Özge İdem Karadağ ◽  
Halİl Aslan ◽  
Erdem Turhan ◽  
...  
Keyword(s):  
Randomised Controlled Trial ◽  
Controlled Trial ◽  
Low Risk ◽  
Term Pregnancy ◽  
Risk Patients ◽  
Randomised Controlled

scholarly journals Dental therapists compared with general dental practitioners for undertaking check-ups in low-risk patients: pilot RCT with realist evaluation

2021 ◽  
Vol 9 (3) ◽  
pp. 1-118
Author(s):  
Paul Brocklehurst ◽  
Zoe Hoare ◽  
Chris Woods ◽  
Lynne Williams ◽  
Andrew Brand ◽  
...  
Keyword(s):  
Process Evaluation ◽  
Outcome Measure ◽  
Controlled Trial ◽  
Realist Evaluation ◽  
Low Risk ◽  
Bleeding On Probing ◽  
Floor Effects ◽  
Risk Patients ◽  
Dental Practices ◽  
Randomised Controlled

Background Many dental ‘check-ups’ in the NHS result in no further treatment. The patient is examined by a dentist and returned to the recall list for a further check-up, commonly in 6 or 12 months’ time. As the oral health of regular dental attenders continues to improve, it is likely that an increasing number of these patients will be low risk and will require only a simple check-up in the future, with no further treatment. This care could be delivered by dental therapists. In 2013, the body responsible for regulating the dental profession, the General Dental Council, ruled that dental therapists could see patients directly and undertake check-ups and routine dental treatments (e.g. fillings). Using dental therapists to undertake check-ups on low-risk patients could help free resources to meet the future challenges for NHS dentistry. Objectives The objectives were to determine the most appropriate design for a definitive study, the most appropriate primary outcome measure and recruitment and retention rates, and the non-inferiority margin. We also undertook a realist-informed process evaluation and rehearsed the health economic data collection tool and analysis. Design A pilot randomised controlled trial over a 15-month period, with a realist-informed process evaluation. In parallel, we rehearsed the health economic evaluation and explored patients’ preferences to inform a preference elicitation exercise for a definitive study. Setting The setting was NHS dental practices in North West England. Participants A total of 217 low-risk patients in eight high-street dental practices participated. Interventions The current practice of using dentists to provide NHS dental check-ups (treatment as usual; the control arm) was compared with using dental therapists to provide NHS dental check-ups (the intervention arm). Main outcome measure The main outcome measure was difference in the proportion of sites with bleeding on probing among low-risk patients. We also recorded the number of ‘cross-over’ referrals between dentists and dental therapists. Results No differences were found in the health status of patients over the 15 months of the pilot trial, suggesting that non-inferiority is the most appropriate design. However, bleeding on probing suffered from ‘floor effects’ among low-risk patients, and recruitment rates were moderately low (39.7%), which suggests that an experimental design might not be the most appropriate. The theory areas that emerged from the realist-informed process evaluation were contractual, regulatory, institutional logistics, patients’ experience and logistics. The economic evaluation was rehearsed and estimates of cost-effectiveness made; potential attributes and levels that can form the basis of preference elicitation work in a definitive study were determined. Limitations The pilot was conducted over a 15-month period only, and bleeding on probing appeared to have floor effects. The number of participating dental practices was a limitation and the recruitment rate was moderate. Conclusions Non-inferiority, floor effects and moderate recruitment rates suggest that a randomised controlled trial might not be the best evaluative design for a definitive study in this population. The process evaluation identified multiple barriers to the use of dental therapists in ‘high-street’ practices and added real value. Future work Quasi-experimental designs may offer more promise for a definitive study alongside further realist evaluation. Trial registration Current Controlled Trials ISRCTN70032696. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 3. See the NIHR Journals Library website for further project information.

Safety of early discharge after primary angioplasty in low-risk patients with ST-segment elevation myocardial infarction: A meta-analysis of randomised controlled trials

2018 ◽  
Vol 25 (8) ◽  
pp. 807-815 ◽  
Author(s):  
Wei Gong ◽  
Aobo Li ◽  
Hui Ai ◽  
Han Shi ◽  
Xiao Wang ◽  
...  
Keyword(s):  
Randomised Controlled Trials ◽  
Meta Analysis ◽  
Early Discharge ◽  
Primary Angioplasty ◽  
Low Risk ◽  
Controlled Trials ◽  
St Segment Elevation ◽  
St Segment ◽  
Risk Patients ◽  
Randomised Controlled

Background Early discharge after successful primary angioplasty is common, but the evidence supporting the practice is still lacking. We therefore performed a meta-analysis assessing the safety of early discharge after primary angioplasty in low-risk patients with ST-segment elevation myocardial infarction (STEMI). Methods Randomised controlled trials were identified and extracted from PubMed, Embase, Cochrane Library databases and reference lists of relevant papers. Heterogeneity was analysed using the I2 test. If there was a lack of heterogeneity, fixed effects models would be used for the meta-analysis, otherwise random effects models were used. Statistical analyses were performed using Review Manager 5.3. Results Five randomised controlled trials involving 1575 STEMI patients met the criteria. Meta-analysis showed that the early discharge strategy group had a significantly shortened length of hospital stay compared to the conventional discharge strategy group (standardised mean difference −1.46, 95% confidence interval (CI) −2.04 to −0.88; P < 0.0001), and there was no difference in mortality and readmission rates between the two groups (risk ratio 0.78, 95% CI 0.50 to 1.22; P = 0.41). Conclusions The findings of this meta-analysis suggested that the early discharge strategy after successful primary angioplasty is safe among selected low-risk STEMI patients. A shorter hospital stay could benefit both the patients and the healthcare systems.

scholarly journals LDL-C: lower is better for longer—even at low risk

BMC Medicine ◽  
2020 ◽  
Vol 18 (1) ◽  
Author(s):  
Peter E. Penson ◽  
Matteo Pirro ◽  
Maciej Banach
Keyword(s):  
Low Density Lipoprotein ◽  
Density Lipoprotein ◽  
Low Risk ◽  
Lipid Lowering ◽  
Mendelian Randomisation ◽  
Lipid Lowering Therapy ◽  
Cardiovascular Risks ◽  
Suggested Approach ◽  
Risk Patients ◽  
Randomised Controlled

Abstract Background Low-density lipoprotein cholesterol (LDL-C) causes atherosclerotic disease, as demonstrated in experimental and epidemiological cohorts, randomised controlled trials, and Mendelian randomisation studies. Main text There is considerable inconsistency between existing guidelines as to how to effectively manage patients at low overall risk of cardiovascular disease (CVD) who have persistently elevated levels of LDL-C. We propose a step-by-step practical approach for the management of cardiovascular risks in individuals with low (< 1%) 10-year risk of CVD, and elevated (> 140 mg/dL, 3.6 mmol/L) LDL-C. The strategy proposed is based on the level of adherence to lifestyle interventions (LSI), and in case of non-adherence, stepwise practical management, including lipid-lowering therapy, is recommended to achieve a target LDL-C levels (< 115 mg/dL, 3.0 mmol/L). Conclusions Further studies are necessary to answer the questions on the long-term efficacy, safety, and cost-effectiveness of the suggested approach. This is critical, considering the ever-increasing numbers of such low-risk patients seen in clinical practice.

Two-year cost-effectiveness of different COBRA-like intensive remission induction schemes in early rheumatoid arthritis: a piggyback study on the pragmatic randomised controlled CareRA trial

2020 ◽  
Vol 79 (5) ◽  
pp. 556-565 ◽  
Author(s):  
Sofia Pazmino ◽  
Annelies Boonen ◽  
Veerle Stouten ◽  
Diederik De Cock ◽  
Johan Joly ◽  
...  
Keyword(s):  
Rheumatoid Arthritis ◽  
Cost Effectiveness ◽  
High Risk ◽  
Risk Group ◽  
Low Risk ◽  
Remission Induction ◽  
Avant Garde ◽  
Risk Patients ◽  
Step Down ◽  
Randomised Controlled

ObjectivesTo evaluate the cost-effectiveness of treat-to-target strategies among recently diagnosed patients with rheumatoid arthritis (RA) using methotrexate (MTX) and a step-down glucocorticoid (GC) scheme (COBRA Slim) compared with (1) this combination with either sulphasalazine (COBRA Classic) or leflunomide (COBRA Avant-Garde) in high-risk patients and (2) MTX without GCs (Tight-Step-Up, TSU) in low-risk patients.MethodsThe incremental cost-utility was calculated from a healthcare perspective in the intention-to-treat population (n=379) of the 2-year open-label pragmatic randomised controlled Care in early RA trial. Healthcare costs were collected prospectively through electronic trial records. Quality-adjusted life years (QALYs) were estimated using mapping algorithms for EuroQoL-5 Dimension. Multiple imputation was used to handle missing data and bootstrapping to calculate CIs. Robustness was tested with biological disease-modifying antirheumatic drugs at biosimilar prices.ResultsIn the high-risk group, Classic (∆k€1.464, 95% CI −0.198 to 3.127) and Avant-Garde (∆k€0.636, 95% CI −0.987 to 2.258) were more expensive compared with Slim and QALYs were slightly worse for Classic (∆−0.002, 95% CI −0.086 to 0.082) and Avant-Garde (∆−0.009, 95% CI −0.102 to 0.084). This resulted in the domination of Classic and Avant-Garde by Slim. In the low-risk group, Slim was cheaper (∆k€−0.617, 95% CI −2.799 to 1.566) and QALYs were higher (∆0.141, 95% CI 0.008 to 0.274) compared with TSU, indicating Slim dominated. Results were robust against the price of biosimilars.ConclusionsThe combination of MTX with a GC bridging scheme is less expensive with comparable health utility than more intensive step-down combination strategies or a conventional step-up approach 2 years after initial treatment.Trial registration numberNCT01172639.

scholarly journals Emperical Oral Antibiotic Therapy for Children with Low Risk Febrile Neutropenia during Cancer Chemotherapy

1970 ◽  
Vol 29 (1) ◽  
pp. 22-25 ◽  
Author(s):  
PN Shrestha ◽  
K Sah ◽  
R Rana
Keyword(s):  
Febrile Neutropenia ◽  
Cancer Chemotherapy ◽  
Empirical Therapy ◽  
Low Risk ◽  
Oral Antibiotic ◽  
Oral Antibiotics ◽  
Safe Alternative ◽  
Oral Antibiotic Therapy ◽  
Intravenous Antibiotics ◽  
Risk Patients

Introduction: In patient with fever and neutropenia during cancer chemotherapy who have a low risk of complications, oral antibiotic may be an acceptable alternative to intravenous antibiotics. Methods: We conducted a prospective hospital based study to the patients who had fever and neutropenia during caner chemotherapy. Only low risk patients i.e. neutropenia of less than seven days, ANC >250/cmm, without any signs of shock were included in the study. All the patients were hospitalized and given oral antibiotics Ofloxacin and Amoxy-Clav and were closely observed until fever subsided for more than 48 hours and improved from neutropenia. Results: A total of 54 cases were enrolled in the study. Out of 54 patients two patients were lost, 8 needed IV antibiotics for different reasons and 44 patients (81%) improved well with oral antibiotics only. Conclusion: In hospitalized low risk patients who have fever and neutropenia, empirical therapy with oral ofloxacin and amoxy-clav may be a safe alternative to IV antibiotics. Key words: Febrile Neutropenia, Cancer Chemotherapy, ANC.   doi:10.3126/jnps.v29i1.1596 J. Nepal Paediatr. Soc. Vol.29(1) p.22-25   

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