Abstract
Introduction Chemotherapy (CHT) administration is a high risk process. In particular, in the Day Hospital (DH) patient setting, the potential toxicity of medications is coupled with some organizational aspects, e.g. rapid patient turnover, multiprofessional involvement, lack of continuity of medical care, which can increase the risk of adverse events. The aim of this study was to evaluate the appropriateness of CHT administration for lymphoprolipherative disease in DH setting and the quality of medical charts, by using clinical audit. Audit is a quality improvement process that allows improvement of patient care and outcome through systematic review of care against explicit criteria and the implementation of change. The following evidence-based criteria were established for reviewing CHT administration: o CHT treatment plan (including histology, stage, goals of therapy, patient’s performance status, co-morbidities, CHT regimen) must be established prior to the initiation of CHT, and reported on medical record o CHT treatment summary (including number of cycles administered, extent of dose reduction and/or delay, reason for treatment delay or discontinuation, major toxicities or unexpected hospitalizations, biochemistry data) must be reported in medical records o Maintaining dose-density and dose-intensity may improve clinical outcome; the appropriate use of G-CSFs, in order to prevent neutropenia-related dose reduction or time delay, is particularly relevant when the intent of treatment is curative or to prolong survival o Inclusion of informed consent form in medical records is recommended, in order to verify the informative process and complete patient identification
Patients and methods A random sample of 15% of all CHT courses administered for Lymphoma and Chronic Lymphocitic Leukemia from July 2006 to June 2007 in five Hematological DHs was analysed. A total of 282 courses were examined: 87 ABVD, 122 CHOP(R) and 73 FC(R). We collected data about patients, chemotherapy and medical charts. Patients’ clinical characteristics were similar between participating centres. Dose or time violations were considered significative if exceeding one day or 10% of scheduled timing or dosing, respectively.
Results Results are reported in Table 1 and 2
Tab 1: courses with dose reduction or delay
CHOP(R) (%) ABVD (%) FC(R) (%) Total (%) Dose reduction 30/122 (24,6) 9/87 (10,3) 5/73 (6,8) 44/282 (15,6) Delay 43/116 36/84 (42,9) 24/73 103/273 (37,7)
Tab 2: causes of dose or time violation
Dose reduction (%) Delay (%) Extra-hematological toxicity 14/44 (31,8) 6/103 (5,8) Neutropenia 3/44 (6,8) 27/103 (26,2) Infection - 17/103(16,5) Other clinical reasons (age, PS, comorbidity) 17/44 (38,7) 3/103 (2,9) Organizational causes - 25/103 (24,3) Not reported 10/44 (22,7) 25/103 (24,3)
Pre-therapy biochemistry was available in 279/282 cycles (99%), while informed consent form was included in 131/282 (46.5%) medical charts. Post-therapy follow up revealed 4 unexpected hospitalizations.
Conclusions Three main problems emerged:
a lot of patients delayed treatment due to organizational causes (e.g. intermediate radiological restaging, holidays, lack of bed, biochemistry pending); in too many cases medical charts lacked causes of dose reduction (22,7%) or delay (24,3%); could guidelines driven use of G-CSF have prevented neutropenia-related delay? At the end of clinical audit, an action plan should be developed to improve the care process.
In our study we induced and supported changes in the CHT administration process by various means: dissemination of educational material (as guidelines), interactive educational interventions, professional reminders, decision support. One year after a re-audit will be performed, in order to assess expected improvement.
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