Assessing the impact of a targeted electronic medical record intervention on the use of growth factor in cancer patients.

Febrile neutropenia (FN) is a complication of chemotherapy that can lead to hospitalization. Inpatient mortality for FN is estimated to be 9.5% in 115 US medical centers between 1995 and 2000, and together with comorbidities, cancer type, and documented infection, is associated with poorer outcomes.1 In addition, episodes of FN or prolonged afebrile neutropenia often result in chemotherapy dose delay or dose reduction, which compromise the effectiveness of the antineoplastic treatment.2,3 The use of prophylactic granulocyte colony-stimulating factors (G-CSFs) is a way to mitigate the complications associated with myelosuppressive chemotherapy. The appropriate use of prophylactic G-CSFs has been shown to reduce the duration and severity of neutropenia, decrease the risk of FN, improve the relative dose intensity (RDI) of chemotherapy, decrease hospital length of stay, and reduce the risk of infection-related mortality and early death during chemotherapy.3,8,10 The use of G-CSFs, however, is not without risk. The primary toxicity associated with G-CSF therapy is bone pain in up to 30% of patients.9 Serious toxicities, including rare cases of splenic rupture, can occur. Balancing the clinical and cost-effectiveness of a treatment is an essential component in ensuring the delivery of the highest quality patient care. The American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN) have composed guidelines for patient care based on comprehensive review of the evidence and cost-effectiveness models.6,10 Adherence to those guidelines increases the quality of patient care and reduces costs of care. In oncology practice, adherence to the guidelines for using G-CSFs for prevention of FN is highly variable, ranging from 0%-88% depending on the practice site.9 The decision to use G-CSFs for prophylaxis of FN is complex, and consideration must be given to a number of factors. Both ASCO and the NCCN recommend a risk-based approach to this decision. Primary prophylaxis is recommended for patients who receive a chemotherapy regimen that is associated with a risk for FN of more than 20%. For patients who receive regimens with a risk for FN of 20% or less than, the decision to use G-CSFs is based on a thorough risk assessment, taking into account patient-specific factors such as cancer type, treatment intent, and comorbid conditions. An electronic medical record (EMR) system with computerized physician order entry (CPOE) and well-designed decision support tools may increase adherence to established guidelines. In January 2009, an EMR system was established at West Virginia University Hospitals (WVUH). A major advantage of this new system is the ability to establish a standard that automatically includes pegfilgrastim, a long-acting G-CSF, in chemotherapy order sets if the risk of FN for the selected regimen is greater than 20%. In this study, we examined institutional adherence to ASCO and NCCN guidelines for G-CSF after the implementation of automatic electronic orders for pegfilgrastim in patients who received a high-risk chemotherapy regimen. The results were compared with a similar study that had been conducted before the implementation of the EMR system.