de Lalla Fausto
Department of Infectious Diseases and Tropical Medicine, S. Bortolo Hospital, Vicenza, Italy.
Pharmacoeconomics. 2003;21(6):397-413. doi: 10.2165/00019053-200321060-00004.
Although febrile episodes in neutropenic patients remain a potentially life-threatening complication of anticancer chemotherapy, considerable progress has been achieved in understanding this issue. Febrile neutropenic patients represent a heterogeneous population that displays a very variable risk for serious medical complications. It has also been ascertained that in low-risk patients, the standard of care can be safely and effectively shifted from traditional hospital-based, parenteral, empiric, broad-spectrum antibacterial therapy to outpatient treatment, even for the entire duration of the febrile episode. Furthermore, in the last years some risk assessment models have been developed to identify, at the onset of febrile episodes, low-risk neutropenic patients who are most likely to have a favourable outcome (and who can effectively and safely be treated on an outpatient basis). With respect to traditional hospital-based therapy, the outpatient treatment of low-risk patients is associated with several advantages, including a conspicuous cost saving. Some strategies for inpatient therapy, such as switching from intravenous to oral antibacterials and early discharge, can allow some cost containment; however, the most substantial decrease in costs can be obtained by using outpatient treatment over the entire febrile episode, especially by using oral antibacterials. In spite of the considerable number of clinical studies published over the past 20 years, only limited pharmacoeconomic data on this issue are available. Future comparative studies between outpatient and inpatient treatment of febrile neutropenia, in addition to clinical outcomes (e.g. survival, time to clinical response), should therefore include the following: (i) a detailed analysis of total costs, specifying the setting of outpatient treatment and the method of administration of antimicrobial agents (home nursing, self administration or treatment at infusion centres or at a low-care unit of the hospital); (ii) cost of inpatient treatment if outpatient therapy fails; and (iii) out-of-pocket expenses incurred by the patients.
尽管中性粒细胞减少患者的发热发作仍然是抗癌化疗潜在的危及生命的并发症，但在理解这个问题方面已经取得了相当大的进展。发热性中性粒细胞减少患者是一个异质性群体，严重医疗并发症的风险差异很大。还已确定，在低风险患者中，即使在整个发热发作期间，护理标准也可以安全有效地从传统的基于医院的肠外经验性广谱抗菌治疗转向门诊治疗。此外，在过去几年中，已经开发了一些风险评估模型，以在发热发作开始时识别最有可能有良好预后（并且可以在门诊有效且安全地接受治疗）的低风险中性粒细胞减少患者。与传统的基于医院的治疗相比，低风险患者的门诊治疗有几个优点，包括显著节省成本。住院治疗的一些策略，如从静脉抗菌药物改为口服抗菌药物和提前出院，可以实现一定程度的成本控制；然而，通过在整个发热发作期间使用门诊治疗，特别是使用口服抗菌药物，可以实现最大幅度的成本降低。尽管在过去20年中发表了大量临床研究，但关于这个问题的药物经济学数据仍然有限。因此，未来发热性中性粒细胞减少门诊和住院治疗的比较研究，除了临床结果（如生存率、临床反应时间）外，还应包括以下内容：(i) 对总成本的详细分析，具体说明门诊治疗的设置和抗菌药物的给药方法（家庭护理、自我给药或在输液中心或医院的低护理病房治疗）；(ii) 如果门诊治疗失败，住院治疗的成本；以及(iii) 患者自付费用。
