Management of neutropenic fever during a transition from traditional hematology/oncology service to hospitalist care.

OBJECTIVES

Increasingly, hospitalists across the United States provide primary inpatient care for almost all subspecialty patients, including hematology and medical oncology. Febrile neutropenia (FN) is a serious condition often seen as a complication of cytotoxic chemotherapy or in patients with underlying bone marrow defects. The purpose of this study was to document the change of inpatient management of a common admission diagnosis during a transition of providers from hematologists/oncologists to the use of hospitalists in a tertiary care medical center, and to compare the appropriateness of treatment and outcomes over a period of 5.5 years of this transition.

METHODS

The medical records of all patients with neutropenia at a community-based teaching hospital during a period of conversion from hematologist/oncologist to hospitalist coverage were retrospectively reviewed. Patients with fever and absolute neutrophil counts of less than 500/ microL (.5 x 10(9)/L) on admission were included. Study cases were divided into 3 groups by admission date, roughly demarcating the nascent hospitalist era, the era of transition to hospitalist, and the mature hospitalist era. Management of FN during these eras was compared.

RESULTS

Three hundred ninety-nine inpatients were identified as neutropenic. Of these, 184 did not meet case-inclusion criteria. The remaining 215 cases were included in the study. The internal medicine hospitalist service admitted less than 10% of this population in 2003, but by 2007-2008 it admitted over 90%. The use of 4th-generation cephalosporins and carbapenems increased over time (P = .027), and the infectious disease service was consulted more frequently over time (P = .007). Outcomes varied due to changes in underlying disease states, use of hospice services, and changes in the types of patients hospitalized with FN. Morbidity decreased due to the change in the type and nonantibiotic therapy of cases, but inappropriate antimicrobial treatment was unusual, and septic morbidity or mortality related to inappropriate therapy was too rare to compare through these eras.

CONCLUSION

Over the 3 eras compared, care of most neutropenic fever patients was transferred from specialists to hospitalists. Care became more uniform, guideline based, and used more infectious disease consultation, and mortality decreased. Complex changes in the types and treatments of cancer, neutropenia therapy, and in the types of patients hospitalized with FN prevent any conclusion of added value for this change in the type of primary provider management.