Raghavendra Meghana, Hoeg Rasmus T, Bottner Wayne A, Agger William A
WMJ. 2014 Apr;113(2):53-8.
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.
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.
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.
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.
在美国，越来越多的住院医师为几乎所有专科患者提供住院基本治疗，包括血液科和内科肿瘤患者。发热性中性粒细胞减少症（FN）是一种严重病症，常见于细胞毒性化疗并发症患者或存在潜在骨髓缺陷的患者。本研究旨在记录在一家三级医疗中心，医疗服务提供者从血液科医生/肿瘤内科医生转变为住院医师期间，一种常见入院诊断的住院治疗管理变化，并比较在这一转变的5.5年期间治疗的适宜性和治疗结果。
回顾性分析一家社区教学医院在从血液科医生/肿瘤内科医生负责转变为住院医师负责期间，所有中性粒细胞减少症患者的病历。纳入入院时发热且绝对中性粒细胞计数低于500/μL（0.5×10⁹/L）的患者。研究病例按入院日期分为3组，大致划分出新住院医师时代、向住院医师转变时代和成熟住院医师时代。比较这些时期FN的治疗管理情况。
共识别出399例住院中性粒细胞减少症患者。其中，184例不符合病例纳入标准。其余215例纳入研究。2003年，内科住院医师服务收治的该类患者不到10%，但到2007 - 2008年，收治比例超过90%。随着时间推移，第四代头孢菌素和碳青霉烯类药物的使用增加（P = 0.027），感染病科会诊频率也随时间增加（P = 0.007）。由于基础疾病状态变化、临终关怀服务使用情况以及FN住院患者类型的改变，治疗结果有所不同。由于病例类型和非抗生素治疗的改变，发病率有所下降，但不恰当的抗菌治疗并不常见，且与不恰当治疗相关的败血症发病率或死亡率非常罕见，无法在这些时期进行比较。
在比较的3个时期内，大多数中性粒细胞减少性发热患者的治疗从专科医生转移至住院医师。治疗变得更加统一、基于指南，且更多地使用了感染病科会诊，死亡率有所下降。癌症类型和治疗、中性粒细胞减少症治疗以及FN住院患者类型的复杂变化，使得无法得出初级医疗服务提供者类型改变带来附加价值的结论。
