Impact Of Guidelines

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The ASCO Health Services Research Committee sought to assess patterns of CSF use before the publication of the first guideline. A questionnaire describing various clinical scenarios was mailed to oncologists and hematologists in the United States. In each scenario, the physician was asked whether he/she would prefer to use a CSF to prevent or treat neutropenia. Most physicians preferred to use CSFs for secondary prophylaxis in patients receiving chemotherapy at rates of 44-85% rather than reduce doses. Patterns of use did not differ for palliative, curative, or adjuvant chemotherapy. More than half of the physicians chose to use CSFs in the treatment of febrile neutropenia, which was not supported in subsequent guidelines. Interestingly, physicians who practiced at academic medical centers and those practicing at health maintenance organizations (HMOs) had the same opinions. Physicians at the academic or HMO centers were more likely to prefer dose reduction strategies, whereas physicians receiving a fee for service used CSFs more often. It was believed, therefore, that the guidelines would be most likely to reduce the use of CSFs for the treatment of afebrile and uncomplicated febrile neutropenia (6).

A similar finding was made by a further survey by the ASCO Health Services Committee. A questionnaire was sent to oncologists and hematologists describing the clinical scenario for a 67-yr-old man with newly diagnosed de novo acute myeloid leukemia. Physicians were asked about their preference for adjunctive use of a CSF after induction and consolidation chemotherapy. Support for the use of a CSF was 40% after induction chemotherapy and was similar to that for not using the agent. The most important determinant of support for the use of CSF, however, was being in a fee-for-service practice, i.e., use was accompanied by financial profit to the physician practice. Support was low otherwise (7).

A French group did a multicenter study of the impact of prescription guidelines on the use of CSFs (8). Two hospital groups were compared: a guidelines group (seven teaching hospitals) that circulated guidelines and a control group (eight teaching hospitals) that did not circulate guidelines. Times before and after distribution of the guidelines were assessed also. Data from approx 404 patients were analyzed for the indication of postchemotherapy neutropenia. The total compliance in the first period, i.e., before the publication of the guidelines, was 44% in the control group and 51% in the guideline group, a nonsignificant difference statistically. During the second period, i.e., after the publication of the guidelines, compliance was 32% vs 60% in the two groups (p < 0.001). The authors concluded that prescription reference systems needed to be continually redefined according to available data and circulated widely to improve the quality of health care and to control expenses (8).

Further studies of the relationship between the introduction of the ASCO guidelines and the use of CSFs were made (9). The study was performed in a large, 830-bed university hospital in Paris before and after the ASCO guidelines were implemented. The guidelines were first disseminated as a continuing medical education program and then actively implemented using a CSF prescription order form summarizing the guidelines. Seven other university-associated hospitals in Paris at which the ASCO guidelines were not actively implemented comprised the control group. The main outcome measure was the proportion of prescriptions in compliance with the 1996 update of the ASCO guidelines.

Before implementation of the ASCO guidelines, compliance with guidelines was 39% at the study site and 31% at the control site (p > 0.0.05). Six months after dissemination and implementation of the guidelines, compliance with the ASCO guidelines increased significantly compared with baseline in the study group to 61% (p = 0.003). Even after the guidelines were implemented, however, compliance with guidelines for the use of CSFs as primary prophylaxis did not change significantly vs. before implementation in the study group ([12%] before implementation vs 6% after implementation [p > 0.05]) (9).

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