Cost effectiveness of outpatient treatment for febrile neutropaenia in adult cancer patients

Abstract

Background: There is uncertainty whether low-risk episodes of febrile neutropaenia (FN) in adult cancer patients are best managed in the in- or outpatient setting.

Methods: A Monte Carlo cost-utility model was created to compare four treatment strategies for low-risk FN: (1) treatment in hospital with intravenous antibiotics (HospIV); (2) early discharge after 48 h in-patient observation, followed by oral outpatient treatment (EarlyDC); (3) outpatient management with IV antibiotics (HomeIV); and (4) outpatient management with oral antibiotics (HomePO). The model used a health-care payer perspective and a time horizon of one FN episode. Outcome measures were quality-adjusted FN episodes (QAFNE), costs (Canadian dollars) and incremental cost-effectiveness ratios (ICER). Parameter uncertainty was assessed with probabilistic sensitivity analyses.

Results: HomePO was cost saving ($3470 vs $4183), but less effective (0.65 QAFNE vs 0.72 QAFNE) than HomeIV. The corresponding ICER was $10,186 per QAFNE. Both EarlyDC ($6115; 0.66 QAFNE) and HospIV ($13,557; 0.62 QAFNE) were dominated strategies. At a willingness-to-pay (WTP) threshold of $4,000 per QAFNE, HomePO and HomeIV were cost effective in 54 and 38% of simulations, respectively.

Interpretation: For adult cancer patients with an episode of low-risk FN, treatment in hospital is more expensive and less effective than outpatient strategies.

Figure 1

Clinical decision model to compare different treatment strategies for low-risk febrile neutropaenia in adult cancer patients; four treatment strategies are evaluated: (1) entire HospIV; (2) EarlyDC; (3) HomeIV; and (4) HomePO. HCR indicates health-care-related infection.

Figure 2

The ICE scatter plot includes a single set of points representing pairs of incremental cost and effectiveness values from the simulation results (n=10 000) relative to a baseline (oral treatment at home; HomePO). The comparator in this scatter plot is IV treatment at home (HomeIV). The slope intersecting the y axis at $4000 displays the WTP threshold. In addition to the WTP line, a 95% confidence ellipse is drawn in the ICE scatter plot. The graph can be divided into several distinct regions: (1) HomeIV dominates HomePO (17%); (2) HomeIV is more costly and effective, and its ICER is less than or equal to the WTP, so it is cost effective (19%); (3) HomePO is more costly and effective, but its ICER is greater than the WTP, so HomeIV is optimal (4%); (4) HomeIV is more costly and effective, but its ICER is greater than the WTP, so HomePO is optimal (26%); (5) HomePO is more costly and effective, and its ICER is less than or equal to the WTP, so its optimal (6%); and (6) HomePO dominates HomeIV (28%).

Figure 3

This chart presents the cost-effectiveness acceptability curve for the base–case analysis. The curves represent the proportion of simulations in which oral outpatient therapy and IV outpatient therapy, respectively, were the cost-effective option at various WTP thresholds. For example, at a WTP threshold of $4000 per quality-adjusted febrile neutropaenia episode (vertical axis), oral therapy was cost effective in 54% of the simulations.