A new study evaluating the use of automated standing orders for primary prophylaxis colony-stimulating factor (PP-CSF) use in patients being treated with chemotherapy in community clinics did not reveal significant differences in use of PP-CSF compared with usual care. Rates of febrile neutropenia were also similar across the study arms. However, the study investigators considered the use of PP-CSF to be generally in accordance with the level of risk. The study findings were reported in JAMA Network Open.
The use of PP-CSF is recommended for patients with cancer receiving chemotherapy with a high risk of febrile neutropenia, but not for patients at low risk of febrile neutropenia, according to clinical practice guidelines. However, PP-CSF has been overused in patients at low risk and underutilized in those at high risk, the study investigators noted in their report.
The investigators launched this study to assess whether automated orders based on risk status improved adherence to guidelines for PP-CSF use and had a clinical effect of reducing incidence of febrile neutropenia. The multicenter, randomized, controlled Trial Assessing CSF Prescribing Effectiveness and Risk study (TrACER; ClinicalTrials.gov Identifier: NCT02728596) was conducted across 32 community oncology clinics.
Patients were randomly assigned 3:1 to 2 trial arms: an intervention group for whom PP-CSF was prescribed using guideline-based automatic standing orders and a control group for whom PP-CSF was prescribed per usual care. The primary outcomes were an increase in PP-CSF use for high-risk patients and a decrease in PP-CSF use for low-risk patients, in addition to the 6-month incidence of febrile neutropenia following trial registration.
There were 2287 patients in the intervention group and 659 in the control group. Patients were a median age 59.0 years (range, 50.0 to 67.0) and were being treated for breast, colorectal, or non-small cell lung cancer. An observational cohort of 719 patients was also separately analyzed.
Among the high-risk patients, the investigators found that PP-CSF use occurred with similar proportions in both study arms (89.2% in the intervention arm and 95.8% in the control arm [P =.21]). Among the low-risk patients, PP-CSF use occurred in 6.3% of the intervention arm and 5.5% of the control arm (P =.74). In the observational cohort, PP-CSF was given to 93.0% of high-risk patients and 8.3% of low-risk patients.
Among the high-risk patients, febrile neutropenia occurred in 6.1% of those in the intervention arm and in 4.2% of those in the control arm (P =.26). Among the low-risk patients, it occurred in 1.5% of those in the intervention arm and in 0.8% of those in the control arm (P =.51).
The study investigators determined that prescribing PP-CSF through an automated order entry system did not effectively improve prescribing adherence or rates of febrile neutropenia in the study. “Use of guideline-based computerized clinical decision support systems in this setting was ineffective and, therefore, not recommended for community oncology practice settings,” the study investigators concluded in their report.
Disclosures: Some authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures.
Ramsay SD, Bansal A, Sullivan SD, et al. Effects of a guideline-informed clinical decision support system intervention to improve colony-stimulating factor prescribing: a cluster randomized clinical trial. JAMA Netw Open. 2022;5(10):e2238191. doi:10.1001/jamanetworkopen.2022.38191