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Wilson K, Umana E, McCleary D, Waterfield T, Woolfall K. Exploring communication preferences and risk thresholds of clinicians and parents of febrile infants under 90 days presenting to the emergency department: a qualitative study. Arch Dis Child 2024:archdischild-2023-326727. [PMID: 38986575 DOI: 10.1136/archdischild-2023-326727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 06/17/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Febrile infants under 3 months of age are at higher risk of invasive bacterial illness (IBI) when compared with older children. Increasingly sequential assessment based on age, clinical appearance and biomarkers is used to determine the risk of IBI, and appropriateness of invasive procedures such as lumbar puncture. The purpose of this qualitative study is to report parents and clinicians' opinions on communication of risks and benefits of sequential assessment and tailored treatment. METHODS 18 parents enrolled in the Febrile Infant Diagnostic Assessment and Outcomes study and seven clinicians from England, Wales and Northern Ireland were purposively selected to participate in virtual qualitative interviews. Data were analysed thematically. RESULTS Tailored treatment plans were widely supported. Confidence in the clinician was central to parents' attitude towards management recommendations. Parents' decision-making preferences change throughout their child's clinical journey, with an initial preference for clinician-led decisions evolving towards collaborative decision-making as their stress and anxiety reduce. There were widespread differences in preferences for how risk was discussed. Parents self-reported poor retention of information and felt communication adjuncts helped their understanding. Clinicians were generally positive about the use of clinical decision aids as a communication tool, rather than relying on them for decision-making. DISCUSSION Parents want to feel informed, but their desire to be involved in shared decision-making evolves over time.Clinicians appear to use their clinical judgement to provide individualised information, evolving their communication in response to perceived parental needs.Poor information retention highlights the need for repetition of information and use of communication adjuncts. TRIAL REGISTRATION NUMBER NCT05259683.
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Affiliation(s)
- Kathryn Wilson
- Wellcome Wolfson Institute for Experimental Medicine, Queen's University Belfast School of Medicine, Dentistry and Biomedical Sciences, Belfast, UK
- Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Etimbuk Umana
- Wellcome Wolfson Institute for Experimental Medicine, Queen's University Belfast School of Medicine, Dentistry and Biomedical Sciences, Belfast, UK
| | - David McCleary
- Wellcome Wolfson Institute for Experimental Medicine, Queen's University Belfast School of Medicine, Dentistry and Biomedical Sciences, Belfast, UK
| | - Thomas Waterfield
- Wellcome Wolfson Institute for Experimental Medicine, Queen's University Belfast School of Medicine, Dentistry and Biomedical Sciences, Belfast, UK
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Vargas C, Haeusler GM, Slavin MA, Babl FE, Mechinaud F, Phillips R, Thursky K, Lourenco RDA. An analysis of the resource use and costs of febrile neutropenia events in pediatric cancer patients in Australia. Pediatr Blood Cancer 2023; 70:e30633. [PMID: 37592047 DOI: 10.1002/pbc.30633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/31/2023] [Accepted: 08/05/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Febrile neutropenia (FN) in children with cancer generally requires in-hospital care, but low-risk patients may be successfully managed in an outpatient setting, potentially reducing the overall healthcare costs. Updated data on the costs of FN care are lacking. METHODS A bottom-up microcosting analysis was conducted from the healthcare system perspective using data collected alongside the Australian PICNICC (Predicting Infectious Complications of Neutropenic sepsis In Children with Cancer) study. Inpatient costs were accessed from hospital administrative records and outpatient costs from Medicare data. Costs were stratified by risk status (low/high risk) according to the PICNICC criteria. Estimated mean costs were obtained through bootstrapping and using a linear model to account for multiple events across individuals and other clinical factors that may impact costs. RESULTS The total costs of FN care were significantly higher for FN events classified as high-risk ($17,827, 95% confidence interval [CI]: $17,193-$18,461) compared to low-risk ($10,574, 95% CI: $9818-$11,330). In-hospital costs were significantly higher for high-risk compared to low-risk events, despite no differences in the cost structure, mean cost per day, and pattern of resource use. Hospital length of stay (LOS) was the only modifiable factor significantly associated with total costs of care. Excluding antineoplastics, antimicrobials are the most commonly used medications in the inpatient and outpatient setting for the overall period of analysis. CONCLUSION The FN costs are driven by in-hospital admission and LOS. This suggests that the outpatient management of low-risk patients is likely to reduce the in-hospital cost of treating an FN event. Further research will determine if shifting the cost to the outpatient setting remains cost-effective overall.
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Affiliation(s)
- Constanza Vargas
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Broadway, New South Wales, Australia
| | - Gabrielle M Haeusler
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- The Paediatric Integrated Cancer Service, Victoria State Government, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Franz E Babl
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Francoise Mechinaud
- Unité d'hématologie Immunologie Pédiatrique, Hopital Robert Debré, APHP Nord Université de Paris, Paris, France
| | - Robert Phillips
- Centre for Reviews and Dissemination, University of York, York, UK
- Leeds Children's Hospital, Leeds General Infirmary, Leeds, UK
| | - Karin Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- NHMRC National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Department of Emergency Medicine, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Broadway, New South Wales, Australia
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Seneviratne N, Yeomanson D, Phillips R. Short-course antibiotics for chemotherapy-induced febrile neutropaenia: retrospective cohort study. Arch Dis Child 2020; 105:881-885. [PMID: 32184200 DOI: 10.1136/archdischild-2019-317908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 01/17/2020] [Accepted: 02/24/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Recent research in febrile neutropaenia (FN) has focused on reducing the intensity of treatment for those thought to be at low risk of significant morbidity or mortality. This has not led to a reduced burden of treatment for either families or healthcare systems. An alternative approach is to discharge all patients who remain well after 48 hours of inpatient treatment, either with no ongoing treatment or with appropriate antibiotics if the cultures are positive. This paper aimed to demonstrate that this approach is safe. METHODS Patients treated according to this approach in a single centre were reviewed retrospectively, with a random selection of patients from a 4-year period. Data were collected according to the Predicting Infectious Complications of Neutropenic sepsis in Children with Cancer dataset. In addition, all septic deaths over a 10-year period were reviewed in the same manner. RESULTS 179 episodes of FN were reviewed from 47 patients. In 70% (125/179) of episodes, patients were discharged safely once 48-hour microbiology results were available, with only 5.6% (7/125) resulting in readmission in the 48 hours following discharge. There were no septic deaths in this cohort.There were 11 deaths due to FN over the 10-year study period. Almost all patients were identified as severely unwell in the early stages of their final presentation or had a prolonged final illness. CONCLUSION This paper indicates that the policy described provides a balance between safety and acceptability. Further work is needed to demonstrate non-inferiority and cost-benefit.
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Affiliation(s)
- Nicola Seneviratne
- Haematology and Oncology, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Daniel Yeomanson
- Haematology and Oncology, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Robert Phillips
- Centre for Reviews and Dissemination, University of York, York, UK
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Szymczak JE, Getz KD, Madding R, Fisher B, Raetz E, Hijiya N, Gramatges MM, Henry M, Mian A, Arnold SD, Aftandilian C, Collier AB, Aplenc R. Identifying patient- and family-centered outcomes relevant to inpatient versus at-home management of neutropenia in children with acute myeloid leukemia. Pediatr Blood Cancer 2018; 65:10.1002/pbc.26927. [PMID: 29286570 PMCID: PMC6857179 DOI: 10.1002/pbc.26927] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 11/08/2017] [Accepted: 11/09/2017] [Indexed: 11/12/2022]
Abstract
Efficacy of therapeutic strategies relative to patient- and family-centered outcomes in pediatric oncology must be assessed. We sought to identify outcomes important to children with acute myeloid leukemia and their families related to inpatient versus at-home management of neutropenia. We conducted qualitative interviews with 32 children ≥8 years old and 54 parents. Analysis revealed the impact of neutropenia management strategy on siblings, parent anxiety, and child sleep quality as being outcomes of concern across respondents. These themes were used to inform the design of a questionnaire that is currently being used in a prospective, multiinstitutional comparative effectiveness trial.
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Affiliation(s)
- Julia E. Szymczak
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Kelly D. Getz
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rachel Madding
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brian Fisher
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Infectious Diseases, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elizabeth Raetz
- Department of Pediatrics and Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Nobuko Hijiya
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Pediatric Hematology Oncology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Maria M. Gramatges
- Department of Pediatrics, Section of Hematology-Oncology, Baylor College of Medicine, Houston, Texas
| | - Meret Henry
- Division of Hematology/Oncology, Children’s Hospital of Michigan, Wayne State University, Detroit, Michigan
| | - Amir Mian
- Department of Pediatric Hematology-Oncology, College of Medicine, Arkansas Children’s Hospital, University of Arkansas Medical Sciences, Little Rock, Arkansas
| | - Staci D. Arnold
- Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Catherine Aftandilian
- Division of Pediatric Hematology/Oncology, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | - Anderson B. Collier
- Division of Hematology/Oncology, Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Richard Aplenc
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Meta-ethnography of experiences of early discharge, with a focus on paediatric febrile neutropenia. Support Care Cancer 2018; 26:1039-1050. [PMID: 29285558 PMCID: PMC5847030 DOI: 10.1007/s00520-017-3983-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 11/15/2017] [Indexed: 11/02/2022]
Abstract
PURPOSE (STATING THE MAIN PURPOSES AND RESEARCH QUESTION) Many children have no significant sequelae of febrile neutropenia. A systematic review of clinical studies demonstrated patients at low risk of septic complications can be safely treated as outpatients using oral antibiotics with low rates of treatment failure. Introducing earlier discharge may improve quality of life, reduce hospital acquired infection and reduce healthcare service pressures. However, the review raised concerns that this might not be acceptable to patients, families and healthcare professionals. METHODS This qualitative synthesis explored experiences of early discharge in paediatric febrile neutropenia, including reports from studies of adult febrile neutropenia and from other paediatric conditions. Systematic literature searching preceded meta-ethnographic analysis, including reading the studies and determining relationships between studies, translation of studies and synthesis of these translations. RESULTS Nine papers were included. The overarching experience of early discharge is that decision-making is complex and difficult and influenced by fear, timing and resources. From this background, we identified two distinct themes. First, participants struggled with practical consequences of treatment regimens, namely childcare, finances and follow-up. A second theme identified social and emotional issues, including isolation, relational and environmental challenges. Linking these, participants considered continuity of care and the need for information important. CONCLUSIONS Trust and confidence appeared interdependent with resources available to families-both are required to manage early discharge. Socially informed resilience is relevant to facilitating successful discharge strategies. Interventions which foster resilience may mediate the ability and inclination of families to accept early discharge. Services have an important role in recognising and enhancing resilience.
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Simon A, Furtwängler R, Graf N, Laws HJ, Voigt S, Piening B, Geffers C, Agyeman P, Ammann RA. Surveillance of bloodstream infections in pediatric cancer centers - what have we learned and how do we move on? GMS HYGIENE AND INFECTION CONTROL 2016; 11:Doc11. [PMID: 27274442 PMCID: PMC4886351 DOI: 10.3205/dgkh000271] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Pediatric patients receiving conventional chemotherapy for malignant disease face an increased risk of bloodstream infection (BSI). Since BSI may represent an acute life-threatening event in patients with profound immunosuppression, and show further negative impact on quality of life and anticancer treatment, the prevention of BSI is of paramount importance to improve and guarantee patients' safety during intensive treatment. The great majority of all pediatric cancer patients (about 85%) have a long-term central venous access catheter in use (type Broviac or Port; CVAD). Referring to the current surveillance definitions a significant proportion of all BSI in pediatric patients with febrile neutropenia is categorized as CVAD-associated BSI. This state of the art review summarizes the epidemiology and the distinct pathogen profile of BSI in pediatric cancer patients from the perspective of infection surveillance. Problems in executing the current surveillance definition in this patient population are discussed and a new concept for the surveillance of BSI in pediatric cancer patients is outlined.
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Affiliation(s)
- Arne Simon
- Pädiatrische Onkologie und Hämatologie, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Rhoikos Furtwängler
- Pädiatrische Onkologie und Hämatologie, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Norbert Graf
- Pädiatrische Onkologie und Hämatologie, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Hans Jürgen Laws
- Klinik für Pädiatrische Onkologie, Hämatologie und Immunologie, Universitätskinderklinik, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Sebastian Voigt
- Klinik für Pädiatrie m. S. Onkologie / Hämatologie / Stammzelltransplantation, Charité – Universitätsmedizin Berlin, Germany
| | - Brar Piening
- Institut für Hygiene und Umweltmedizin, Charité – Universitätsmedizin Berlin, Germany
| | - Christine Geffers
- Institut für Hygiene und Umweltmedizin, Charité – Universitätsmedizin Berlin, Germany
| | - Philipp Agyeman
- Pädiatrische Infektiologie und Pädiatrische Hämatologie-Onkologie, Universitätsklinik für Kinderheilkunde, Inselspital, Bern, Switzerland
| | - Roland A. Ammann
- Pädiatrische Infektiologie und Pädiatrische Hämatologie-Onkologie, Universitätsklinik für Kinderheilkunde, Inselspital, Bern, Switzerland
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Henry M, Sung L. Supportive care in pediatric oncology: oncologic emergencies and management of fever and neutropenia. Pediatr Clin North Am 2015; 62:27-46. [PMID: 25435110 DOI: 10.1016/j.pcl.2014.09.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Advancements in the care of children with cancer have, in part, been achieved through improvements in supportive care. Situations that require prompt care can occur at the time of presentation as well as during treatment. This article discusses the approach to children with fever and neutropenia, a complication encountered daily by care providers, as well as oncologic emergencies that can be seen at the time of a child's initial diagnosis: hyperleukocytosis, tumor lysis syndrome, superior vena cava syndrome, and spinal cord compression.
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Affiliation(s)
- Meret Henry
- Division of Hematology/Oncology, Children's Hospital of Michigan/Wayne State University, 3901 Beaubien, Detroit, MI 48201, USA.
| | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G1X8, Canada
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The Multinational Association for Supportive Care in Cancer (MASCC) risk index score: 10 years of use for identifying low-risk febrile neutropenic cancer patients. Support Care Cancer 2013; 21:1487-95. [PMID: 23443617 DOI: 10.1007/s00520-013-1758-y] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 02/11/2013] [Indexed: 01/20/2023]
Abstract
The Multinational Association for Supportive Care in Cancer risk index score developed, through a multinational collaboration, was published in 2000 with the aim to identify patients with chemotherapy-induced febrile neutropenia at low risk of serious medical complication development. It has been endorsed as a reliable tool since 2002 by Infectious Diseases Society of America. Ten years after, we thought worth to review its use, its characteristics in the external validations that occurred after the initial publication and also to review how the recognition of a group of patients at low risk has changed the management of febrile neutropenia. We also raise the issue of identification of high-risk patients that remains a challenge today.
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The Hematology and Oncology Pediatric Patient: A Review of Fever and Neutropenia, Blood Transfusions, and Other Complex Problems. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2012. [DOI: 10.1016/j.cpem.2012.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Sung L. Initial Management of Low-Risk Pediatric Fever and Neutropenia: Efficacy and Safety, Costs, Quality-of-Life Considerations, and Preferences. Am Soc Clin Oncol Educ Book 2012:570-574. [PMID: 24451798 DOI: 10.14694/edbook_am.2012.32.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Initial management options for pediatric low-risk fever and neutropenia (FN) include outpatient compared with inpatient management and oral compared with intravenous therapy. Single-arm and randomized trials have been conducted in children. Meta-analyses provide support for the equivalence of outpatient and inpatient approaches. Outpatient oral management may be associated with a higher risk of readmission compared with outpatient intravenous management in children with FN, although other outcomes such as treatment failure and discontinuation of the regimen because of adverse effects were similar. Importantly, there have been no reported deaths among low-risk children treated as outpatients or with oral antibiotics. Costs, whether derived directly or through cost-effectiveness analysis, are consistently reduced when an outpatient approach is used. Quality of life (QoL) and preferences should be considered in order to evaluate different strategies, plan programs, and anticipate uptake of outpatient programs. Using parent-proxy report, child QoL is consistently higher with outpatient approaches, although research evaluating child self-report is limited. Preferences incorporate estimated QoL, but, in addition, factor in issues such as costs, fear, anxiety, and logistical issues. Only approximately 50% of parents prefer outpatient management. Future research should develop tools to facilitate outpatient care and to measure caregiver burden associated with this strategy. Additional work should also focus on eliciting child preferences for outpatient management. Finally, studies of effectiveness of an ambulatory approach in the real-world setting outside of clinical trials are important.
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Affiliation(s)
- Lillian Sung
- From the Division of Haematology/Oncology, and Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
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