Cost-effectiveness of outpatient management for febrile neutropenia in children with cancer.

OBJECTIVE Inpatient management remains the standard of care for treatment of febrile neutropenia (FN) in children with cancer. Clinical data suggest, however, that outpatient management might be a safe and efficacious alternative for patients with low-risk FN episodes. METHODS A cost-utility model was created to compare 4 treatment strategies for low-risk FN. The base case considered pediatric cancer patients with low-risk FN. The model used a health care payer's perspective and a time horizon of 1 FN episode. Four treatment strategies were evaluated: (1) entire treatment in hospital with intravenous antibiotics (HospIV); (2) early discharge consisting of 48 hours of inpatient observation with intravenous antibiotics followed by oral outpatient treatment (EarlyDC); (3) entirely outpatient management with intravenous antibiotics (HomeIV); and (4) entirely outpatient management with oral antibiotics (HomePO). Outcome measures were quality-adjusted FN episodes (QAFNEs), costs (Canadian dollars), and incremental cost-effectiveness ratios. Parameter uncertainty was assessed with probabilistic sensitivity analyses. RESULTS The most cost-effective strategy was HomeIV. It was cost-saving ($2732 vs $2757) and more effective (0.66 vs 0.55 QAFNE) as compared with HomePO. EarlyDC was slightly more effective (0.68 QAFNE) but significantly more expensive ($5579) than HomeIV, which resulted in an unacceptably high incremental cost-effectiveness ratio of more than $130 000 per QAFNE. HospIV was the least cost-effective strategy because it was more expensive ($14 493) and less effective (0.65 QAFNE) than EarlyDC. CONCLUSION The findings of this decision-analytic model indicate that the substantially higher costs of inpatient management cannot be justified on the basis of safety and efficacy considerations or patient/parent preferences.