This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn.

This study examined the cost-effectiveness of various in-patient or out-patient treatments for low-risk episodes of febrile neutropenia in adult cancer patients, from the perspective of the health care system. The authors concluded that out-patient oral or intravenous treatments were more effective and less expensive than in-patient treatments. The methods were valid, the data sources were reported, and the uncertainty was addressed. The authors’ conclusions appear to be robust.

Cost-utility analysis

This study examined the cost-effectiveness of various in-patient or out-patient treatments for low-risk episodes of febrile neutropenia, in adult cancer patients.

Four treatment strategies were examined: treatment in hospital with intravenous antibiotics; early discharge after 48 hours in-patient observation, followed by oral out-patient treatment; out-patient management with intravenous antibiotics; and out-patient management with oral antibiotics.

The combination of piperacillin and tazobactam, plus tobramycin was the first-line intravenous antibiotic treatment, while the oral treatment consisted of ciprofloxacin plus the combination of amoxicillin and clavulanate. All treatments were administered for six days.

Canada/in-patient and out-patient care.

Analytical approach:

Effectiveness data:

Monetary benefit and utility valuations:

Measure of benefit:

Cost data:

Analysis of uncertainty:

Costs were CAD 3,470 (95% CI 1,669 to 6,564) with home oral treatment, CAD 4,183 (95% CI 2,001 to 7,616) with home intravenous treatment, CAD 6,115 (95% CI 2,471 to 12,394) with early discharge, and CAD 13,557 (95% CI 4,592 to 30,000) with hospital intravenous treatment.

The QAFNE were 0.65 (95% CI 0.13 to 0.91) with home oral, 0.72 (95% CI 0.18 to 0.98) with home intravenous, 0.66 (95% CI 0.22 to 0.92) with early discharge, and 0.62 (95% CI: 0.15 to 0.94) with hospital intravenous treatment.

Early discharge and with hospital intravenous treatment were dominated, as they were more expensive and less effective than another strategy. Compared with home oral, which was the least costly strategy, the incremental cost per QAFNE gained with home intravenous was CAD 10,186.

Home oral treatment was cost-effective in 54% of simulations, while home intravenous was cost-effective in 38% of simulations. Early discharge was cost-effective in 8% of simulations and hospital intravenous was cost-effective in less than 1% of simulations.

The model outcomes were sensitive to variations in the costs of in-patient stay, out-patient visits, and home nurse visits. The duration of treatment and some utility assumptions were also key inputs. In some scenarios, home intravenous treatment was the preferred strategy, but the in-patient treatments were never cost-effective.

The authors concluded that out-patient oral or intravenous treatments were more effective and less expensive than in-patient treatments.

Interventions:

Effectiveness/benefits:

Costs:

Analysis and results:

Concluding remarks:

Funding received from the Swiss Cancer League, the Canadian Cancer Society, and the Canadian Institutes of Health Research.