This CMA aimed to evaluate the economic outcomes associated with sequential outpatient treatment versus inpatient treatment for pediatric patients experiencing febrile neutropenia (FN) episodes. The analysis took a societal perspective, considering both direct and indirect medical costs associated with each treatment strategy. Notably, unlike other cost studies, our research utilized real-world data prospectively collected from patients enrolled in a clinical trial across three hospitals.
Our findings revealed that outpatient treatment of FN in children with cancer resulted in an average cost savings of $1,108 compared to inpatient treatment. The significantly lower cost of outpatient management primarily stemmed from reductions in hospitalization expenses and human resource costs, which accounted for 36% and 41% of direct medical costs, respectively. We meticulously documented the number of healthcare professionals involved in patient care on a daily basis, enabling us to identify healthcare professional fees as the most substantial cost driver. This category encompassed fees for medical staff, consulting specialists, nursing personnel, and other supportive care professionals such as psychologists and social workers.
Previous economic studies on FN have commonly focused on bed days as the most cost-intensive aspect. (11, 12, 15) For instance, Hendricks et al. reported that bed day costs constituted 58.2% of total hospital costs for adults with cancer,(15) while Costa et al. found that bed day costs accounted for 62% of total treatment costs in the pediatric population. (10)
Other economic analyses in this domain have either exclusively examined patients at lower risk of complications, such as those with solid tumors, (13) or have solely reported hospitalization costs of FN episodes without comparing them to an outpatient group. (9) Furthermore, some studies have solely considered the perspective of healthcare payers. (11) In contrast, our CMA stands out by prospectively capturing information and adopting a societal economic perspective. This approach not only provides decision-makers with valuable insights into the costs of FN treatment but also sheds light on the financial burden faced by parents or caregivers when caring for children with FN in a hospital setting.
Among the expenses borne by parents or caregivers, the cost of hiring additional caregivers to support patient care emerged as the most significant out-of-pocket cost in both treatment groups. Primary caregivers reported the need to hire additional assistance to care for their children so that they could continue working. Despite this, 69% of primary caregivers in the outpatient group and 47% in the inpatient group reported partial or complete cessation of work, with similar average income loss in both groups.
Most cost studies on FN in oncology patients have utilized data from over a decade ago, with the most recent study analyzing data from 2012 but published in 2017. (8) Consequently, there is a knowledge gap concerning the current costs of treating these patients, given the rise in healthcare costs in recent years and the increasing number of adult patients receiving outpatient treatment. Outpatient management of FN episodes in children remains less common. Nonetheless, our clinical trial-based economic analysis demonstrates the safety and effectiveness of outpatient treatment for FN episodes in children and underscores the substantial cost reduction potential. (17) This evidence can further support the case for early discharge and continued treatment at home.
Current information regarding the costs of treating children with FN in Latin America is outdated and limited. (2, 9) A study conducted 19 years ago in Brazil examined a small sample of 22 hospitalized patients with FN episodes, reporting a median cost of $2,660 per episode, with bed days accounting for 62% of total costs. (9)
Another study conducted in Chile 18 years ago reported average costs of $638 for outpatient treatment and $903 for inpatient treatment of FN episodes. (2) In this study, patients participated in a trial where, during the first 24 to 36 hours of hospitalization, they were randomly assigned to receive antibiotics either on an outpatient or inpatient basis. However, both groups continued to receive intravenous antibiotics (ceftriaxone and teicoplanin). After at least 72 hours of intravenous treatment, it was determined individually whether patients could switch to oral antibiotics or continue with intravenous antibiotics. In the outpatient group, patients had to visit the clinic daily for laboratory sampling and intravenous antibiotic infusion, followed by a one-hour observation period. It is possible that the costs associated with clinic visits, daily laboratory studies, and intravenous medication administration increased the costs of outpatient treatment. As a result, the cost difference between the treatment groups in the study was not substantial. Previous reports indicate that oral administration of medications, as opposed to intravenous administration, can reduce costs by approximately 80%. (16) In our study, we observed a remarkable 92% decrease in average costs.
Our study has several limitations. Firstly, direct medical costs were underestimated because the public hospitals where the study was conducted subsidize all services. Consequently, the actual savings may be even greater than what is reported. Secondly, although transfusion therapy is an important support for cancer patients, the costs associated with the blood bank were not quantified in this study. Thirdly, the costs for patients in both treatment strategy groups were collected prospectively from the moment they met the inclusion criteria and signed the informed consent form. Therefore, the costs of the initial 48–72 hours of treatment were not quantified for either group. This indicates that both outpatient and inpatient treatments incur higher costs during this initial period. However, it is likely that the cost difference between the groups maintained a similar proportion since all patients received the same treatment during the first 48 to 72 hours.
This CMA is the first in Mexico to demonstrate the cost-saving potential of step-down outpatient treatment compared to inpatient treatment for FN episodes in children with cancer, resulting in an average 92% reduction in direct costs.