| BackgroundChemotherapy-induced neutropenia(CIN)is a frequent toxicity after myelosuppressive therapy in patients with hematological malignancies.Febrile neutropenia(FN)and infection are its main complications,and serious cases may develop sepsis,infectious shock,and even death.In addition,because of severe or prolonged CIN,it is often clinically necessary to reduce the intensity of chemotherapy or change the chemotherapy regimen,and ultimately it is hard to achieve the desired anti-tumor treatment effect.Thus,timely and effective restoration of neutrophil levels in patients with CIN is an important guarantee for the safety and efficacy of chemotherapy for hematological malignancies.CIN management is an important part of Chemotherapy nursing.recombinant human Granulocyte Colony-Stimulating Factor(rhG-CSF),as a standard drug for the prevention and treatment of CIN,is expensive and widely used in patients with hematological malignancies.Nurses should do a good job of related medication care to maximize the efficacy of rhG-CSF,so as to control the cost of treatment while improving the prognosis of patients.In clinical practice,there are various routes of administration of short-acting rhG-CSF,including subcutaneous(SC)injection,intravenous(IV)bolus injection,and IV drip.The effect of different administration modes of rhG-CSF on CIN in patients with hematological malignancies is an important issue worthy of further discussion and research by oncology nurses.ObjectiveTo compare the efficacy of subcutaneous(SC)injection versus intravenous(IV)injection of recombinant human granulocyte colony-stimulating factor(rhG-CSF)for the treatment of chemotherapy induced-neutropenia in hematological malignancies.To understand the clinical application status of the two administration routes of rhG-CSF,analyze barriers to implementation of the evidence that SC injection of rhG-CSF is more effective,and propose optimization strategies.MethodsPart Ⅰ:Efficacy of different administration routes of rhG-CSF in patients with neutropenia after chemotherapy for hematological malignanciesWe retrospectively collected clinical data of patients who received rhG-CSF for the treatment of CIN in the Department of Hematology of a tertiary grade A general hospital in Chongqing,which were divided into SC group and IV group.The propensity score(PS)method was used to control for confounding bias,and differences in absolute neutrophil count(ANC)recovery time and complications were compared between groups.The research is divided into three stages:pre-experimental analysis,overall analysis and baseline-stratified analysis.Part Ⅱ:Clinical experience analysis of different administration routes of rhG-CSF in patients with neutropenia after chemotherapy for hematological malignanciesTo understand the application status of the two administration routes of rhG-CSF,individual interviews were conducted among doctors,nurses and patients in the hemato-oncological ward using the purposeful sampling method.Based on the Comprehensive Framework of Implementation Research(CFIR),barriers to implementation of the evidence that SC injection of rhG-CSF is more effective were analyzed,as well as optimization strategies were proposed.ResultsPart Ⅰ:Efficacy of different administration routes of rhG-CSF in patients with neutropenia after chemotherapy for hematological malignancies(1)The pre-experimental analysis included 308 non-Hodgkin’s lymphoma cases,and the three PS methods obtained consistent results.The 1:2 matching analysis(SC=77,IV=106)showed that,compared with IV group,the time for ANC recovery to≥0.1×10~9/L in SC group was shortened by 1.25 days(P=0.011),the time for ANC recovery to≥0.5×10~9/L was shortened by 1.14 days(P=0.002),and the risk of infection was also reduced(OR=0.42,P=0.049);the median recovery time from CIN in the SC group was 6(95%CI:5 to 7)days,and 7(95%CI:7 to 8)days in the IV group,and the probability of CIN recovery in the SC group was 1.59 times that of the IV group(P=0.005);a slightly shorter duration of Febrile neutropenia(FN)(β=-0.28 day,P=0.327)was observed in the SC group,but the difference was not statistically significant.The full matching analysis(SC=108,IV=200)showed that,compared with the IV group,the time to ANC recovery to≥0.1×10~9/L in the SC group was shortened by 0.87 day(P=0.026),the time to ANC recovery to≥0.5×10~9/L was shortened 0.79 day(P=0.006),and the risk of infection was also reduced(OR=0.49,P=0.044);the median recovery time from CIN was 6(95%CI:5 to 6)days in the SC group and 7(95%CI:6 to 7)days in the IV group,and the probability of CIN recovery in the SC group was 1.51 times that of the IV group(P=0.002);a slightly shorter duration of FN(β=-0.23 day,P=0.374)was observed in the SC group,but the difference was not statistically significant.The PS regression adjustment showed that,compared with the IV group,the time to ANC recovery to≥0.1×10~9/L in the SC group was shortened by 1.14(P=0.006)days,the time to ANC recovery to≥0.5×10~9/L was shortened 0.94(P=0.003)day,and the risk of infection was also reduced(OR=0.52,P=0.030);the median recovery time from CIN was 6(95%CI:5 to 6)days in the SC group and 7(95%CI:7 to 7)days in the IV group,and the probability of CIN recovery in the SC group was 1.58 times that of the IV group(P=0.001);the SC group had a slightly shorter duration of FN than the IV group(β=-0.29 day,P=0.329),but there was no statistical difference.In the overall analysis phase,890 cases of hematological malignancies were included,and the two PS matching analyses yielded consistent results.The 1:1 matching analysis(SC=220,IV=220)provided results that,compared with the IV route,the time to ANC recovery to≥0.1×10~9/L in the SC group was shortened by 1.44(95%CI:-2.15 to-0.74;P<0.001)days,the time to ANC recovery to≥0.5×10~9/L was shortened by 1.75(95%CI:-2.35 to-1.15;P<0.001)days,the duration of FN was shortened by 0.75(95%CI:-1.18 to-0.32;P<0.001)days,and the risk of infection was also reduced(OR=0.42,95%CI:0.23 to 0.75,P=0.004);the median recovery time from CIN was 7(95%CI:6 to 7)days in the SC group and 9(95%CI:8 to 10)days in the IV group,and the probability of CIN recovery in the SC group was 1.66(95%CI:1.34 to 2.05;P<0.0001)times that of the IV group;but difference in the incidence of bone pain was not significant.The 1:2 matching analysis(SC=220,IV=393)provided results that,compared with the IV route,the time to ANC recovery to≥0.1×10~9/L in the SC group was shortened by 1.46(95%CI:-2.09 to-0.82;P<0.001)days,the time to ANC recovery to≥0.5×10~9/L was shortened by 1.76(95%CI:-2.33 to-1.20;P<0.001)days,the duration of FN was shortened by 0.81(95%CI:-1.25 to-0.37;P<0.001)days,and the risk of infection was also reduced(OR=0.47,95%CI:0.28 to 0.79;P=0.004);the median time to recovery from CIN was 7(95%CI:6 to 7)days in the SC group and 9(95%CI:8 to 10)days in the IV group,and the probability of CIN recovery in the SC group was 1.70(95%CI:1.41 to 2.06;P<0.0001)times that of the IV group;but difference in the incidence of bone pain was not significant.Post-stratification PS matching analysis provided results that,rhG-CSF SC injection significantly shortened the time to ANC recovery to≥0.1×10~9/L and≥0.5×10~9/L compared with IV injection in all subgroups except the one that the rhG-CSF used was under the trade name of Li Shengsu;the probability of CIN recovery was significantly higher with rhG-CSF SC than with IV in all subgroups,except for the one with fever at the start of administration.Part Ⅱ:Clinical experience analysis of different administration routes of rhG-CSF in patients with neutropenia after chemotherapy for hematological malignanciesA total of 5 doctors,8 nurses and 9 patients were interviewed in this study.There were28 determinants of SC injection of rhG-CSF in hemato-oncological wards,including 8barriers,11 facilitators and 9 neutral influencing factors.Barriers to implementation exist in CFIR items such as evidence quality and strength,intervention relative advantages,patient needs,organizational communication networks,and learning atmosphere.Conclusions1.SC injection of rhG-CSF was generally more effective than IV injection in promoting CIN recovery in hematological malignancies,with a lower incidence of infection and shorter duration of FN,regardless of hematological tumor type,age,gender,chemotherapy stage,and baseline level of ANC.2.In order to improve the clinical application of SC injection of rhG-CSF,the following optimization strategies are proposed:(1)It is recommended to carry out a multi-center prospective randomized controlled study;(2)To create a good academic atmosphere,strengthen the relevant professional knowledge,and improve the medical staff’s cognition of evidence;knowledge and self-efficacy.(3)Based on a comprehensive consideration of clinical scenarios,best evidence,patient requirements and preferences,the administration route of rhG-CSF is determined.(4)Improve the technique of subcutaneous injection of rhG-CSF to relieve pain in patients.(5)Promote communication between doctors,nurses and patients,improve patient cognition and self-efficacy. |
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