This study aimed to describe HCPs' preferences regarding the different options for administering Pegfilgrastim and how these preferences are reflected in the daily practice of general practitioners, nurses, and patient management specialists in cancer care settings. So far, we are not aware of any previous studies in Colombia that have evaluated preferences in the use of Neulastim® OBI compared to Pre-FS. Our results indicate that the majority of professionals prefer to avoid having the patient re-enter the care center. However, the patient's characteristics and ease of transport are some determining factors for those surveyed when deciding the best option for administering Pegfilgrastim.
One study estimated that, in the United States, the travel burden on patients and informal caregivers to be around 60 million miles and time devoted to such visits at 4.9 million hours or over 12 hours per patient treated, annually . Even so, another study comparing access to general (not oncological) healthcare in Colombia and Brazil, found that the mean journey time for patients to reach outpatient secondary level of care is about 62.7 minutes in Colombia, compared to 36.1 minutes in Brazil . A long journey time for health reasons could affect working hours, home time and might also imply greater expenses on transportation for both patients and their companions.
Colombian patients from rural areas differ very much from patients in Colombian urban areas when evaluating general access to health services and, particularly, to healthcare of chronic and complex diseases such as cancer. Nevertheless, our results elucidate that the viability of recurring visits in each patient is a priority for Colombian healthcare professionals when choosing how to administrate Pegfilgrastim without undermining therapeutic efforts. Previous research projects have set the precedent for the detrimental effects of time and economic burden on the likelihood of attendance to follow-up visits for GCSF prophylaxis and optimal care, in general [8, 10].
When analyzing the hypothetical cases presented to the surveyed professionals other reasons for avoiding re-admission include the release of the nursing staff in order to provide care to other patients. Similar findings were already reported by Heubers et al., with OBI as an approach to decrease care burden on healthcare staff while assuring Pegfilgrastim administration within the recommended time frame .
A global survey on the delivery of cancer care documented that oncologists from low and middle-income countries see more patients, work more days and are more often on call ; additionally, the higher volume of patients they face is associated with less time spent with them. Our findings support previous reports of a perceived need to rearrange oncology staff to meet patients’ needs, possibly due to a very high volume of patients.
According to our results, the majority of physicians we included have chosen Pre-FS administration within the first 24 hours after myelosuppressive therapy is the preferred clinically-validated option for time and form of administration of Pegfilgrastim, following the international guidelines. However, the proportion of professionals who choose OBI is very close to this, with 48.02% choosing OBI and 51.98% choosing Pre-FS, according to our results. This seems to indicate that both alternatives could be chosen as frequently in daily medical practice. This result is consistent with the general tendency of respondents to avoid having the patient re-enter 48 or 72 hours after myelosuppressive therapy and could vary according to each patient's specific case, as seen in hypothetical clinical situations.
When evaluating our results considering the distribution of cancer centers in the national territory, we find that the greatest concentration of them is in the northern and western region of the country, with the largest cities contributing with the greatest proportion of participants. It is worth noting that Bogotá contributed with 73.3% of the participants, which provides an additional perspective on the presumed flow of patients to specific cities and cancer care centers, making these institutions the most likely healthcare providers for patients referred from the country's periphery where access to cancer specialists is not an option. By the year 2019 in Colombia, a deficit of between 125 and 179 medical oncologists was estimated to cover the demand for patient care .
Finally, it is important to emphasize that approximately 16% of professionals do not report using any risk index for FN in the evaluation of oncological patients. Considering the wide use of risk indexes for clinical decision-making, it would be important to evaluate the performance of the most frequently used tools related to the choice of Pegfilgrastim administration option. Moreover, other studies have evaluated the relevance of FN risk assessment in order to avoid unnecessary treatment with Pegfilgrastim to optimize patients’ welfare and clinical outcomes . Evaluating these variables exceeds the scope of the present study and is proposed as a potential investigational objective for future studies.
Based on these results, the importance that Colombian professionals have attributed to the heterogeneous characteristics of patients, both in the clinical and social environment, is reflected on the prioritization of the patient's comfort and optimization of human resources in healthcare when choosing the best option for the administration of Pegfilgrastim. Our results do not differ from those reported previously  evaluating the same variables, but complement the profile of some of the obstacles faced by HCPs in Colombia, given the tendency to optimize time and resources and to avoid the re-entry of patients, as each case allows. More importantly, our results are consistent with previous findings and suggests that OBI might increase persistence, adherence and compliance to treatment, determining HCPs’ preference towards its use .
As a cross-sectional observational study, results may be limited by the availability of HCPs to participate in the study. Because participants work in specialized centers and because sampling is non-probabilistic, results may not be generalizable. Study participants may not be representative of all patients receiving Pegfilgrastim or all physicians prescribing Pegfilgrastim, potentially limiting the generalization of study findings. Furthermore, it is important to take into account recall bias, considering that the surveyed participants had to report the most frequent behaviors they had in their professional performance during at least 6 months prior to the survey; in order to control this bias, a control call was made to each participant in order to ensure the information obtained during both calls was the same.