16 minute read
Collaboration speeds access to less costly oral oncolytics
Collaborative Ca Agreements Cut Time, Costs
A collaborative practice agreement (CPA) for oral oncolytics implemented at St. Luke’s Cancer Institute, in Boise, Idaho, slashed turnaround times for oral oncolytic drug processing and saved thousands in drug costs.
The CPA expanded the scope of pharmacy practice while helping patients and providers, according to Amanda Wright, PharmD, an oncology pharmacist at St. Luke’s. “Implementing a CPA for oral oncolytics has helped our providers devote more time to aspects of patient care they are uniquely skilled to do,” said Wright, “while pharmacists have been able to make sure that treatments are dosed appropriately and that patients initiate and continue their therapy safely and in a timely manner.”
St. Luke’s already had a CPA in place allowing five clinical pharmacists at their oral oncolytic office to help providers individualize antiemetic regimens for patients at the institute’s ambulatory care clinics, she said.
These pharmacists also helped optimize oral oncolytic regimens by ensuring new prescriptions were indication appropriate, reviewing laboratory tests and concurrent medications, providing patient medication counseling, performing follow-ups to complete refills, and assessing adverse effects, adherence issues and new medications.
However, “any changes pharmacists made to a prescription required provider approval, which took between a few hours to a few days to receive,” Wright said. This interrupted pharmacists’ workflow and, “since we needed to check the patient’s electronic medical record to see if the prescriptions had been signed,” she said, “it also resulted in occasional delays in treatment initiation or continuation.”
Wright and her team decided a CPA could overcome these inefficiencies. They identified a list of clinical activities that pharmacists could perform as part of an oral oncolytic CPA. These activities ranged from dose adjustments based on patient indications, renal and hepatic function, and toxicities; dose rounding to help cut drug costs; signing off on medication renewals; and ordering laboratory tests and examinations.
“We presented these ideas as well as some metrics we would be looking at to our P&T [pharmacy and therapeutics] committee and to the providers and pharmacists that would be involved in a pilot project, and we incorporated their feedback and received approval,” Wright said.
The CPA proved its value in a pilot project conducted between November 2018 and February 2019, said Wright, presenting data on the project during the Association of Community Cancer Centers 2020 Virtual National Oncology Conference. Comparing the intervention group of 54 patients treated by four providers with a group to 87 patients managed during the same period by 11 providers not operating under the CPA, they found prescription turnaround times averaged seven minutes in the CPA group and 55 hours in the control group. Dose-rounding interventions for two patients in the pilot group also led to significant cost savings, with one capecitabine prescription rounded to the nearest tablet size resulting in $547 in savings per treatment cycle ($9,858 annually), and a rounded temozolomide prescription saving $252 per cycle ($3,281 annually).
Most providers were very satisfied with the new oral oncolytic CPA and believed it had a positive impact, saying they would recommend its use across other clinics at St. Luke’s, Wright noted.
Indeed, the CPA was subsequently rolled out across St. Luke’s. Data collected over a three-month period from all 15 providers found the average prescription processing turnaround time was six minutes.
“Not only were we able to improve the pharmacy workflow, we also reduced the time to initiation or continuation of patient treatment,” said Wright, noting that they have not yet found cost savings associated with the CPA since the systemwide rollout.
Jane Rogers, PharmD, a clinical pharmacy specialist at The University of Texas MD Anderson Cancer Center, in Houston, who was not involved with the initiative, said the reductions in prescription turnaround time and cost savings that Wright and her team reported are “striking” and demonstrate the value of pharmacists in cancer care.
“Oncology is an area with a tremendous need for services such as the ones highlighted in this study,” Rogers commented. Management of complex polypharmaceutical cancer regimens and their adverse effects and counseling on use of herbal and vitamin supplements are other important areas where clinical pharmacists can improve patient care, she said, predicting that “more publications like Wright and her team’s will help pave the way to make these services a normal part of everyday practice.” —David Wild
—Amanda Wright, PharmD
6 Strategies for Implementing a Successful CPA
Amanda Wright, PharmD, an oncology pharmacist at St. Luke’s Cancer Institute, in Boise, Idaho, shared some tips for pharmacists trying to set up collaborative practice agreements (CPAs) at their institutions to help oncology providers and improve patient care.
Develop rapport with the interdisciplinary
team. “This is one of the most important steps, because establishing a relationship of trust with nurse practitioners and providers will allow pharmacists to complete their interventions without interruption.”
Identify areas where pharmacy can help provid-
ers with oral oncolytics. “Find areas where providers’ medication management workflows are challenging. The goal is for both pharmacists and providers to complete their tasks in a timely manner.”
Discuss and determine the best approach
with the provider team. “Make sure the goals of pharmacists and providers are aligned, with the best interest of patients at heart, and identify provider champions to review the pharmacist clinical activities and offer feedback on their expectations in the initial stages of creating the CPA.”
Create and present the CPA to the administra-
tive team. “Provide a comprehensive look at the agreement you’ve created, including what goals you have for implementing the CPA. This will help get the buy-in and support you need before going ahead with this.”
Evaluate the CPA to share its impact on the
clinic workflow. “A great aspect of how we set up our agreement was that we created data collection goals as part of the CPA. We found ways to evaluate the CPA and its impact within the clinic.”
Request feedback from all members of the
team. “Make sure necessary adjustments are made so that patients receive the best care. The great thing about CPAs is that they’re really easy to tailor to the needs of your clinic” to allow you “to provide the best patient care.”
Clinics, Home Rx Spur Chemotherapy Savings
With the right mix of people and processes, many chemotherapy treatments can be safely transitioned from inpatient to outpatient settings, reducing inpatient stays and slashing hundreds of thousands of dollars from the drug budget, according to a presentation at the Association of Community Cancer Centers 2020 Virtual National Oncology Conference.
“Institutions can save money they may otherwise lose in the inpatient setting by seeking reimbursement based on a buy-and-bill model, purchasing therapies under 340B if they’re eligible, billing for waste, and gaining access to patient assistance programs,” Ali McBride, PharmD, the clinical coordinator and supervisor of hematology/oncology at the University of Arizona Cancer Center, in Tucson, told attendees.
McBride explained that several years ago, he and his colleagues reviewed some of the highest-cost inpatient chemotherapies administered at their institution and found that some treat-
ments were appropriately being administered in the inpatient setting because of the need for closer monitoring in higher acuity patients, but “more often than not, chemotherapy was being given in the inpatient setting just because it could be given in that setting.”
Building the Right Team
To shift some of these therapies to the outpatient setting safely and successfully and champion the program to get buy-in from leadership and physicians, McBride and his colleagues assembled a team that included physicians, advanced practitioners, nurse coordinators, risk management and information technology staff, and others.
Clinical and staff pharmacists have played leading roles on the team and throughout the initiative, he said. Specifically, functions have included screening patients for outpatient chemotherapy eligibility, ensuring individuals have a way of getting to infusion centers, helping arrange after-hours care for patients and caregivers, and securing infusion pumps for home infusion recipients. They also provide supportive care medications and review patients’ medication lists and laboratory tests for any safety concerns, McBride said.
“Another important piece our clinical pharmacists provide is staff and patient clinical education, and they also address adherence to supportive care medications and decrease inpatient drug waste, which has been key to the cost savings aspect of the program,” McBride said.
Staff pharmacists also resolve billing issues, transition eligible
inpatient chemotherapy orders to the outpatient setting, and help reduce drug waste by batch compounding therapies when possible, McBride added.
Starting With Rituximab
As McBride reported, his team identified rituximab as a good place to start in their shift to outpatient chemotherapy administration. “While most of our rituximab patients were receiving this drug on the same day as their inpatient chemotherapy, they were also all being given pegfilgrastim in the outpatient setting the day after discharge, so we moved [rituximab] to the day after discharge,” McBride said. He noted that this transition does not affect the safety or efficacy of the drug or the broader regimen.
The team analyzed the use of rituximab for lymphoma patients during a four-year period beginning in 2015, when they implemented the rituximab transition, identifying 35 patients who received rituximab in the inpatient setting and 137 who received it in the outpatient setting. “Some of those who received it as inpatients required other inpatient therapy, while others may have been admitted as inpatients for their first cycle of chemotherapy,” McBride noted.
Nearing $1 Million in Savings
Switching to outpatient administration for the 137 rituximab recipients yielded an estimated savings of $925,000, due to approximately $450,000 in drug cost savings, since patients made use of medication assistance programs, as well as reduced hospital costs from an average nine-hour reduction in inpatient stays. “We also billed to the nearest milligram, which increased reimbursement for waste,” McBride added. Ultimately, his team hopes to provide 90% of rituximab doses in the outpatient setting and is transitioning several other chemotherapy treatments to outpatient administration.
McBride said modifying order sets and integrating outpatient and inpatient electronic health records led to a “rapid uptick” in physician prescribing of outpatient treatment.
“Physicians really welcomed the shorter inpatient stays,” said McBride, noting that concerns about preserving inpatient resources and keeping patients out of the hospital, when possible, during the COVID-19 pandemic has made the program even more popular.
Karen Fancher, PharmD, an associate professor of pharmacy practice in oncology acute care at Duquesne University School of Pharmacy, in Pittsburgh, said she was “very impressed by the number of chemotherapy regimens transitioned to the outpatient setting” at the University of Arizona Cancer Center. “This program provides a lot of tangible evidence that many traditionally inpatient chemotherapy regimens can be safe, feasible and cost-effective to provide in the outpatient setting,” said Fancher, who was not involved with the initiative.
Obtaining Buy-In
Although the results of the program are compelling, she said obtaining buy-in from practitioners and creating the workflow changes necessary for a successful outpatient chemotherapy program could make it challenging for others to implement similar initiatives. “Individual institutions would need to spend a lot of time and personnel resources preparing to get this type of program up and running,” Fancher said. “I think it will take a while for this approach to be widely utilized, especially in smaller centers.”
—Ali McBride, PharmD
Chemotherapy Transition Checklist
Is the selected chemotherapy available to be administered on an outpatient basis?
Do you have financial approval, including that for reimbursement for infusion pumps, from insurers?
Do infusion center hours allow for the administration of the chemotherapeutic agents?
Are nursing staff, including nurse coordinators and infusion nurses, trained to provide patient education and monitor side effects for the given agent?
Are pharmacy staff trained to provide patient education on the regimens and supportive care treatments?
—David Wild
Data Show the Way to Safer Cancer Care
Outpatient chemotherapy clinics are finding innovative ways to better manage patients at the highest risk for hospital admission or emergency department (ED) visits within 30 days of treatment.
Tennessee Oncology and Mercy, a health system with facilities in Arkansas, Kansas, Missouri and Oklahoma, have been have been using technology to improve communication between facilities and help cancer patients get the care they require in the outpatient setting, reducing the need for emergency hospital care.
“Through proactive management, we should be able to avoid many of the treatments outpatient chemotherapy patients are receiving at the hospital or ED,” Michelle Smith, DC, the director of oncology services at one of Mercy’s hospitals (Mercy St. Louis), said at the Association of Community Cancer Centers (ACCC) 2020 Virtual National Oncology Conference.
Smith’s sentiment is in line with recommendations from the Centers for Medicare & Medicaid Services (CMS). Earlier this year, as part of its Hospital
Outpatient Quality Reporting Program, CMS rolled out the Admissions and Emergency Department (ED) Visits for Patients Receiving Outpatient Chemotherapy measure (OP-35) (https://cmit. cms.gov/CMIT_public/ReportMeasure? measureRevisionId=672). “Chemotherapy-related admissions and ED visits may be due to outpatient chemotherapy patients having unmet needs and gaps in care,” the agency pointed out.
Identifying Risk Factors
After finding that Mercy’s 30-day hospital admission rate for outpatient chemotherapy recipients was 15.9%, compared with the CMS benchmark of 12.9%, Smith and her colleagues sought to identify risk factors for admission or ED visits within 30 days of outpatient chemotherapy.
To that end, they analyzed medical records from 8,319 of their adult patients with cancer who received at least one outpatient chemotherapy infusion between 2016 and 2018. They found that malnutrition and certain types of chemotherapy were most strongly associated with 30-day inpatient admission, whereas severe pain and social deprivation were strong predictors of ED visits within 30 days of chemotherapy.
Using these and other risk factors, the Mercy team developed a predictive algorithm that pulls data from their electronic health record (EHR) system. The algorithm identifies patients at high or intermediate risk for a hospital admission or ED visit within 30 days of outpatient chemotherapy and automatically generates a report every night that is added to the system’s oncology dashboard.The report also is sent to the system’s clinics, infusion centers and nurse navigators each day, Smith explained.
“Once the clinic receives the report, if a patient on the list has an appointment that day, they will be asked to complete a questionnaire to identify areas of need ahead of their physician appointment, so that the physician has an opportunity to address those needs at the clinic visit,” she said.
Staff at infusion centers act as “a second set of eyes” for patients with an infusion appointment that day, Smith said, explaining that they administer the same questionnaire and identify needs that they can address on their end. These include interventions such as educating patients about medication side effects, reviewing their home medications or, if necessary, alerting the treating physician about any issues they need to address.
Finally, if a patient does not have a clinic or infusion appointment on the day they are flagged as being at high risk for an ED visit or hospital admission, a nurse navigator will call them and identify areas of need, either addressing them during the call or contacting the physician if needed, Smith said.
Tennessee Oncology
Tennessee Oncology, an outpatient chemotherapy network with more than 30 locations across that state, also is employing algorithms to reduce rates of hospital admission and ED visits within 30 days of chemotherapy.
“Prior to our project, we had no way of knowing when a patient presented to an ED or hospital or when they were discharged,” said Larry Bilbrey, the network’s care data systems manager, during the ACCC meeting. That was important information for them to have because it would allow them to share information with the hospital to expedite the visit, he said. Tennessee Oncology now contracts with a data vendor in Tennessee, which alerts a nurse care coordinator at the network when any of their chemotherapy patients have registered at an ED or a hospital admissions desk.
“The coordinator can then log into a portal to identify the patient and call the hospital to find out the reason for their visit or admission,” he explained, noting that direct contact with the hospital is important because hospitals sometimes do not document a diagnosis in their EHR until after admission or discharge.
During the phone call, the nurse care coordinator can share test results or other information on file at Tennessee Oncology, avoiding duplicate testing, and they can also determine whether the patient can receive any of the suggested treatments in the outpatient setting. When appropriate, the nurse care coordinator contacts the patient’s Tennessee Oncology physician for guidance, and the provider can contact the hospital directly to discuss the patient’s management, Bilbrey said.
“The goal is to get the hospital as much information as we can to make that visit as quick and efficient as possible,” Bilbrey said, adding that the nurse care coordinator also receives a patient discharge alert and follows up with the patient to provide additional care
or schedule a follow-up visit or clinic appointment, if needed.
Proactively Targeting Comorbid Conditions
Beyond making their patients’ hospital visits more efficient, Bilbrey and his team also wanted to improve how they manage some of the common comorbidities, such as chronic obstructive pulmonary disease, diabetes mellitus, congestive heart failure and pain, that account for a large number of hospital admissions and ED visits.
“The problem is that many of our patients do not disclose comorbidities to the chemotherapy clinic,” he said.
To overcome this obstacle, information technology experts at Tennessee Oncology developed a management algorithm that draws information from their EHR that points to one of the high-risk comorbid conditions. This includes laboratory values, medications and information from physician notes, which the algorithm incorporates using natural language processing.
When the algorithm identifies a patient as possibly having one of these comorbidities, it alerts a nurse care coordinator, who calls the patient and further employs the algorithm to confirm a diagnosis and provide clinical support, Bilbrey said.
While the Tennessee Oncology team is in the process of studying the impact of the initiative in a subset of patients, Bilbrey said, “it’s hard to imagine that having this data won’t improve our care.” He predicted that “using these algorithms and managing comorbidities on our end, rather than having patients wait to see their primary care provider or specialist or going to the ED and hospital, can drive costs down and improve patient satisfaction.”
—Larry Bilbrey
—David Wild
