October 2020 Edition Vol.11, Issue 10

Big Practice Changes for Community Oncologists Unveiled at ACCC

By Christina Bennett, MS

The Association of Community Cancer Centers (ACCC) hosted their 37th National Oncology Conference virtually this year and featured presentations on innovative practice changes some community cancer centers have implemented to improve the quality of care, which has become especially relevant as patients are cared for during the COVID-19 pandemic. Presentations of interest showcased the benefit of expanding the clinical role of oncology pharmacists, gaining access to real-time hospital data to rein in costs, and moving chemotherapy to the outpatient setting.

Expanding the Role of Pharmacists

By expanding the clinical role of their pharmacists, St. Luke’s Cancer Institute in Boise, Idaho, has substantially decreased the turnaround time for processing oral oncolytic prescriptions, thereby reducing treatment delays.

Presenter Amanda Wright, PharmD, Oncology Pharmacist, St Luke’s, explained the reason pharmacists’ roles were expanded was to avoid sending a prescription back to the prescriber and having to wait for their signature when a medication adjustment was needed.

Depending on a provider’s workload, it could take a few hours to sign the prescription or in some instances, several days, which not only caused interruptions with the pharmacists’ workflow, but also resulted, on occasion, in delays of treatment for patients while pharmacists waited for the prescriber’s signature to authorize the change.

To address the issue, St Luke’s piloted a three-month collaborative practice agreement (CPA), where pharmacists were able to adjust doses, round doses to the nearest tablet size, renew prescription refills, order laboratory tests, and sign off on the tasks on behalf of the treating physician.

Pharmacists carried out their expanded role for only 4 of the 15 providers at St. Luke’s, leaving 11 providers to serve as a control group. Interventions that pharmacists performed were tracked during the pilot for all providers.

The most common intervention revealed in the pilot program was prescription refill renewal, followed by dose adjustment for toxicity.

When pharmacists had an expanded role the prescription turnaround time was an average of 7 minutes per intervention. In contrast, when pharmacists did not have an expanded role the turnaround time was an average of 2.5 days — a difference that was statistically significant (P<0.0001).

A survey of the pilot group showed that the treating physicians were satisfied with the interventions made by the pharmacists and felt that the program had a positive impact on their time.

Moreover, rounding doses to the nearest tablet size led to cost-savings for capecitabine and temozolomide prescriptions. Patient cost-savings were $548 per cycle of capecitabine ($9,858 annually), and $252 per cycle of temozolomide ($3,282 annually).

“At St. Luke’s Cancer Institute, not only were we able to improve the pharmacy workflow through decreasing the amount of interruptions in processing of prescriptions, but we also reduced the amount of delays that we see in either continuation or initiation of patient treatment,” said Wright.

Reducing Costs in the OCM Two-sided Risk Arrangement

To help drive down unnecessary emergency department and hospital visits to contain costs, which is critical for practices participating in two-sided risk arrangements in the Oncology Care Model (OCM), Tennessee Oncology is accessing real-time hospital data to improve their management of patients with comorbidities.

“We’ve been very successful in the Oncology Care Model so far,” said presenter Larry Bilbrey, Care Data Systems Manager, Tennessee Oncology. “But even as successful as we’ve been, we know going into two-sided risk that we’re going to have to do better.”

OCM practices participating in two-sided risk are penalized if their Medicare costs for an episode of care exceeds the allowable amount.1

The total cost of patients’ care in the OCM, which — aside from drug costs — are largely driven by emergency department and hospital visits. However, oncology practices typically are not notified when a patient is admitted or discharged from an emergency department or hospital, and the medical problem a patient had may not have required an expensive emergency room visit, where unnecessary labs and additional tests may have been ordered.

Looking for a solution, Tennessee Oncology contracted with a third-party vendor that has access to data for more than 100 hospitals and includes all payers. The practice has created an ongoing pilot project to track admissions and discharges for a cohort of approximately 4,500 of their patients.

In this project, the practice receives an alert when a patient from their cohort shows up in the emergency department or hospital. A nurse care coordinator from the practice calls the facility to obtain or send additional information, which can help avoid duplicate testing. If the patient’s admission is related to cancer, an oncologist from the practice can contact the provider at the emergency department or hospital and discuss management options if appropriate.

The practice is also notified when a patient is discharged, and a nurse care coordinator follows up with the patient and schedules an appointment as needed.

Among the data thus far, the practice has observed several trends that can be used to inform practice decisions, such as staffing. Over a four-week period, nearly 3,300 out of 40,000 patients seen by the practice were admitted to the emergency department or hospital.

“We had no idea the numbers would be that high,” said Bilbrey.

Most of the admissions — nearly 2,000 — were emergency department visits. Admissions followed a peak and valley trend, with the highest number being on Monday and lowest on Sunday (Figure 1). Discharges tended to be highest in the middle of the week and lowest on Sunday.

Additional data being collected and mined include time of admission and location, and the plan is to use data for predictive analytics.

Tennessee Oncology has also implemented decision-making algorithms for four comorbidities — chronic obstructive pulmonary disease, congestive heart failure, diabetes mellitus, and pain— to better document these illnesses and intervene. The hope is that proactive management of these comorbidities will lead to a drop in emergency department and hospital visits and drive costs down.

Moving Chemotherapy to the Outpatient Setting

Given the rising cost of chemotherapy and the inconvenience patients face when administered chemotherapy in the inpatient setting, the University of Arizona Cancer Center, Banner University Medical Center Tucson has been transitioning a growing list of chemotherapy drugs from the inpatient to the outpatient setting since 2013. The outcome seen is a dramatic reduction in costs and drop in the number of days patients stay in the hospital, ultimately improving the patient experience.

With COVID-19, keeping patients out of the hospital is “crucial,” said presenter Ali McBride, PharmD, MS, BCOP, Clinical Coordinator, Hematology/Oncology, University of Arizona Cancer Center, Banner University Medical Center Tucson.

McBride presented data on two drugs and two regimens in particular that were transitioned outpatient: rituximab, high-dose cytarabine (HiDAC), ifosfamide-based regimens, and regimens that contain EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin hydrochloride).

Rituximab is a common component of chemotherapy regimens for hematologic malignancies, and the rituximab portion for several regimens was moved outpatient and given with pegfilgrastim the day after a patient was discharged for inpatient chemotherapy. Previous data have shown that rituximab efficacy is the same whether given the day of or day after chemotherapy, McBride said.

Overall, 137 patients received rituximab outpatient and 35 inpatient, leading to a drug cost-savings of approximately $400,000 annually and an inpatient stay that is an average of 9 hours shorter.

For HiDAC, 52 patients were evaluable for analysis who received a total of 138 cycles, which included 35 inpatient cycles and 103 outpatient cycles.

Patients who received HiDAC outpatient had a lower rate of infection (33% vs 62%), nausea and vomiting (62% vs 85%), and dose delays (13% vs 23%) compared with inpatient administration. Overall, this transition led to 1,751 fewer total days patients stayed in the hospital and cost-savings of approximately $4.6 million for the healthcare system.

For ifosfamide-based regimens, 86 patients were evaluable for analysis, of whom 57 received their regimen outpatient and 29 inpatient. This transition led to 783 fewer total days patients stayed in the hospital and cost-savings of approximately $2.1 million for the healthcare system.

For EPOCH-containing regimens, 35 patients received 137 cycles, which included 17 via inpatient, 55 outpatient, and 66 a hybrid inpatient–outpatient model. This transition led to 432 fewer total days patients stayed in the hospital and cost-savings of approximately $1.1 million for the healthcare system. McBride noted that a more recent calculation of these data has been done and the aforementioned results for EPOCH-containing regimens are “very conservative.”

The University of Arizona Cancer Center has plans to move additional chemotherapy regimens outpatient, including DCEP (dexamethasone, cyclophosphamide, etoposide, cisplatin), VTD-PACE (dexamethasone, thalidomide, cisplatin, doxorubicin, cyclophosphamide, etoposide, bortezomib), and CPX-351, which is a liposomal formulation of daunorubicin and cytarabine.


Reference

  1. Oncology Care Model overview. Centers for Medicare & Medicaid Services Innovation Center. February 2020. https://innovation.cms.gov/Files/slides/ocm-overview-slides.pdf. Accessed September 22, 2020.

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