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Conference News
EPO Ordering Form Improves Guidelines Compliance, Saves Practices Money NEW ORLEANS—Implementation College of Pharmacy in Pomona, of an explicit order form for darbepoet- California. in alfa significantly improved compli“We wanted to detect prescribing ance with current guidelines and led to errors in the daily encounters with large cost savings, California pharma- patients,” Wong said. To this end, the cists report. investigators retrospectively In July 2007, the Centers reviewed cases in which for Medicare & Medicaid Serpatients received darbepoetin vices (CMS) implemented alfa between May 2008 and stricter guidelines for treating February 2009. They discovchemotherapy-induced aneered that in 50% of cases, the mia with erythropoiesis-stimudrugs were not given in lating agents. “This changed accordance with the updated the prescribing requirements CMS guidelines. and created some confusion,” “There was a fairly high Siu-Fun Wong, said Siu-Fun Wong, PharmD, noncompliance rate, and PharmD of the Hematology-Oncology this also was associated with Medical Group of Orange loss of revenue,” Wong said. County, Orange, California, who preIn an effort to correct the high nonsented the study at the meeting. compliance event rate, they developed a The lead author was her student, Darbepoetin alfa (Aranesp) AdminStacy L. Yang, a PharmD candidate at istration Order Form (AAOF), then Western University of Health Sciences assessed compliance once it was institut-
ed. The form is quite explicit, although it is designed to be self-directed. Staff attended in-service training on its use. The study evaluated guideline compliance before use of the AAOF, involving 38 patients receiving 231 interventions. After implementation, 53 patients received 143 interventions. Implementation of the AAOF significantly reduced noncompliance events pertaining to initial dosing and maintenance dose frequency, the review found. Prior to the AAOF, 27 (71.1%) of 38 patients received an inappropriate initial weight-based dose but this practice occurred only in two (3.8%) of 53 patients when the form was used (P <.001). Inappropriate dose frequency occurred at baseline in 41 (17.7%) of 231 interventions, but with the AAOF, no cases occurred at all (P <.0001). There were no significant changes in inappropriate dosing, dose
reduction, or dose escalation. In total, there were 19 inappropriate documentations after the intervention, and in eight (15.1%) of 53 patients providers did not use the AAOF. Failure to document doses given or laboratory values occurred in <5% of interventions, she added. “Most important, better compliance impacted reimbursement,” Wong said. The projected cost-avoidance analysis showed that $72,611 per year was captured by implementation of the form. The projected number of noncompliance events per year was 132 before AAOF and just 18 after AAOF, representing projected reimbursement losses of $84,076 versus $11,465. “Even with the declining use of darbepoetin alfa, we saved the practice over $70,000,” she noted. ● —CH
Oncology Pharmacists Can Significantly Reduce Chemotherapy Waste NEW ORLEANS—Oncology pharmacists can save their institutions thousands of dollars annually by reducing chemotherapy waste, according to the experience of the Veterans Affairs’ North Texas Health Care System in Dallas. Sarah Gressett Ussery, PharmD, described her institution’s chemotherapy monitoring and management. “Our findings speak to the role of the hematology/oncology pharmacist in reviewing orders for their appropriateness, and knowing which drugs are expensive,” Ussery told The Oncology Pharmacist. “Having an oncology pharmacist in charge significantly reduced waste. Before this, we were not even aware of how much was wasted.” Ussery and colleagues documented chemotherapy waste over a 2-month period in 2005 and found that 143 chemotherapy doses were wasted, most frequently bevacizumab, docetaxel, gemcitabine, oxaliplatin, and rituximab. The total cost of waste was $90,400, which extrapolated to more than $500,000 annually. Documenting waste again, this time in a 2-month period in 2007, they identified 61 wasted doses costing $42,000, extrapolating to $250,000 annually. The reasons for drug waste were disease progression (23%), symptomatic toxicity (18%), patient no-show (15%), wrong order or ordered too early (13%), treatment delay per
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patient preference (12%), dose adjustment (8%), laboratory abnormality (8%), and other reason (3%). Concerns over this waste precipitated the hiring of a hematology/oncology pharmacist who implemented a chemo-
therapy management program and provided oversight. The key to this program was to delay the preparation of expensive chemotherapies. Waste was then calculated with this program in place. Under the
chemotherapy management program, waste over a 2-month period was only $15, extrapolating to $90 annually, Ussery reported. ● —CH
Standardized Forms Facilitate COG Treatment NEW ORLEANS—The use of standardized pediatric chemotherapy forms can improve safety by creating a consistent and streamlined method of ordering Children’s Oncology Group (COG) trial protocols and regimens, according to investigators from Memorial Regional Hospital and Joe DiMaggio Children’s Hospital in Hollywood, Florida. Wayne R. Shipman, RPh, and Maribeth Arzola, PharmD, showcased the order set they developed for this purpose. It consists of a preprinted chemotherapy ordering form, preprinted medication administration record, and preprinted pharmacy dispensing record that correspond to the 14 COG treatment protocols they use. The forms reflect the protocol for a complete plan of care, they noted. “Prior to the introduction of our standardized pediatric order sets, we encountered many mistakes in pediatric chemotherapy orders, and these required
multiple pharmacy interventions. After the introduction of the preprinted forms, there was a 93% reduction in chemotherapy transcribing and calculations errors,” Arzola said. These errors were mostly illegible or confusing orders; wrong dosing; and crossed out, altered, or incomplete orders, she explained. “We decided to revamp the process,” she said. “We redid how we order chemotherapy, dispense chemotherapy, and check chemotherapy on the medication administration record.” A multidisciplinary team (Chemotherapy Safe Practice Committee) and the oncology pharmacy team created the templates. The standardized order set consists of a COG protocol template (per tumor site) for chemotherapy orders with a medication dose calculator, which requires two physician signatures; a medication administration record per
COG protocol; and a pharmacy triplecheck form, which reflects the COG protocol template and enables the pharmacist to interpret and verify the patient’s plan of care. The system is not perfect, they acknowledged. Second signatures are sometimes missing, heights and weights may be inconsistent between the order forms, incomplete forms are still sent to the pharmacy, reasons for dose modifications are sometimes lacking, and “crossing out” doses is still an issue. But the order set has greatly improved accuracy in writing, checking, interpreting, and entering chemotherapy orders; has decreased pharmacy chemotherapy preparation turnaround times; has increased nursing chemotherapy administration efficiency; and has shortened length of stay and throughput times for pediatric patients and their families. ● —CH
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