Chemotherapy Stewardship: Managing Patient
Outcomes and Healthcare Costs
Peter Campbell, PharmD BCOP
Clinical Pharmacy Manager, Hematology/Oncology
New York Presbyterian Hospital/Columbia University Medical Center
New York, NY
The cost of medical care in the United States is increasing at an alarming rate, and the cost of cancer care is becoming a larger percentage of overall medical care spending. It is estimated that by 2020, the cost of cancer care will be higher than $157 billion—representing a 27% increase from 2010 spending.1 A portion of the increased cost of cancer care is directly related to the increasing prices of chemotherapeutic and targeted therapies used in the treatment of various cancers. Prior to the year 2000, the average cost for 1 year of chemotherapy treatment was approximately $10,000. Now a large percentage of recently approved chemotherapeutic agents exceed $100,000 for 1 year of treatment.2
As the cost of cancer care becomes increasingly burdensome, many institutions are pursuing means through which to reduce costs. Though stewardship efforts in fields such as infectious diseases have improved outcomes and reduced costs, no universal stewardship approaches have been applied to the field of oncology. Strategies that have been applied to reduce chemotherapy costs and promote chemotherapy stewardship include restricting agents to outpatient settings (including inpatient- and outpatient-specific formularies), utilization of regimen-specific order sets, and multidisciplinary input during treatment decisions.3
Institutions frequently use formulary restrictions or preferred-drug lists to control the prescribing and administration of expensive medications. Formulary restrictions have been shown to be an effective method to reduce the cost of medications but have not been proven to reduce overall drug expenditures.4 Though having specific preferred chemotherapeutic agents on the formulary may help to reduce medication costs, additional restrictions to outpatient administration only may further improve medication cost savings. The restriction of certain chemotherapeutic agents to outpatient-only administration may allow for a more favorable reimbursement, as opposed to the significant costs that can frequently be associated with an inpatient admission for chemotherapy administration.
An alternative to outpatient formulary restrictions is the development of separate inpatient and outpatient medication formularies. A downside that may be associated with two institutional formularies is the increased cost of staff time necessary to manage, maintain, and enforce the respective formularies. With a knowledge base of chemotherapeutic regimens that may be safely and effectively administered in an outpatient setting, pharmacists can play an active role in formulary restriction and management.
Another method of controlling chemotherapy costs is through the use of electronic chemotherapy order sets. The use of order sets has long been linked to improved chemotherapy administration safety. The safe administration of chemotherapy can assist in cost reduction through the elimination of additive spending that results from medical errors, which totaled $19.5 billion in 2008.5 Although electronic chemotherapy order sets have widely been shown to improve the safety of chemotherapy administration, they may also be used to increase the appropriateness of chemotherapy administration. With order sets, providers are steered toward prescribing preferred formulary agents, which often have been determined to be cost-effective options by the Formulary and Therapeutics Committee. Order sets also allow certain medications to be restricted to certain providers through privileges, which can prohibit the ordering of inappropriate medications according to U.S. Food and Drug Administration (FDA) or institutional approvals. Electronic chemotherapy order sets also allow for the auditing and review of chemotherapy ordering and administration. By using order sets as a source of data, institutions are able to more easily review their chemotherapy prescribing and administration practices. These reviews make it possible for institutions to make necessary changes to policies and guidelines in order to administer chemotherapy in a more cost-effective manner.
Obtaining multidisciplinary input during treatment decisions may also be used to reduce chemotherapy costs. Antimicrobial stewardship has been proven to be a successful method for improving outcomes and reducing costs in the treatment of infectious diseases, with pharmacists often playing an integral role.6 In a survey conducted among U.S. and Canadian oncologists, the majority of practitioners favored the use of more cost-effectiveness data in treatment decisions, but few felt comfortable with interpreting and applying these cost-effectiveness data.7Though most physicians are adequately equipped with the knowledge to make evidence-based treatment decisions, pharmacists may be able to supplement the clinical knowledge base and cost-effectiveness aspects of treatment. Pharmacists can use their clinical knowledge to recommend less expensive treatments that have been shown to have similar efficacy.
As cancer treatment continues to evolve and increase in price, institutions are continually forced to re-evaluate their methods of chemotherapy prescribing and administration. Several methods may assist institutions in controlling costs, and pharmacists are in a prime position to help develop and carry out these methods. With pharmacists having been used successfully to develop antimicrobial stewardship programs, their role in chemotherapy stewardship may help control the ever-rising cost of chemotherapy while optimizing patient outcomes.
References
1. Mariotto AB, Yabroff KR, Shao Y, et al. Projections of the cost of cancer care in the United States: 2010–2020. J Natl Cancer Inst. 2011;103:117-28.
2. Kantarjian H, Steensma D, Sanjuan JR, et al. High cancer drug prices in the United States: reasons and proposed solutions. J Oncol Pract. 2014;10:e208-11.
3. Li E, Schlief R, Edelen B. Hospital management of outpatient oncology treatment decisions: a survey to identify strategies and concerns. J Oncol Pract. 2013;9:e248-54.
4. Carlton RI, Bramley TJ, Nightengale B, et al. Reviews of outcomes associated with formulary restrictions: focus on step therapy. Am J Pharm Benefits. 2010;2:50-8.
5. Andel C, Davidow SL, Hollander M, et al. The economics of healthcare quality and medical errors. J Health Care Finance. 2102;39:39-50.
6. Paskovaty A, Pflomm JM, Myke K, et al. A multidisciplinary approach to antimicrobial stewardship: evolution into the 21st century. J Antimicro. 2005;25:1-10.
7. Berry SR, Bell CM, Ubel PA, et al. Continental divide? the attitudes of US and Canadian oncologists on the costs, cost-effectiveness, and health policies associated with new cancer drugs. J Clin Oncol. 2010;28:4149-53.