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Supplements Evaluating the Treatment of Chemotherapy-Induced Nausea and Vomiting
Overview of the Prevention and Management of CINV
James J. Natale, PharmD, BCOP
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Strategies to Improve CINV Outcomes in Managed Care
Scott A. Soefje, PharmD, MBA, BCOP, FCCP
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Strategies to Improve CINV Outcomes in Managed Care

Scott A. Soefje, PharmD, MBA, BCOP, FCCP
Managing chemotherapy-induced nausea and vomiting (CINV) is an opportunity for better clinical, economic, and humanistic outcomes. Clinicians working in managed care settings must understand background information about CINV’s causes, likelihood, and treatment. They need to understand how CINV creates collateral damage (eg, psychological effects, electrolyte disturbances, dehydration, malnutrition, and esophageal injury). Patients with CINV are costly to treat and may be unable or unwilling to continue chemotherapy at doses needed. Several guidelines offer recommendations for selecting appropriate antiemetic medications. Most managed care organizations use or encourage their oncology staffs to use established guidelines. A trend is to tailor guidelines to address institution-specific policies, procedures, and idiosyncrasies. Patients receiving guideline-directed care for CINV tend to have better outcomes. Prophylaxis and treatment for CINV must be patient specific and consider risk factors that increase the likelihood of nausea and vomiting or, conversely, decrease the likelihood. Managed care clinicians should know that most of the guidelines do not include patient-specific factors in their prediction models for CINV. Although research has indicated that clinicians tend to underestimate and undertreat CINV, some research has indicated that clinicians can be too aggressive when providing prophylaxis for various types of CINV. Patient education is the cornerstone of good treatment planning, and educating patients on how and when to report symptoms is critical. Tools are available to help patients track symptoms. The multidisciplinary team must ensure that patients receive prophylaxis and appropriate treatment for their diagnoses, as well as treatment plans.
Am J Manag Care. 2018;24:-S0
The appropriate management of chemotherapy-induced nausea and vomiting (CINV) offers opportunities to impact outcomes in 3 major areas: clinical, economic, and humanistic.1 For patients, CINV can be physically and psychologically taxing. It impacts not only the patient’s quality of life, but may also be a prognostic factor for overall survival and has economic implications, both in the cost of therapy and the cost of failure of therapy.2 Prevention is the key; depending on the emetogenicity of the chemotherapy regimen, acute CINV may be prevented in 50% to 90% of patients.3,4 However, delayed nausea and vomiting (NV), especially nausea, can still have significant impacts on patient outcomes.5 CINV is likely to occur unless the interdisciplinary care team takes steps to prevent it. Healthcare providers and administrators who work in managed care systems need strategies to ensure that patients with cancer receive appropriate medications that address CINV proactively.

Clinical Outcomes

CINV has the potential to cause severe physiologic effects, electrolyte disturbances, dehydration, malnutrition, and esophageal injury.6 Symptoms often cause treatment nonadherence or dose reductions and can increase the cost of care for patients with cancer.7-11 Oncology practitioners (N = 2000) indicate that 30% of all patients delay or discontinue therapy because of CINV.12 Patients who have severe CINV may refuse treatment, request or require dose reductions, or seek alternative therapy options; these actions can negatively impact treatment efficacy.2,6

Poorly controlled CINV increases the possibility that the patient will develop additional NV, including anticipatory NV (ANV), a conditioned response that develops after experiencing CINV during treatment, which may also create difficulties.13,14 If CINV is poorly controlled or uncontrolled, patients may begin to associate the oncology staff, the entrance to the treatment center, and the treatment room’s sights and/or smells with NV. Over time, these sensory experiences alone may elicit NV in the absence of chemotherapy as a stimulus.14 Once ANV develops, traditional antiemetics tend to be ineffective and patients may require psychotropic medication and/or behavioral therapy.14

Economic Outcomes

Value is a constant concern in healthcare. The cost of the treatment of CINV must be compared with the value of a successful cancer care outcome or the cost of failure to prevent CINV. Failing to prevent CINV can cause or contribute to higher costs in several ways. The clinical outcomes of nonadherence resulting in dose reductions or delays have already been discussed. There are other costs associated with CINV. Results published in 2011 of a study of 178 patients with cancer found increased costs associated with severe CINV. In the study, the average per-patient costs due to healthcare utilization for patients who reported severe nausea was $802.40. Conversely, patients who reported moderate nausea had average costs of $32.30 per patient, and those reporting mild nausea incurred average costs of $6.70 per patient. These researchers estimated that uncontrolled CINV costs healthcare facilities $778 during the first 5 days of chemotherapy.8 Other study findings have revealed that uncontrolled CINV can double the cost of healthcare and can add between $33 and $1300 in costs.9-11 A single CINV-related event in an inpatient, outpatient, or emergency department (ED) may cost more than $5200.15

CINV also creates substantial indirect costs. The effects on patient and caregiver productivity can be tremendous, as managing CINV and making unanticipated visits consumes much time. A survey completed by 15,532 patients highlighted indirect costs. On average, patients with active cancer missed 18 workdays annually due to CINV, and visits to clinicians’ offices to deal with CINV’s numerous effects forced 28% of respondents to reduce their work hours from full time to part time.11

Humanistic Outcomes

The largest impact of CINV is on the patient’s quality of life. Performing daily tasks, seeing friends and family, and enjoying meals are all vital to keep morale high. These activities influence patients’ outlook about chemotherapy treatment, improving motivation to complete therapy successfully. Patients already experiencing the psychological tolls of a cancer diagnosis may experience further negative impact if treatment begins and is accompanied by NV.

Guideline-directed Treatments

Combined, the patient outcomes and cost data call for systemic approaches that ensure antiemetics are available and can be used appropriately. Understanding CINV and its direct and indirect fiscal consequences, and the medications used to prevent and treat it, ensures that the healthcare provider’s rationale is clinically and fiscally sound.2,16 Researchers have analyzed the costs of antiemetics in numerous studies; however, a recent review of economic studies indicates that the cost of CINV is highly variable and attributes the range of costs to the heterogeneity of strategies used to address it. They stated that the failure to effectively treat CINV resulted in increases in the costs of medical care associated with increases in hospitalizations, medication expenditures, and ED and clinic visits. These researchers also indicated that unbiased comparisons of treatments are extremely difficult to make.17

Educating healthcare professionals on the impact that CINV has on their patients motivates them to address CINV more proactively. Improving communication among providers and patients could help improve patient outcomes, as there appears to be a disconnect between what providers perceive and what patients experience. Research shows that 88% to 95% of oncology providers said that their patients’ CINV was well controlled with their current antiemetic regimens, but also indicated that 25% of their patients experienced uncontrolled CINV. Regardless, many of these same providers indicated that they stopped or delayed their patients’ chemotherapy after CINV symptoms.12 This highlights a difference in providers’ perceptions and patients’ realities. Managed care providers need to actively engage with patients and each other regarding CINV. Open communication among all parties is especially important to address each patient’s unique NV symptoms.

Many managed care organizations use guidelines to direct therapy, improve outcomes, and manage medication costs. Table  118-21 lists the current evidence-based guidelines for CINV. Typical processes rely on examining the rationale for inclusion/exclusion into the guidelines and determining cost-effectiveness. The general assumption is that evidence-based guidelines will lead to better overall outcomes, reduce costs, and provide the value that the patient and the system are seeking. This appears to be the case in CINV.

In a large European observational study, 1000 patients who had received guideline-consistent antiemetic treatment had significantly better CINV control than those who did not receive guideline-consistent treatment. The complete control rates were 60% versus 51%, respectively.22 Results of a study conducted in the United States23 and a single-center United Kingdom observational study24 found similar rates of control with evidence-based treatment guidelines. In the US study, the incidence of no CINV was significantly higher among those receiving guideline-consistent CINV prophylaxis than those who did not (53.4% vs 43.8%, respectively).23

Although the findings of each study demonstrated a clear association between guideline-consistent antiemetic prophylaxis and enhanced CINV control, unfortunately they also showed low rates of utilization. The overall adherence to guidelines was just 29% in the European study. Similar results were also seen in a large study in Asia-Pacific countries. Although the serotonin receptor antagonists were generally prescribed per guidelines, corticosteroids were not consistently administered, especially in the delayed phase. In the HEC setting, the neurokinin-1 antagonists (NK1s) were also frequently underused.25

Improving adherence to guidelines has been examined by several studies, with limited success.25-29 Communication of a patient’s CINV outcomes to the provider seems to be the key factor in improving adherence, but, often, multitargeted strategies are necessary to see an impact.

Institutions should use evidence-based guidelines to direct the development of institution-specific guidelines. Economic decisions may impact the guidelines because new drugs are costlier; however, many drugs in the CINV guidelines are generically available or will soon be available. When multiple products within a therapeutic category are available, which is the case with antiemetics, organizations often use drug class reviews to investigate therapeutic equivalence and keep a preferred agent or a ranked listing of preferred agents in the guidelines. Traditionally, pharmacy and therapeutics committees have looked at safety, efficacy, outcomes, and, all things being equal, acquisition costs when deciding on drugs to add to their formulary. However, today, the healthcare environment is more complicated, and medication management has broader responsibilities and evolving concerns (see Table 2).29 Increasingly, complex pharmacoeconomic analyses contribute heavily to the discussion, and several organizations now offer value-based frameworks to help determine cost-effectiveness and guide medication management decision making (see Table 3).30 Keeping the institution guidelines up-to-date can be a challenge as new drugs and data emerge that change the recommended therapy. Periodic review and updating of the guidelines should be done with analysis of instructional guideline compliance. Timely feedback of the compliance analysis and of patient outcomes should be given to the providers.

Treatment Planning: Patient-specific Antiemetic Regimens

 
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