Developing a Model of Care for Home Infusions of Natalizumab for People With Multiple Sclerosis

The handling of biopharmaceuticals used in home-based therapy for cancer patients

BACKGROUND

Due to their low bioavailability, biopharmaceuticals are typically administered via injection or infusion in a hospital setting. Home-based therapy could be a valuable alternative for cancer patients. However, when exposed to stressors, such as high or low temperatures, particles can form in the biopharmaceutical solution, compromising the safety and efficacy of the biopharmaceutical.

AIM

This research investigated current practises with ready-to-administer biopharmaceuticals to determine if it is possible to offer cancer patients home-based therapy with monoclonal antibodies.

METHODS

First, a questionnaire was conducted with the survey tool Survalyzer among Amsterdam UMC patients receiving immunoglobulins at home. Secondly, a web-based questionnaire (Survalyzer) was sent to pharmacists throughout Europe with a home-based therapy programme in place.

RESULTS

The patient questionnaire (n = 52) showed that the biopharmaceutical is stored outside the recommended temperature range by 38% of the patients. Additionally, 17% of the patients do not recall getting any information on how to store their biopharmaceuticals, and 23% would like more information on the subject. Furthermore, the questionnaire amongst pharmacists (n = 21) showed that there is a lack of resources and logistical challenges when home-based therapy is applied to biopharmaceuticals used in cancer therapy.

CONCLUSION

Home-based therapy with monoclonal antibodies for cancer patients is challenging to implement.

Customer-centric product presentations for monoclonal antibodies

Delivering customer-centric product presentations for biotherapeutics, such as monoclonal antibodies (mAbs), represents a long-standing and paramount area of engagement for pharmaceutical scientists. Activities include improving experience with the dosing procedure, reducing drug administration-related expenditures, and ultimately shifting parenteral treatments outside of a controlled healthcare institutional setting. In times of increasingly cost-constrained markets and reinforced with the coronavirus pandemic, this discipline of "Product Optimization" in healthcare has gained momentum and changed from a nice-to-have into a must. This review summarizes latest trends in the healthcare ecosystem that inform key strategies for developing customer-centric products, including the availability of a wider array of sustainable drug delivery options and treatment management plans that support dosing in a flexible care setting. Three disease area archetypes with varying degree of implementation of customer-centric concepts are introduced to highlight relevant market differences and similarities. Namely, rheumatoid arthritis and inflammatory bowel disease, multiple sclerosis, and oncology have been chosen due to differences in the availability of subcutaneously dosed and ready-to-use self-administration products for mAb medicines and their follow-on biologics. Different launch scenarios are described from a manufacturer's perspective highlighting the necessity of platform approaches. To unfold the full potential of customer-centric care, value-based healthcare provider reimbursement schemes that incentivize the efficiency of care need to be broadly implemented.

Digital health as an enabler for hospital@home: A rising trend or just a vision?

Background

Hospital@home is a model of healthcare, where healthcare professionals actively treat patients in their homes for conditions that may otherwise require hospitalization. Similar models of care have been implemented in jurisdictions around the world over the past few years. However, there are new developments in health informatics including digital health and participatory health informatics that may have an impact on hospital@home approaches.

Objectives

This study aims to identify the current state of implementation of emerging concepts into the hospital@home research and models of care; to identify strengths and weaknesses, opportunities, and threats associated with the models of care; and to suggest a research agenda.

Methods

We employed two research methodologies, namely, a literature review and a SWOT (strengths, weaknesses, opportunities, and threats) analysis. The literature from the last 10 years was collected from PubMed using the search string "hospital at home" OR "care at home" OR "patient at home." Relevant information was extracted from the included articles.

Results

Title and abstract review were conducted on 1,371 articles. The full-text review was conducted on 82 articles. Data were extracted from 42 articles that met our review criteria. Most of the studies originated from the United States and Spain. Several medical conditions were considered. The use of digital tools and technologies was rarely reported. In particular, innovative approaches such as wearables or sensor technologies were rarely used. The current landscape of hospital@home models of care simply delivers hospital care in the patient's home. Tools or approaches from taking a participatory health informatics design approach involving a range of stakeholders (such as patients and their caregivers) were not reported in the literature reviewed. In addition, emerging technologies supporting mobile health applications, wearable technologies, and remote monitoring were rarely discussed.

Conclusion

There are multiple benefits and opportunities associated with hospital@home implementations. There are also threats and weaknesses associated with the use of this model of care. Some weaknesses could be addressed by using digital health and wearable technologies to support patient monitoring and treatment at home. Employing a participatory health informatics approach to design and implementation could help to ensure the acceptance of such care models.

Development of a Quality Assessment Tool for Outpatient Infusion Clinics: A Literature Review and Pilot Survey

This study aimed to develop a quality assessment tool for outpatient infusion clinics, as a lack of literature exists on the subject. The authors conducted a literature review targeting studies since 2016 to identify variables that affect patient satisfaction in outpatient infusion clinics. Due to the limited number of relevant studies found, the authors shadowed 2 infusion clinic nurses to capture additional determinants of outpatient infusion clinic quality. A total of 72 variables relevant to an outpatient infusion quality assessment tool were listed. From this list of variables, a pilot survey was conducted at an outpatient rheumatology infusion clinic to assess patient satisfaction with 16 variables of interest. The pilot survey (N = 43) revealed that patients were relatively dissatisfied with walking to clinics, lack of access to public transit, lack of parking and/or free parking, lack of privacy, and flexible scheduling and/or cancellation policies. These findings demonstrate how the assessment tool may highlight specific areas of concern at an infusion clinic to identify targets for future quality improvement initiatives. Therefore, the tool presented has the potential to improve the quality of care provided to patients attending infusion facilities.

Home infusions of natalizumab for people with multiple sclerosis: a pilot randomised crossover trial

OBJECTIVE

The delivery of healthcare at home has expanded to intravenous infusions of monoclonal antibodies. A recently developed model of care for home infusions of natalizumab for people with relapsing-remitting multiple sclerosis was evaluated. This pilot study of home infusions of natalizumab and usual care (attendance in a hospital out-patients' clinic) compared safety, feasibility, patient satisfaction, effectiveness and costs.

METHODS

In this randomised AB/BA crossover trial, 37 adults were randomised to usual care (n = 19) or home infusions (n = 18). After three infusions, patients crossed over to the alternate treatment for another three infusions. Patient safety outcomes and adherence, satisfaction, quality of life, disability and costs were compared.

RESULTS

No adverse events were recorded from 207 infusions from 35 patients across both home and clinic infusions. There was no difference in adherence (p = 0.71) and infection rates (p = 0.84) between home and clinic settings. Satisfaction with "convenience" of home infusions was significantly greater (p = 0.008) but there were no differences in quality of life measures. Excluding pharmacy, costs were A$74 lower per infusion at home, including A$16 of patients" out-of-pocket costs.

INTERPRETATION

There were no differences in safety and effectiveness between clinic and home infusions of natalizumab. The home infusions were shown to be feasible, more convenient and less expensive than usual care. Larger scale studies are required to verify these preliminary findings, particularly around safety and management of hypersensitivity adverse events in the home setting and for equivalence of clinical outcomes.

Qualitative factors shaping MS patients' experiences of infusible disease-modifying drugs: a critical incident technique analysis

OBJECTIVE

To explore factors shaping the experiences of patients with relapsing-remitting multiple sclerosis with infusible disease-modifying drugs in a hospital setting.

DESIGN AND SETTINGS

The critical incident technique served as a framework for collecting and analysing patients' qualitative account practices involving infusible disease-modifying drugs. Data were collected through semistructured interviews and one single-case study. Participants were recruited from all five regions in Denmark. Inductive thematic analysis was used to identify and interpret factors shaping patients' infusion journey over time.

PARTICIPANTS

Twenty-two patients with relapsing-remitting multiple sclerosis receiving infusion with disease-modifying drugs (natalizumab, alemtuzumab and ocrelizumab).

RESULTS

Four time scenarios-preinfusion, day of infusion, long-term infusion and switch of infusion-associated with the infusion of disease-modifying drugs were analysed to reveal how different factors could both positively and negatively affect patient experience. Time taken to make the treatment decision was affected by participants' subjective perceptions of their disease activity; this may have set off a treatment dilemma in the event of a pressing need for treatment. Planning and routine made infusion practices manageable, but external and internal surroundings, including infusion room ambience and the quality of relationships with healthcare professionals and fellow patients, affected patients' cognitive state and well-being irrespective of the infusion regimen. Switching the infusion regimen can reactivate worries akin to the preinfusion scenario.

CONCLUSION

This study provides novel insight into the positive and negative factors that shape patients' experience of infusion care practices. From a patient's perspective, an infusion practice is not a solitary event in time but includes planning and routine which become an integral part of their multiple sclerosis management. The quality of space and the ambience of the infusion room, combined with the relationship with healthcare professionals and fellow patients, can be a significant source of knowledge and support people with relapsing-remitting multiple sclerosis in their experience of agency in life.