Successful implementation of outpatient R ± DHAX (rituximab, dexamethasone, oxaliplatin, cytarabine) for select patients with lymphoma: a single-center experience

R ± DHAX has been traditionally administered to inpatient due to the timing of chemotherapy administration and the perceived need for close monitoring of adverse effects. To administer R ± DHAX outpatient, a multidisciplinary task force created clinical and educational guidelines which were implemented through two phases: pilot and expansion. The pilot program determined the feasibility of transitioning R ± DHAX outpatient at a single infusion site. The expansion phase led to a service-wide implementation across all outpatient sites. A total of 40 patients were included, of which 23 patients completed all cycles, outpatient, 12 transitioned inpatient to outpatient administration, and 5 transitioned outpatient to inpatient administration. The success rate of outpatient R ± DHAX administration was 90% (36 patients successfully completed outpatient administration/40 total patients). No cytarabine-related cerebellar or ophthalmic toxicity was reported. Outpatient R ± DHAX saved 192 hospital days. R ± DHAX could be successfully administered outpatient with minimal safety concerns and reduced hospital bed utilization.

Safety and financial analysis of outpatient dose-adjusted EPOCH for B-cell lymphoma at a tertiary comprehensive cancer center

INTRODUCTION

Dose-adjusted (DA-) EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin) is a front-line treatment option for aggressive B-cell lymphomas. Due to regimen complexity, inpatient administration of DA-EPOCH has been historically required. Moffitt Cancer Center (MCC) developed an Inpatient/Outpatient (IPOP) program to facilitate administration of complicated regimens in the outpatient setting. We hypothesized that outpatient administration of DA-EPOCH at a comprehensive cancer center is both safe and cost-effective.

METHODS

We conducted a single-center, retrospective chart review including B-cell lymphoma patients who were 18 years or older and who had received DA-EPOCH at MCC from April 26, 2017 through August 10, 2019. The primary endpoint was hospital admissions during outpatient chemotherapy administration. Additional safety endpoints included hospitalizations between cycles, infectious complications, extravasations, drug spills, pump-malfunctions, and drug-related adverse events. Financial analysis included drug cost, resource utilization, and impact of hospital bed backfill.

RESULTS

56 patients received 219 cycles of DA-EPOCH with 193 cycles administered outpatient. Zero patients required hospitalization during outpatient administration of DA-EPOCH, resulting in 965 saved hospital days. 23 patients (41%) were hospitalized between cycles, most commonly due to neutropenic fever (52%). No extravasations were documented throughout the study period. There were few incidences of drug spills or pump malfunctions. Based on current regimen utilization, the annual transition of 84 cycles of DA-EPOCH to the outpatient setting has a positive impact on margin of $1,444,548.

CONCLUSIONS

Routine outpatient administration of DA-EPOCH is both safe and feasible with a positive annual impact on margin of $1,444,548 at a comprehensive cancer center.

Continuous-infusion and outpatient setting: A chance for patients, a challenge for hospital pharmacists

The use of continuous-infusion in outpatient setting could be widely used in oncology and haematology care. Many times the lack of data stability about single drug or admixture of drugs, together with patient education and safety, make difficult the transition from inpatient to outpatient setting. Nowadays, this is a big challenge for hospital pharmacists, who must take into consideration the critical issues related to chemical and physical stability, besides microbiological one, in order to ensure high quality preparations and guarantee the safety and quality of care, to protect patients and their health. The aim of this article is to highlight the critical issues concerning the transition from inpatient to outpatient setting, with particular interest regarding chemotherapy protocols, which require preparation with long-term continuous-infusion.

Reducing Hospitalizations: Institution of Outpatient Infusional EPOCH-Based Chemotherapy at a Safety Net Hospital

PURPOSE:

EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) -based chemotherapy is traditionally administered inpatient because of its complex 96-hour protocol and number of involved medications. These routine admissions are costly, disruptive, and isolating to patients. Here, we describe our experience transitioning from inpatient to outpatient ambulatory EPOCH-based chemotherapy in a safety-net hospital, associated cost savings, and patient perceptions.

METHODS AND MATERIALS:

Guidelines for chemotherapy administration and educational materials were developed by a multidisciplinary team of physicians, nurses, and pharmacists. Data were collected via chart review and costs via the finance department. Patient satisfaction with chemotherapy at home compared with hospitalization was measured on a Likert-type scale via direct-to-patient survey.

RESULTS:

From January 30, 2017, through January 30, 2018, 87 cycles of EPOCH-based chemotherapy were administered to 23 patients. Sixty-one ambulatory cycles (70%) were administered to 18 patients. Of 26 cycles administered in the hospital, 18 (69%) were the first cycle of treatment. Rates of inappropriate prophylactic antimicrobial prescription and laboratory testing were lower in the outpatient setting. Eight of nine patients surveyed preferred home chemotherapy to inpatient chemotherapy. Per-cycle drug costs were 57.6% lower in outpatients as a result of differences in the acquisition cost in the outpatient setting. In total, the transition to ambulatory EPOCH-based chemotherapy yielded 1-year savings of $502,030 and an estimated 336 days of avoided hospital confinement.

CONCLUSION:

Multiday ambulatory EPOCH-based regimens were successfully and safely administered in our safety-net hospital. Outpatient therapy was associated with significant savings through avoided hospitalizations and reductions in drug acquisition cost and improved patient satisfaction.

A Retrospective Study of the Effects of Oncology Pharmacist Participation in Treatment on Therapeutic Outcomes and Medical Costs

Specialist oncology pharmacists are being trained in Japan to assist cancer treatment teams. These specialized pharmacists address patients' physical and mental problems in pharmacist-managed cancer care clinics, actively participate in formulating treatment policies, and are beneficial in offering qualitative improvements to patient services and team medical care. However, the effect of outpatient treatment by oncology pharmacists on therapeutic outcomes and medical costs is still unknown. A retroactive comparative analysis of the treatment details and clinical course was conducted among three groups of patients: patients who underwent adjuvant chemotherapy managed by a gynecologic oncologist only (S arm), patients managed by a non-oncologist (general practice gynecologist) only (NS arm), and patients managed by both a non-oncologist and a specialist oncology pharmacist (NS+Ph arm). The medical cost per course was significantly lower for patients in the NS+Ph arm than for those in the other two arms. Surprisingly, the outpatient treatment rate in the NS+Ph arm was overwhelmingly high. The involvement of an oncology pharmacist did not make a significant difference in therapeutic outcomes such as recurrence rate and survival. The participation of oncology pharmacists in the management of cancer patients undergoing chemotherapy enables safe outpatient treatment and also reduces medical costs.

Stability of vincristine sulfate, doxorubicin hydrochloride and etoposide phosphate admixtures in polyisoprene elastomeric pump supporting transition of the EPOCH regimen to outpatient care

Background

The EPOCH regimen, consisting of vincristine sulfate, doxorubicin hydrochloride, and etoposide phosphate, is typically administered by continuous infusion over four days to oncology inpatients. If the EPOCH regimen was available to be administered through portable elastomeric pumps, chemotherapy could be transitioned to an outpatient setting, reducing inpatient bed days and overall healthcare costs. However, a lack of stability data for the admixtures in the elastomeric infusion devices currently prevents the transition of the regime to an outpatient setting. The purpose of this study is to determine the physical and chemical stability of the admixture in polyisoprene elastomeric pumps under different storage conditions to support the transition of the EPOCH regime to an outpatient setting.

Methods

The physico-chemical stability of three admixtures at a range of clinically relevant concentrations compounded in polyisoprene elastomeric infusors was determined when refrigerated at 2–6℃ over a 14-day period followed by 35℃ up to 7 days in the dark, and under standardized fluorescent light to simulate scenarios in clinical practice.

Results

All tested admixtures were compatible and the drugs were stable in the elastomeric infusors for up to 14 days when stored at 2–6℃ followed by 7 days at 35℃ in the dark, with nominal losses of <5%. The major degradant of etoposide phosphate was its active form etoposide. There was no degradation (<1% loss) found when the admixture was exposed to a standardized fluorescent light dose of 80 klux-h (25℃) for 10 h. The temperature and light conditions the infusors were exposed to during the stability study were more severe than the conditions determine during clinical administration.

Conclusion

The extended stability of the three infusional admixtures compounded in elastomeric infusion pumps demonstrated herein permits advance preparation and storage of these drugs, reducing pharmacy compounding resources. The demonstrated stability at 35℃ and under light exposure, conditions more severe than those experienced during clinical practice, support continuous infusions for up to seven days from the elastomeric infusors without a loss of potency. The proven stability of the EPOCH regimens in the tested elastomeric infusion device supports the transition of treatment to an outpatient setting which will reduce inpatient bed days and overall healthcare costs.