Moving Chemotherapy Delivery to the Outpatient Setting Results in Substantial Savings

Ali McBride, PharmD, MS, BCOP

Transitioning select chemotherapy regimens from the inpatient setting to the outpatient setting has many advantages. There’s a decrease in overall costs compared with chemotherapy delivered in the inpatient setting; it allows for safe, easy drug administration; oncologists have direct and immediate control of drug administration; and it allows patients to be eligible for patient assistance programs. Changing the delivery setting of chemotherapy also respects the patient’s wishes to avoid hospitalization and improves patient satisfaction,Ali McBride, PharmD, MS, BCOP, said during the Association of Community Cancer Centers (ACCC) 37th Virtual National Oncology Conference.

The impetus for taking a closer look at cancer drug spending starts with their costs. But the other side of the equation, the revenue coming in, can also be a factor that requires adjusting.

“The cost of cancer care has been rising, with spending on drug costs skyrocketing,” McBride, residency program director, University of Arizona Cancer Center; clinical assistant professor, University of Arizona College of Pharmacy; and past president of ACCC, said. “We have to address other contributing factors as well.”

Regarding the revenue coming in, that is, reimbursement, inpatient delivery of chemotherapy often results in lost revenue. As payment is tied to codes for diagnosis-related groups, the high-cost of therapies is often not reimbursed.

Conversely, outpatient reimbursement is based on the “buy and bill” model, the traditional methodology in which physicians buy chemotherapy drugs, treat the patient in the office, and bill the payer. Other positive characteristics are that waste can be billed, and in the case of hospitals, chemotherapy agents can be purchased under the 340B Drug Pricing Program, a law protecting specified clinics and hospitals from drug price increases while giving them access to price reductions.

“Outpatient billing also allows for alternative payment models. By using outpatient billing, you decrease the cost of inpatient stays and maximize the savings in the outpatient setting,” McBride emphasized.

McBride offered an overview of how to go about implementing a practice model that is focused on patient characteristics and practice management structure, based on the successes seen at the University of Arizona Cancer Center. Some patient factors to consider when transitioning to the outpatient setting include identifying patients who have a reliable means of transportation and those patients who have a good home support system.

In general, challenges that the center saw with the inpatient setting revolved around the inconvenience of dosing and the amount of preparation required. In some instances, said McBride, patients would visit the infusion center and end up waiting until the next day to start their chemotherapy because they either arrived after the designated chemotherapy cut-off time, they had to be observed for 24 hours prior to starting the treatment, or chemotherapy orders had not been signed by the time they arrived.

As such, after-hours care is important to have in place, eg, having a triage nurse or an on-call fellow available. To successfully implement such a model, McBride emphasized the importance of the buy-in from the entire multidisciplinary team including physicians, advanced practitioners, nurse coordinators, financial counselors and finance teams, and clinical pharmacists (Checklist).

Rituximab

As an example of an inpatient therapy that could be transitioned to the outpatient setting, McBride pointed to rituximab (Rituxan). He noted that the majority of inpatient delivery was given on the same day as inpatient chemotherapy. All patients also received pegfilgrastim (Neulasta) in the outpatient setting on the day after discharge. Yet, data had shown that giving rituximab on the day after discharge had equal efficacy as day-of- or day-after-chemotherapy administration. Further, giving rituximab after chemotherapy resulted in a lower rate of infusion reactions. The transition to outpatient rituximab delivery was able to be implemented for patients with non-Hodgkin lymphoma, lymphoma, mantle cell lymphoma, and acute lymphoblastic leukemia.

As a result of moving the delivery setting of rituximab to the outpatient setting, McBride said the hospital saw decreased inpatient bed stays, increased utilization of the model after implementation of standard order sets, automatic uptick and adoption of the model, increased use of the hospital’s own specialty pharmacy, and decreased costs for chemotherapy. He also emphasized that the physicians had no issues with the change in practice.

Infusion pumps

Because many chemotherapies require the use of infusion pumps, careful attention should be paid to this piece of equipment when it’s used in the outpatient setting. McBride noted a number of chemotherapy regimens require infusion pumps including EPOCH (rituximab, etoposide phosphate, prednisone, vincristine sulfate, cyclophosphamide, and doxorubicin), VAD (vincristine, doxorubicin, and dexamethasone), doxorubicin 24-hour infusions, cytarabine, and ifosfamide (Ifex).

McBride said it was important to provide education to patients and caregivers to address pump issues that may arise when the patient is not scheduled for an outpatient visit.

Key Metrics

To measure how well the transition to outpatient administration was adopted at the University of Arizona Cancer Center, McBride identified key metrics for review. These included inpatient days per admission, admissions due to febrile neutropenia, emergency department visits, the hours between inpatient admission and start of chemotherapy administration, length of time for each day of outpatient chemotherapy, and outcomes.

McBride and his team identified a benchmark goal of 90% implementation. As a result of their efforts, they transitioned 35 patients from outpatient to inpatient but were able to treat 137 patients with rituximab in the outpatient setting. The initial inpatient rituximab savings was more than $925,000, with drug cost savings around $400,000 to $450,000 a year. The average inpatient stay was also decreased by about 9 hours.

They identified unrealized reimbursement potential for outpatient treatment and they implemented automatic billing for waste with rituximab.

The team also developed proposed restrictions for inpatient rituximab use including immune thrombocytopenic purpura, cold agglutinin disease, post-transplant lymphoproliferative disease, and autoimmune hemolytic anemia.

McBride noted that as a result of this model, other forms of chemotherapy were now under consideration as potential outpatient delivery agents.

Checklist for Transitioning to the Outpatient Setting

• Selected chemotherapy available to be administered in the outpatient setting
• Financial approval
  • Infusion pumps covered by insurance
• Infusion center hours
  • Current schedules prohibit administration of certain chemotherapeutic agents
• Nursing staff
  • Education for nurse coordinators
  • Education with infusion nurses on administration and side effect monitoring
• Pharmacy/specialty pharmacy
  • Education on regimens and supportive care treatments
  • Large focus on anti-infective prophylaxis

_Reference:

_{McBride A, Persky D. Shifting Chemotherapy administration from the inpatient to the outpatient setting improves care and reduces costs. Presented at: ACCC 37th Virtual National Oncology Conference; September 14-18, 2020; Virtual. https://bit.ly/3koAWAr}