Ali McBride, Pharm.D., M.S., BCPS, BCOP, FAzPA; Christopher Campen, Pharm.D., BCOP; James Camamo, Pharm.D., BCPS; Marie Maloney, Pharm.D.; Daniel Persky, M.D.; Emad Elquza, M.D.; Kurt Wiebel, Pharm.D., M.S.
The University of Arizona Cancer Center, Greenville Health System, Banner - University Medical Center-Tucson, Tucson, Arizona
Chemotherapy regimens are often administered in the acute care inpatient setting for a number of reasons including critical care management secondary to toxicity, evaluation for monitoring parameters, patient caregiver services, emergent treatment, and proximity to the hospital. A majority of these chemotherapy regimens can be transitioned for outpatient management leading to reduced expenditure of inpatient medical resources, reduced inpatient chemotherapy costs, decreased inpatient bed stays, lower infection rates, improved quality of life, and better access to supportive resources. The purpose of our program was to identify and address the transition of chemotherapy from the inpatient setting to the outpatient setting for a select number of hematologic and solid tumor chemotherapy regimens.
We developed a multidisciplinary team of staff members to address the transition of chemotherapy from inpatient to outpatient that included physicians, ambulatory clinical oncology pharmacists, finance, social workers, pharmacy staff, nursing staff, and information technology. Every candidate for the outpatient chemotherapy program was evaluated by the physician/advanced practitioner and clinical pharmacist to address patient criteria for outpatient chemotherapy. Ambulatory clinical oncology pharmacists and nurses counseled patients regarding the side effects of chemotherapy and supportive care medications in order to educate the patient for outpatient chemotherapy and also reviewed the patient’s current medications for treatments that were essential prior to the initiation of chemotherapy.
The program was initiated in May 2014, with a two-year post-implementation evaluation. Chemotherapy order sets were developed in our Electronic Medical Record for transitioning rituximab to the outpatient setting for inpatient chemotherapy orders as well as transitioning leukemia, lymphoma, and solid tumor chemotherapy regimens to be administered in the outpatient setting. Eighteen rituximab containing regimens and 14 chemotherapy protocols were switched to the outpatient setting, with numerous variants of these regimens also created for outpatient only administration. The realized savings for high-cost chemotherapy transitioned to the outpatient setting with rituximab and clofarabine was $1,902,890. Over 747 inpatient bed days were saved, with an approximated cost savings to the health-system of $1,402,866, with a cumulative cost savings to our health-system of $3,305,756.
This model for transition of chemotherapy from the hospital to the outpatient setting enhanced access of care, decreased bed utilization in the hospital, and improved ambulatory oncology pharmacy and financial metrics. The chemotherapy transition to the outpatient setting led to a 20% reduction of our total yearly inpatient oncology costs and increased access to patient assistance programs. Oncology clinical pharmacists were crucial for the success of this program and have since expanded clinical oncology services and duties for cancer patients within the ambulatory setting.