paywalled: Guideline-Based Peer-to-Peer Consultation Optimizes Pegfilgrastim Use With No Adverse Clinical Consequences [Original Contributions]

Guideline-Based Peer-to-Peer Consultation Optimizes Pegfilgrastim Use With No Adverse Clinical Consequences [Original Contributions]:

Purpose:
Practice guidelines do not recommend the routine use of colony-stimulating factors when there is a low risk (< 10%) of febrile neutropenia (FN). We prospectively determined whether expert peer-to-peer consultation with prescribing oncologists would improve adherence to guidelines and whether there would be any adverse events associated with that adherence.

Methods:
Commencing in March 2010, we reviewed requests for pegfilgrastim from 22 community oncology practices comprising 78 physicians providing service to approximately 97,000 Medicare members. Paid claims data on all chemotherapy and supportive care medications were reviewed from fourth quarter (Q4) 2009 through third quarter (Q3) 2010. In total, 82 patients received pegfilgrastim. If the prescribed chemotherapy was associated with a low risk (< 10%) for FN, then a peer review was initiated. The treating physician made the final decision to use, or not use, pegfilgrastim, and no denials were issued.

Results:
A total of 245 units (1 unit = 6 mg) of pegfilgrastim were administered during the four quarters analyzed. Use in the low-risk category decreased from 52 units in Q4 2009 to 15 units in Q3 2010. The per-member per-month (PMPM) cost of pegfilgrastim decreased across quarters, with an average cost of $1.07 PMPM for Q4 2009 and $0.57 PMPM for Q3 2010. No studied patient was admitted for neutropenic fever.

Conclusion:
Active expert peer-to-peer consultation with prescribing oncologists can promote adherence to guidelines and potentially lead to significant cost reductions without significant risk of neutropenic fever, with or without hospitalization, for patients with cancer.

full free access: Personalized Medicine and Cancer Supportive Care: Appropriate Use of Colony-Stimulating Factor Support of Chemotherapy

"Unfortunately, patients in RCTs (randomized clinical trials) are often highly selected, and toxicities, including FN, are frequently underreported (18). In addition, chemotherapy dose intensity and the use of prophylactic CSF or antibiotics are infrequently reported in RCTs, making it difficult to assess the true burden of neutropenic complications associated with a chemotherapy regimen (18)." "....Although there is little debate that both underuse and overuse of the CSFs occur in clinical practice, accurate estimates of the true magnitude and impact of such considerations remain elusive. What is clear is that there is a need for greater attention to chemotherapy-associated toxicities along with accurate prediction tools for the assessment of individual patient risks, including FN (febrile neutropenia) and its complications. Such tools could improve the evidence base for practice guidelines and aid clinicians in the selection of patients with cancer who are at an individual increased risk for FN, and therefore, appropriate candidates for the clinically effective and cost-effective use of the CSFs (40)."