Dose-Monitoring, Split-Fill Programs Reduce Oral Chemotherapy Waste, Save Costs

Caroline Helwick

August 2011, Vol 2, No 5 - Oncology


Dose-monitoring programs for oral chemotherapy drugs can reduce wastage and reduce the risk of serious adverse effects associated with these drugs. This translates into cost-savings for patients and for payers of >$2500 per patient, suggested researchers from Walgreens Specialty Pharmacy.

The company developed an oral chemotherapy cycle management program (CMP) that offers a “split-fill” option and close monitoring of pa – tients for adverse events. This is an optional program, and payers can elect to participate.

The analysis of these programs was simultaneously published in the Jour – nal of Oncology Practice (Khandelwal N, et al. J Oncol Pract. 2011;7:e255-e295) and The American Journal of Managed Care (2011;17[5 Spec No]:e169-e173).

“Due to high drop-off rates for pa – tients on oral chemotherapy drugs, there is a significant likelihood of medication wastage. The split-fill program has the potential to reduce wastage in members who discontinue mid-cycle. Our analysis showed that of those patients that discontinued therapy, 34% would have experienced reduced wastage had they been on a split-fill medication plan,” said lead author Nikhil Khandelwal, PhD, BPharm, of Walgreens.

Nearly 20% of patients using chemo – therapy are prescribed an oral oncolytic, and approximately 25% of antineoplastic agents in development are being studied as oral formulations.

Although patients indicate that they prefer an oral rather than an intravenous chemotherapy, drug self-administration results in the transfer of responsibility to the patient for identifying, monitoring, and managing toxicity. This is important, because risks associated with oral drugs are insignificant.

More than 90% of patients using so – rafenib (Nexavar) or sunitinib (Sutent) experience adverse events; of these, as many as 33% are grade 3 to 4 (based on the 2010 package inserts for these 2 drugs). In addition to risks to the patient’s clinical outcomes, there is also the potential for a patient’s treatment discontinuation without the providers’ knowledge.

Walgreens Chemotherapy Cycle Management Program

In 2008, Walgreens initiated pharmacist- and nurse-facilitated clinical management and support to patients who were receiving sorafenib, sunitinib, or erlotinib (Tarceva) as part of their oral chemotherapy management. Through the CMP, patients receive intensive education, close supervision, and counseling at predetermined intervals.

To minimize medication waste, pharmacists can dispense partialmonth supplies of oral chemotherapy (split-fill), followed by the balance of the monthly supply if the patient demonstrates adherence and tolerability. The objectives of the CMP are to address factors that lead to patient nonadherence; to minimize drug wastage; to improve quality of care; and to maximize satisfaction of the patient, payer, and provider, Dr Khandelwal said.

“The split-fill program reduces wastage when therapy is discontinued during the first half of the month, since the remainder of the monthly supply is withheld,” he explained.

In a retrospective test-control study, Dr Khandelwal and colleagues evaluated medication wastage and potential cost-savings for 1069 patients enrolled in the CMP (June 2008-February 2010) and for 351 patients not enrolled (June 2007-May 2008). Information came from prescription claims and survey assessment data.

Eliminating Wastage for 33% of Patients

Participation in the CMP resulted in significantly lower wastage of medications because of early treatment discontinuation. In the first month of treatment, 261 patients discontinued treatment and 20 (7.7%) could have saved at least half of 1 cycle (14 days) had the payer used the split-fill program. Over the entire study period, 278 (33.8%) of 823 patients could have prevented wasting oral medications through use of the split-fill program, the study found.

On the basis of the prevailing average wholesale price of the drug at the time of dispensing, the estimated total potential savings using split-fill dosing versus a full-month supply for the program’s patients was $768,850 ($2765 per patient). In addition, approximately 34% of patients in the CMP group could have potentially avoided medication wast – age if split-fill plans had been available to them, which could have amounted to another realized savings of $934.20 per patient.

The reasons for drug wastage among patients who discontinued treatment early were: • Death—21.9% • Physician decision—10.1% • Ineffective therapy—9.7% • Medication switch—9.0% • Adverse events—7.2%. The majority of discontinuations, however, were recorded as “reason unknown” or “other.”

The researchers also analyzed hospital admissions resulting from adverse events, showing that the CMP group had a 2.9% probability for fewer hospital admissions (P <.05), resulting in ad – ditional savings of approximately $440 per patient.

“The combined savings from re – duced wastage and fewer hospital admissions was $1374 per patient,” Dr Khandelwal reported. “Our study suggests there is a potential for health plans and other payers to improve quality and achieve significant cost-savings by participating in programs that actively manage oral chemotherapy patients through monitoring programs such as the CMP,” he said.