Building quality improvement initiatives through anti-cancer stewardship in the Veterans Health Administration (VHA): CML pilot

Abstract: The Department of Veterans Affairs (VA) Pharmacy Benefits Management (PBM) Services created a national stewardship with focus on anti-cancer therapeutics within a disease-specific cohort . Directing stewardship initiatives to a cohort of Veterans with a common malignancy is a novel approach. A multidisciplinary team with National PBM and VISNs (Veterans Integrated Service Network) promotes standardization of practice with accountability to monitor outcomes as a continual quality improvement process. A toolkit was built to support stewardship activities and includes: •near-real-time process to identify a national disease-specific Veteran cohort•disease validation process•centralized MUE data collection•educational resources•site for communication and training materials Tyrosine Kinase Inhibitors (TKIs) account for the second highest utilization among outpatient oral anti-cancer therapies in VHA . Imatinib has demonstrated persistent efficacy and is the preferred TKI on the VA National Formulary. Utilizing our toolkit, we developed two MUEs for our national CML cohort to determine why Veterans were not prescribed imatinib as 1L therapy and reasons for switching from first to second line therapy. Methods Business rules identified VISN CML cohorts by using data sources and diagnostic coding from the VA Electronic Health Record (EHR): primary care and hematology/oncology visits (ICD-10), inpatient stays (ICD-10), and problem lists (ICD-10; SNOMED CT). Retrospective chart review of two subsets: Veterans who received a drug other than imatinib as their initial VA prescriptionVeterans who received at least two unique drugs to treat CML Data abstracted for MUE #1: •Disposition of TKI prescription•If new initiation, documented reason(s) for drug selection•If continuation, prior drug therapy history Data abstracted for MUE #2: •Documented reason(s) for switch to 2L•If adverse drug reaction (ADR) included as a reason, is it documented in the EHR? Analysis combined responses with prescription data from the EHR. Results Of the 18 VISNs, 9 participated in MUE data collection. 365 patients were identified as not having received imatinib 1L and 360 were identified as having received at least two unique drugs to treat CML. These counts are each approximately 30% of the total CML patient cohort. In the total cohort, ~50% of patients received imatinib 1L and have not switched to 2L. Responses for 1L TKI therapy (N=365) •199 (55%) continued therapy originally started outside VA with 67% of these patients (n=133) without documentation of prior imatinib therapy•166 (45%) were newly initiating CML therapy with top documented reasons for drug selection: •Intermediate or high risk (e.g., SOKAL risk scoring): 77 (46%)•46 (28%)•18 (11%)Dasatinib was the most prescribed 1L therapy in this cohort (64%; 235), followed by nilotinib (23%; 85), which had a higher prevalence when therapy was continuation (30%).53 patients (15%) had subsequent imatinib therapyResponses for switch from 1L to 2L therapy (N=360) •Top documented reasons for switch from 1L to 2L therapy •215 (60%)•81 (23%)•Resistance / inadequate response: 69 (19%)Only 37 (17%) who experienced an ADR had it documented in the EHRThe most common 2L drug was dasatinib (55%;198). The median number of days between 1L and 2L initiation was 275 (range: 7 - 2, 573)136 patients (38%) received third line therapy or beyond Conclusions A formalized oncology stewardship with focus on disease-specific initiatives within a national healthcare system is feasible. Responses from our 1L MUE indicate that despite geography, imatinib remains the preferred TKI and accounts for the highest utilization. Most veterans not receiving imatinib as 1L therapy, received dasatinib or nilotinib. Continuation of therapy due to transition of care to VA was the primary reason for 1L therapy with a non-preferred TKI. Other reasons included: FDA indication and SOKAL risk scoring. In our pilot 1L to 2L MUE, ADRs were the most common reason for CML patients to be switched to 2L (45%) follo ed by resistance/inadequate response and disease progression . Most ADRs were not documented in the EHR. Further interventions in TKI prescribing may be instituted in select sites . Following initiatives for CML, Anti-Cancer Stewardship will be expanded to other oncologic diseases.

Read the full article
Report a problem with this article

Related articles

  • More for Policy & Practice

    Emerging treatments for common mental health conditions affecting Veterans: D-cycloserine interventions

    Abstract: There are a number of treatments that have an emerging evidence base and could be considered in the management of common mental health conditions affecting veterans. Emerging and adjunct treatments are typically considered when an individual’s adherence or response to accepted or conventional treatment/s is poor (i.e., chronic, treatment-resistant, or treatment-refractory mental health conditions). The aim of the rapid evidence assessment (REA) was to identify and critically evaluate the current evidence on emerging and adjunct treatments for posttraumatic stress disorder (PTSD) and common mental health conditions affecting veterans. From the four databases that were searched, 25 studies met the inclusion criteria, including 12 secondary sources: four (4) systematic reviews (SRs) and eight (8) SRs with accompanying meta-analyses (MAs). The studies within these secondary sources (i.e., those contained within SRs and MAs) were extracted to a database containing the primary sources (i.e., randomised controlled trials, RCTs). From this collated set of articles (281 in total), all studies that did not meet the inclusion criteria were excluded (e.g., cohort and case-control studies), and all duplicate studies were removed (i.e., often the same RCT would appear in multiple SRs and MAs; as well as being directly retrieved by the search strategy). The final set of articles included 13 RCTs. The findings from these studies were narratively synthesised, and risk of bias assessments were conducted for each RCT. Strengths of the REA include the focus on peer-reviewed Level I and Level II evidence (NHMRC, 2009) from scientific journals in the fields of health, medicine, psychiatry, and psychology (including a specialist database developed by the US Department of Veterans’ Affairs focusing on literature relevant to veterans with PTSD). Limitations of the REA include the exclusion of potentially relevant papers that were published prior to 2017 and the exclusion of non-English language papers. It is difficult to draw conclusions and recommendations regarding DCS interventions from the body of evidence considered by the REA. DCS is proposed to enhance fear extinction or extinction learning via partial agonism of the NMDA receptor (neurobiological mechanism of action). Thus, most of the included studies examined the effects of DCS administration in combination with exposure-based psychotherapy for anxiety disorders. Some studies appear to indicate that DCS improves outcomes from evidence-based psychotherapy. However, due to the mixed findings across studies, it is difficult to recommend the use of DCS interventions in specific clinical situations. Further high-quality research is required.

    Mental Health Peer reviewed