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Choosing Wisely recommendation fails to reduce overuse of antiemetics
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Antiemetics are often overused in the prevention of chemotherapy-induced nausea and vomiting, leading to unnecessary costs for patients, according to results of an observational study.
Choosing Wisely guidelines that discourage the overuse of antiemetics did not lead to sustained decreases in their use, results showed.
Antiemetics help prevent chemotherapy-induced nausea and vomiting (CINV), and newer agents — such as serotonin and neurokinin-1 receptor antagonists — have increased efficacy.
However, these newer agents are costly and, in turn, have yielded questions concerning their necessity in managing expected risks for CINV.
“The antiemetic drug costs for patients prescribed serotonin receptor antagonists can be as high as $2,000 per cycle,” William Encinosa, PhD, senior economist in the Center for Delivery, Organization and Markets at the Agency for Healthcare Research and Quality, and Amy J. Davidoff, PhD, health economist and health services researcher at the Yale School of Public Health, wrote. “The neurokinin-1 receptor antagonists are similarly expensive.”
As part of the 2013 American Board of Internal Medicine Foundation’s Choosing Wisely campaign, the ASCO Value in Cancer Care Task Force published a recommendation to reduce the overuse of expensive antiemetics in patients receiving chemotherapy who are at low risk for CINV.
To determine if patterns and trends in antiemetic overuse changed with the publication of the Choosing Wisely recommendation, Encinosa and Davidoff used the nationwide MarketScan Insurance claims database to identify 678,220 privately insured patients (mean age, 59.5 years; 58.2% female) who received chemotherapy from 2008 to 2015.
Twenty percent of patients received oral therapy with a low to minimal risk for CINV, and 48.6% of patients received IV chemotherapy with high to moderate CINV risk.
Researchers determined antiemetic overuse occurred in 24.1% of patients; however, the rates varied by CINV risk group, and the sources of antiemetic overuse were wide ranging. The highest rates of overuse (32.4%) occurred in patients with high- to moderate-risk IV chemotherapy who received prescriptions for medications commonly prescribed to manage breakthrough symptoms several days after treatment.
In the time period before the recommendation, antiemetic overuse rates were stable or slightly decreasing for all risk groups. Six months following the recommendation, the odds for overuse decreased 7% (95% CI, 4.4-9.5); however, the researchers deemed this decrease to be “short-lived” and “transitory.” The odds of antiemetic overuse increased 7.4% (95% CI, 4.6-10.2) 6 months after the recommendation compared with baseline.
Enrollment in Medicare (OR = 0.9; 95% CI, 0.87-0.92) and point-of-service plans (OR = 0.91; 95% CI, 0.88-0.94), as well as receiving out-of-network coverage (OR = 0.89; 95% CI, 0.87-0.91) were associated with reduced odds of antiemetic overuse, whereas patients with high-deductible plans who were hourly or union workers had increased odds.
Mean expense for an antiemetic regimen totaled $299 (95% CI, 297-301). The highest spending on antiemetics was $523 (95% CI, 520-527) for IV chemotherapy with high to moderate risk for CINV.
Researchers determined reducing antiemetic overuse could have paid for 6.1% (95% CI, 5.8-6.4) of the chemotherapy drug costs.
“Our results associated with this Choosing Wisely recommendation create the concern that voluntary measures to reduce antiemetic overuse may have limited effectiveness,” Encinosa and Davidoff wrote. “Such measures may need to be included with financial performance incentives and are likely to be implemented by oncologists participating in the Medicare Shared Savings Programs, including the Oncology Care Model demonstration.”
By 2019, all physicians participating in Medicare will be paid according to the pay-for-performance program — known as the Merit-based Incentive Payment System — in which the Choosing Wisely antiemetic overuse measures may be incorporated.
“However, because antiemetic overuse is a concept often misunderstood by consumers, patient engagement and education will also be critical to the successful implementation of these incentive-based initiatives,” the researchers added.
The appropriate use of antiemetics — which also includes elimination of underuse — for CINV prophylaxis is critical to high-quality cancer care, Devon K. Check, PhD, from the Kaiser Permanente Northern California Division of Research, and Ethan M. Basch, MD, from the UNC Lineberger Comprehensive Cancer Center, wrote in an accompanying editorial.
“Underuse of recommended antiemetic drugs may result in uncontrolled CINV, which can have implications for patients’ quality of life and their ability to continue potentially beneficial chemotherapy,” they wrote. “On the other hand, the overuse of antiemetics in settings in which they are not recommended may result in excess cost and toxic effects.”
Because guidelines and recommendations have not sufficiently altered practice patterns, Check and Basch wrote that dissemination and implementation initiatives could be vital for future success.
To reduce inappropriate use, they recommended:
- CMS revise its antiemetic coverage policy to align more closely with clinical practice guideline recommendations regarding appropriate use;
- insurers adopt innovative coverage designs to encourage appropriate use of antiemetics;
- institutions adopt and implement clear policies governing antiemetic prescribing; and
- appropriate use of antiemetics be included in quality metrics.
“Additional strategies and research are needed to facilitate appropriate use by patients and oncologists,” Check and Basch wrote. – by Kristie L. Kahl
Disclosures: The researchers, Check and Basch report no relevant financial disclosures.
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