Background Chemotherapy regimens historically have required admission of the patient to the hospital for extended infusions running over multiple days to complete each cycle of therapy. With the evolution of monitoring strategies readily available, a renaissance in patient care and healthcare cost utilization is necessary as transitioning the administration of these agents to the outpatient setting is seemingly achievable and is potentially more cost-effective. Purpose This evaluation sought to primarily measure cost-savings for an institution by transitioning inpatient chemotherapy regimens to the outpatient setting. Secondary outcomes evaluated the effect of this transition on overall patient length of stay, prevalence of adverse effects, and overall chemotherapy schedule adherence as a result of implementing transitions in sites of care. Barriers to receiving care in the outpatient setting were assessed by evaluating the acuity of performance status as well as distance from the hospital. Methods This single-center retrospective, quantitative chart and expense analysis evaluated patients receiving rituximab, etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin (R-EPOCH) or rituximab, ifosfamide, carboplatin, and etoposide (R-ICE) chemotherapy regimens based on treatment setting at a single institution. Included patients were treated at the University of Chicago Medical Center. Those receiving inpatient-only management as compared with patients who received therapy in outpatient settings were compared in a matched cohort analysis. The control group was matched from the period before transition of therapy was instituted between November 2014 and November 2015, with those patients transitioned to outpatient therapy (December 2015 to November 2016), using demographic, diagnostic, treatment, and clinical status data to assure group similarity. Mean cost of therapy was compared between inpatient and outpatient regimens. Descriptive and demographic categorical data were compared using the Fisher’s exact test. Continuous data were evaluated using the Student’s t test. A significance level of alpha <0.05 was used for all analysis. Results The cost of R-EPOCH therapy represented a significant difference across groups. R-ICE therapy similarly saw significant cost differences between inpatient and outpatient groups. If this was made standard of care for qualifying patients a retrospective annualized estimation of $466,507.85 with R-EPOCH therapy and $205,977.60 for R-ICE therapy could have been saved if this was utilized for patients who previously received their therapy as an inpatient. Conclusion The population of patients cared for at the University of Chicago Medicine during this time-period qualified for outpatient treatment for those treated with R-EPOCH and R-ICE regimens with no significantly identifiable prohibitive barriers between groups. As no significant complications manifested, it is reasonable to continue transitioning patients receiving these regimens to the outpatient setting where appropriate. R-EPOCH and R-ICE therapies were shown to be reasonable outpatient therapy while providing significant cost-savings for the institution.
Purpose: An introduction to cultural competency is provided for health system pharmacists, including communication tools and considerations to personalize care for diverse patient populations. Summary: Disparities in patient outcomes, health care utilization, and treatment adherence exist across diverse patient populations in the United States. Cultural competence of health system pharmacists is important to optimize medication use in diverse patient populations. The LARA (Listen, Affirm, Respond, and Add) methodology, Kleinman’s explanatory model, and the teach-back method are communication tools to facilitate culturally integrated discussions with patients. Health system pharmacists should be cognizant of cultural considerations that may emphasize spiritual care, nonpharmacologic therapy, patient privacy, and potential distrust of health care professionals. Conclusion: Health system pharmacists should strive to increase awareness of the impact that cultural beliefs and traditions have on patient care.
Background: Childhood immune thrombocytopenia (ITP) is a common bleeding disorder characterized by an isolated thrombocytopenia resulting from unknown causes, commonly presenting between 1 to 10 years of age. Nearly one child in 20,000 will experience ITP each year in the United States. The American Society of Hematology recommends that children with platelet counts of <20,000/μL and significant mucous membrane bleeding, or with platelet counts of <10,000/μL and minor purpura, should receive treatment with intravenous immune globulin (IVIg), IV RhIG, or corticosteroids. Objective: The objectives of this retrospective analysis was to determine if pediatric patients with severe ITP are responding to IVIg treatment with or without concomitant corticosteroids and if different IVIg products have any difference in response. We evaluated mean platelet counts at initial presentation and following IVIg therapy. The endpoints of this study were rate, degree, and rapidity of the platelet count response, cost of treatment, adverse effects and comparison of these with different IVIg products. Methods: This study was a single center, retrospective analysis of patients undergoing IVIg treatment for severe ITP. After institutional IRB approval, subjects were identified through Intermountain's Enterprise Data Warehouse. Subjects were pediatric patients aged ≤18 years of age with immune thrombocytopenia that received treatment with IVIg from January 2009 through April 2015. Patients were eligible for inclusion if they had an initial platelet level of <20,000/mm3 drawn within 48 hours prior to starting IVIg therapy and at least one platelet level within seven days following IVIg administration. Patients were excluded if they received a platelet transfusion prior to IVIg therapy. Platelet increase was assessed by analyzing the mean difference in platelet increase between initial values preceding IVIg administration compared to the highest drawn platelet level within a 7 day period post-IVIg therapy. Three different IVIg products were used which included Gammagard, Gammagard S/D and Gamunex. Response was defined as a platelet rise to at least 20,000/mm3. Cost-effectiveness was also evaluated. Results: At Primary Children's Hospital between January 2009 and April 2015, approximately 150 patients were diagnosed with ITP, the majority of whom were either observed without treatment or received corticosteroid therapy. Forty six patients were identified as having severe ITP requiring IVIg therapy, of which 72% were males. Median age of ITP patients receiving IVIg was 8 years. Twelve patients were excluded, as eight patients received platelet transfusions, three patients had initial platelet levels above 20,000/mm3, and one patient did not have a documented follow-up platelet level. This left 34 eligible patients for data analysis. Twelve patients (35%) received both IVIg and steroids. Twenty two patients (65%) had an appropriate platelet response within the 7 day period. The mean platelet increase was 76,000/mm3 in patients who received IVIg. Mean platelet increase of 88,000/mm3 was observed in patients receiving only IVIg therapy, compared to 53,000/mm3 in patients receiving both IVIg and corticosteroids. Seventy-six percent of patients received Gammagard with an average platelet response of 88,000/mm3, of which 69% responded by day 7. Twelve percent of patients received Gamunex with an average platelet response of 89,000/mm3, of which 75% responded by day 7. Twelve percent of patients received Gammagard S/D with an average platelet response of 10,000/mm3, of which 25% responded by day 7. Average IVIg cost per patient was $2,736 with a mean expense of $36 per 1000/mm3 increase in platelet counts. Conclusion: Similar to other published reports, patients with severe ITP responded well to IVIg therapy. Patients who failed to respond to initial steroid treatment experienced a platelet response with concomitant corticosteroid and IVIg therapy. Though the numbers are small, our study suggests for the first time that IVIg product with >98% IgG levels (i.e. Gammagard, Gamunex) have better response rates than Gammagard S/D which has 90% IgG level. Further analysis needs to be completed evaluating duration of therapeutic effect from IVIg. This information will be used to help detect a clinically meaningful response to IVIg therapy directed at increasing platelet counts and preventing ITP complications. Disclosures No relevant conflicts of interest to declare.
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