Antiemetics Remain Overused in Chemo Patients

By David Douglas

NEW YORK - A campaign to discourage excessive use of costly antiemetics in patients with low risk of chemotherapy-induced nausea has had some initial impact but has not been effective overall, according to a large observational study.

The American Society of Clinical Oncology's antiemetic recommendations in the 2013 'Choosing Wisely' (CW) campaign were intended to address this overuse, noted Dr. William Encinosa of the Agency for Healthcare Research and Quality, Rockville, Maryland, in email to Reuters Health.

The new study "raises the concern that such (voluntary) measures and campaigns will likely be ineffective in improving the delivery of healthcare unless they are accompanied by financial performance incentives," Dr. Encinosa added.

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To examine the effect of the CW recommendations, released in late October 2013, Dr. Encinosa and Dr. Amy J. Davidoff of Yale School of Medicine in New Haven, Connecticut analyzed insurance data from 2008 to 2015 covering more than 678,000 patients. Use was stratified by risk for chemotherapy-induced nausea and vomiting. Among the categories, for example, were oral high- to moderate-risk chemotherapy and intravenous low-risk chemotherapy

As reported September 15 online in JAMA Oncology, antiemetic overuse was seen in 24.1% of patients overall. The highest rates were in patients receiving intravenous chemotherapy with high- to moderate-risk of chemotherapy-induced nausea and vomiting risk (32.4%), "attributed to prescriptions for medications commonly prescribed to manage breakthrough symptoms several days after chemotherapy."

Compared with baseline before the campaign went into effect, there was a 7.7% drop in the odds of antiemetic overuse in the first six months. The effect was transitory, however. Six months after that, the odds had risen to 7.4% higher than those at baseline.

Nevertheless, in one category - low-risk intravenous chemotherapy - overuse continued to decrease six months after the CW appeared.

Legislation may help change the situation. In 2015, according to the research team, the Centers for Medicare & Medicaid Services requested that CW overuse measures be incorporated into its Merit-Based Incentive Payment System.

"However," they conclude, "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."

Commenting by email, Dr. Ethan M. Basch of The University of North Carolina at Chapel Hill, co-author of an accompanying editorial, told Reuters Health, "Overuse of treatments is a substantial problem in cancer care and in healthcare generally, leading to unnecessary treatments, side effects, and cost."

"This study shows that issuing recommendations about what not to overuse is not enough," Dr. Basch continued. "Although the Choosing Wisely campaign is a terrific start, there need to be interventions that build on Choosing Wisely and work with doctors and practices - to educate and to automate guidelines. As doctors, we are human and have a lot to keep on our minds, and it is easy to be out of compliance with guidelines as cancer care becomes more complicated - so guidelines alone are not enough, we need systems to help us select appropriate care."

"An example," he concluded, "would be an electronic chemotherapy ordering system that automatically prescribes the appropriate anti-nausea medicine depending on what chemotherapy I order. We use such a system at my institution as a part of the electronic medical record system."

SOURCE: https://bit.ly/2d5eYnt and https://bit.ly/2cTbjZu

JAMA Oncol 2016.

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