New Orleans—Strategies that resulted in significant cost savings, including a novel way to extend the beyond-use dating of chemotherapy medications, the judicious use of elastomeric pumps and having pharmacists supervise IV compounding to reduce drug wastage, were presented at the sixth annual meeting of the Hematology/Oncology Pharmacy Association.

Ryan A. Forrey, PharmD, assistant director in the Department of Pharmacy at the Arthur G. James Cancer Hospital, Columbus, Ohio, demonstrated how he and his team were able to use an automated compounding device to extend beyond-use dating of chemotherapy agents from single-dose vials. In doing so, they were able to decrease pharmaceutical wastage while complying with United States Pharmacopeia (USP) Chapter <797> recommendations for sterile compounding.

“The ultimate goal is to save money,” Dr. Forrey said in an interview. “After USP <797> went into place, its latest revisions stated that you could only use a single-dose vial for six hours if it was kept inside the hood. When we evaluated our waste using the six-hour rule, we [estimated that it was] about $1.1 million dollars in 2008.”

The researchers used the Gri-fill System 3.0 automated compounding device (Grifols USA) to save any remaining drug over 5 mL from selected single-dose vials after six hours of use. Two outpatient pharmacies were selected to participate in the study, based on volume and specific pharmaceuticals commonly used, and four drugs—cetuximab (Erbitux, Bristol-Myers Squibb), gemcitabine (Gemzar, Eli Lilly), oxaliplatin (Eloxatin, Sanofi-aventis) and rituximab (Rituxan, Genentech)—were studied. The amount of drug saved for later use in dose compounding was recorded. “The aim was to take the contents of a vial, pass it through the compounding device which has a filter that ensures sterility, and then use the remainder of that vial on subsequent days, instead of throwing it away,” Dr. Forrey explained.

The investigators found that medication that normally would have been wasted was able to be saved and used at a later date. For the four medications, the amount of money saved over a one-year period at the two pharmacies was $111,532, or approximately 10% of the total waste estimated in 2008. The average savings per vial was $233.20 for rituximab, $255.55 for cetuximab, $211.50 for gemcitabine and $535.90 for oxaliplatin.

“The system more than paid for itself,” said Dr. Forrey. “The return on investment was seven months, just for using it to save the remainder of a limited number of chemotherapy agents. If the Gri-fill was also used for compounding, efficiency and workflow gains might have also been realized.”

Elastomeric Versus Electronic Medication Pumps

In another study, Anna Palafox, PharmD, and her colleagues at Evanston Hospital in Evanston, Ill., compared elastomeric and electronic medication pumps for continuous-infusion chemotherapy in their outpatient cancer center and found that the elastomeric infusion pumps were more cost-effective.

Their use also improved workflow efficiency and increased customer (i.e., patient) loyalty and safety, Dr. Palafox said.

“Much chemotherapy is being delivered in an ambulatory care center rather than in a hospitalized setting and these ambulatory medication delivery systems allow for continuous infusion, eliminating the need for a hospital stay,” she said. “There are several types of ambulatory pumps available, and we wanted to evaluate them for efficiency, customer loyalty, economic outcomes and safety.”

The researchers evaluated two elastomeric pumps (the Baxter Infusor and the Grifols Dosi-fuser) and one electronic pump (the CADD Legacy) for continuous infusion of 5-fluorouracil (5-FU) over 48 hours. To evaluate efficiency, Dr. Palafox and her team looked at the time it took for the pharmacist and technician to prepare the pumps.

For the electronic pump, the technician took 20 minutes to draw up solutions, inject solutions into the bag, remove air bubbles and prime the tubing. The pharmacist took 60 minutes for order verification, pump calculations, patient counseling, pump calibration, pump programming and pump cleaning.

The time to prepare the elastomeric pump was shorter for both the technician and the pharmacist. The technician time was 10 minutes to draw up solutions, inject solution into the pump and to prime the tubing. The pharmacist time was 20 minutes for order verification, pump calculations and patient counseling. “Obviously, from a time perspective, the elastomeric was the better choice,” Dr. Palafox commented.

The elastomeric pumps were also less expensive. There was a $20,000 annual cost savings with the elastomeric devices due to decreased equipment costs. The maximum savings were seen with the Dosi-fuser. The more efficient workflow and significant reduction in time and resources with the elastomeric pumps resulted in an additional annual cost savings of $29,572.50. “Medicare reimburses for the electronic pumps but not for the elastomeric pumps, yet costs were still lower with the elastomeric pumps,” Dr. Palafox said.

Patients preferred the elastomeric pump over the electronic pump because they felt it was lighter, more convenient, quieter and more discreet. The pharmacy preferred the elastomeric pump because, in addition to requiring less time to prepare than the electronic pump, it required less storage space and less documentation because it does not need tracking, batteries, calibration or maintenance. Of the two pumps, pharmacy preferred the Dosi-fuser because only one size pump is required for most patients’ doses, Dr. Palafox said.

Oncology staff also preferred the elastomeric device because it came with simpler patient education materials and was also associated with fewer after-hour calls, she added.

In addition, the elastomeric pumps had fewer malfunctions. The electronic pumps had 17 malfunctioning events that occurred after hours, and required intervention by the pharmacist or the physician. “This resulted in patient anxiety, inconvenience, and loss of trust regarding integrity of the infusion,” Dr. Palafox said.

Electronic pumps could also be accidentally disconnected from the administration set, causing medication to free-flow into the patient. They also require the use of an anti-siphon valve, she said.

“For patients on FOLFOX [leucovorin, 5-fluorouracil (5-FU) and oxaliplatin] or FOLFIRI [5-FU, folinic acid and irinotecan], given over 48 hours, the elastomeric pump is exactly what we are geared toward. So for those infusions, it is perfect,” Dr. Palafox said. “Our pump evaluation project resulted in a decision to change to the elastomeric pumps. However, if we have a different duration of infusion, such as continuous infusion for 96 hours, we can’t use elastomeric pumps. In this case, the electronic pumps are more beneficial. But in general, we are now using the elastomeric pumps.”

Hem/Onc Pharmacist A Great Investment

In a third study, having a hem/onc pharmacist oversee the preparation of chemotherapy drugs significantly reduced the amount of chemotherapy wastage and resulted in considerable cost savings as well as reductions in chemotherapy errors.

Sarah M. Ussery, PharmD, a hematology/oncology advanced practice specialist at Veterans Affairs North Texas Health Care System (VANTHCS), Dallas, decided to provide oversight in the monitoring of the chemotherapy preparation shortly after joining this institution. “When we started this project, we had significant chemotherapy wastage occurring that we didn’t even know about because there wasn’t a dedicated hem/onc pharmacist overseeing the preparation of chemotherapy drugs,” Dr. Ussery told Pharmacy Practice News.

The practice at VANTHCS was to mix chemotherapy in a batch-type format, before the patient arrived at the facility, which wasted a lot of chemotherapy drugs along with a half-million dollars annually.

“Chemo was coming back because patients had a dose change, or they couldn’t get their chemo because their blood counts were too low or they weren’t doing well, or there were a lot of toxicities that were stopping them from getting their chemo, and so these drugs were going to waste,” she said.

Dr. Ussery and her colleagues implemented a monitoring and management program with a view to minimizing chemotherapy wastage and optimizing cost savings for the VANTHCS pharmacy department.

They documented chemotherapy wastage on a wastage monitoring log over a two-month period in 2005 and again in 2007. The log captured the date of wastage, the drug name and dose wasted, and the reason for wastage.

In 2006, the hospital implemented a chemotherapy management program that delayed the preparation of expensive chemotherapies with agents such as bevacizumab (Avastin, Genentech/Roche) and rituximab. In 2008, additional expensive chemotherapies such as gemcitabine and oxaliplatin were added to the delayed-preparation list, and chemotherapy wastage was recorded for another two-month period.

The study found that a total of 143 chemotherapy doses of bevacizumab, docetaxel, gemcitabine, oxaliplatin and rituximab were wasted over two months in 2005. For that period, the total cost of the unused medications was approximately $90,000, extrapolated to more than $500,000 annually. The most common reason for wastage was disease progression, which occurred in 23% of cases. (Other reasons are shown in the Figure.)

Drug wastage over two months was monitored again in 2007. This time, the monitoring identified 61 wasted chemotherapy doses, and the chemotherapy drugs were similar to those drugs wasted in 2005. The total cost of wastage was about $42,000, extrapolated to $250,000 annually.

Faced with these results, the system agreed to approve one full-time hematology/oncology clinical pharmacy specialist to oversee chemotherapy ordering and preparation. As a result, when wastage was next measured over a two-month period in 2008, the total cost was $15, or about $90 annually. “I was hired to review the orders and to make sure everything looked good before we mixed the chemo, and that the patient was good to go. I was only in the position for six months, and it resulted in just two doses of 5-FU being wasted,” Dr. Ussery said in an interview.

Before this, the problem of drug wastage was under the radar, she said. “Nobody knew that it was a problem. The hem/onc department didn’t know it was a problem because they’re not in the pharmacy day to day. We had one chemotherapy technician, and in order to keep up with everything, she had to do a lot of chemo mixing in the morning, before the patient showed up. She didn’t even realize how expensive these drugs are. When we built a table with the drug cost for each vial, this helped with the understanding that certain therapies must be kept on hold until we know for sure that the patient is going to receive [the] therapy.”

Hematology/oncology pharmacists can identify problems because of their intimate knowledge of and links to chemotherapy ordering, Dr. Ussery said. In fact, institutions could benefit by having a hem/onc pharmacy specialist come in just to review the process. “You’d be amazed at the things you could find.”

Commenting on these studies for Pharmacy Practice News, Luci Power, MS, RPh, senior pharmacy consultant at Power Enterprises, San Francisco, said that strategies that reduce the wasting of hazardous drugs are needed both for financial considerations and to eliminate as much toxic waste as possible, which has its own financial implications.

“Reduction of hazardous waste by any means is a laudable goal,” she said, “to reduce the actual cost of therapy, reduce the related cost of special disposal and to be environmentally conscious in improving the ‘green’ part of chemotherapy.”