The clinical and financial impact of remote clinical oncology pharmacist engagement in community-based practices within The US Oncology Network.

INTRODUCTION: The integration of clinical oncology pharmacists into multidisciplinary healthcare teams is not well-described in the community practice setting. This study aims to analyze the clinical and financial impact of a remote-based clinical oncology pharmacist in four community oncology practices within The US Oncology Network. METHODS: Oncology-trained clinical pharmacists electronically reviewed chemotherapy orders for clinical optimization and financial stewardship within four community oncology practices. Each pharmacist was appointed at 0.5 full-time equivalents per practice. Financial, clinical, and workload metrics were tracked to monitor the impact of pharmacist engagement. RESULTS: Over 12 months, 5716 order reviews were completed with an intervention rate of 57%. The most common interventions identified by the pharmacists were interventions with clinical impact on the patient (36%), followed by dose rounding (35%) and therapeutic interchange (30%). Overall, interventions improved the cumulative practice margins by $1,455,033 and reduced total medication costs by $5,962,551. The average program return on investment was 415% (range 100-915%). CONCLUSION: Community oncology practices seek to provide high-value care in a lean, resource-constrained model. An oncology clinical pharmacist is a cost-effective and clinically invaluable care team member in community oncology practice. Pharmacists in this setting identified opportunities to improve medication safety and regimen optimization and demonstrated a significant tremendous financial impact on small-scale budgets in community oncology.

Rasburicase dose optimization for tumor lysis syndrome management in a network of community oncology practices.

INTRODUCTION: Single, fixed-dose rasburicase administration has been evaluated as an effective strategy in the management of hyperuricemia in the hospital setting, but this has not yet been described within ambulatory community oncology practices. The objective of this study is to evaluate and optimize the dosing strategy for rasburicase in the management of tumor lysis syndrome (TLS)-associated hyperuricemia in The US Oncology Network (The Network). METHODS: A network-wide guideline was revised to standardize rasburicase dosing from a previous recommended fixed doses of 4.5 or 7.5 mg to either 3 or 6 mg for outpatient rasburicase use in management and prevention of TLS. The primary outcome evaluated mean dose of rasburicase among all patients before and after guideline revision. A retrospective chart review evaluated secondary endpoints. RESULTS: The primary analysis included 291 patients (128 pre-revised and 163 post-revised guideline implementation). The primary outcome, mean rasburicase dose, was reduced in the post-revision compared to the pre-revision population (mean 6.2 mg pre vs. 4.5 mg post, p < 0.00001) resulting in a reduced cost per rasburicase dose of $974. Fifty patients were included for the secondary analysis. Guideline concordance was identified in 12 (48%) and 16 patients (64%), and uric acid <8 mg/dL post-rasburicase administration occurred in 14 (56%) and 16 patients (64%) before and after guideline revision, respectively. CONCLUSIONS: Guideline revision and electronic health record modification resulted in a 27% reduction in the mean rasburicase dose and a 50% reduction in repeat rasburicase dosing without a negative impact on clinical efficacy.

Evaluation of the effect of obesity on voriconazole serum concentrations.

OBJECTIVES: Voriconazole is a second-generation triazole antifungal, approved by the FDA in 2002. Despite a decade of experience with voriconazole, there are limited published data analysing serum concentrations and toxicity in obese patients. Therefore, we evaluated voriconazole trough serum concentrations in obese and normal-weight patients in a retrospective cohort study. METHODS: Voriconazole serum trough concentrations and toxicities were compared for obese (body mass index >35 kg/m(2)) versus normal-weight (body mass index 18.5-24.9 kg/m(2)) patients receiving 4 mg/kg voriconazole every 12 h. RESULTS: The obese group (n = 21) had significantly higher mean serum voriconazole trough concentrations than the normal-weight group (n = 66) (6.2 and 3.5 mg/L, respectively, P < 0.0001). Patients in the obese group also had higher rates of supratherapeutic voriconazole levels (>5.5 mg/L) than patients in the normal-weight group (67% versus 17%, respectively, P < 0.0001). However, hepatotoxicity and neurotoxicity rates did not differ between groups. The secondary endpoint compared mean serum voriconazole concentrations in the obese population when dosed at 4 mg/kg based on ideal body weight, adjusted body weight and actual body weight, which were statistically significantly different at 3.95, 3.3 and 6.2 mg/L, respectively (P = 0.0009). Therapeutic voriconazole concentrations (2.0-5.5 mg/L) occurred in 29% of obese patients when dosed on actual body weight, and 45% and 80% of patients when dosed on ideal body weight and adjusted body weight, respectively. CONCLUSIONS: Our results suggest a strong association between supratherapeutic concentrations and morbidly obese patients when dosed at 4 mg/kg actual body weight. Dosing voriconazole based on an ideal body weight or adjusted body weight may be appropriate for morbidly obese patients.