Issn Print: 0192-8562
Publication Date: 1997/07/01
#658 Balancing efficacy with cost: anti-emetic control in the pediatric bone marrow transplant population
Excerpt
Despite the well-documented superior efficacy of the serotonin antagonists in the acute control of chemo- and radiotherapy-related emesis, the cost of these agents, estimated at 5-20 times that of conventional therapy, necessitates ongoing evaluation of utilization patterns. We reviewed the use of intravenous ondansetron in our pediatric bone marrow transplant population to identify potential cost containment strategies that would not abrogate clinical efficacy. Forty-nine patients received a total of 55 transplants during the study period, (10/1/94-9/30/95). Complete dosing and cost information was available from pharmacy records on 80% of the patients, although ondansetron was used in all transplants. Initial review of dispensing records revealed considerable variability with respect to dosing schedule and duration of treatment. Ondansetron was administered on a daily basis in eight (18%) of the transplants, on a divided schedule in 29 transplants (66%), and a combination of daily and divided dosing in the remaining seven. The median duration of treatment was 10.5 days (range, 1-48 days) at an average dose of 0.45 mg/kg/day, independent of dosing schedule. Two strategies were modeled. The first was to switch to daily dosing, given the evidence of equal efficacy of divided and daily dosing. This change would result in an overall savings of 29% for the population and a 35.6% savings in the subset of patients who previously received only divided dosing. The impact of the change varied by patient weight. For patients weighing less than the median of 30 kg, the savings would be 33% versus 28% for the patients > 30 kg. The second strategy would be to cap the duration of proposed daily treatment to correspond with the duration of the conditioning regimen, based on the maximal efficacy of serotonin antagonists for acute regimen-related emesis. A 10-day cap would result in an additional savings of 29%, while a 7-day cap would translate into a 44% additional savings. Overall, the combined strategy of daily dosing for a fixed duration would result in up to 61% savings (est. $32,100/year) over current practice. Prior to implementing these proposed changes, education of clinical staff and families would be necessary, including formal recommendations of alternate treatment strategies in case of poor emetic control. Post-implementation monitoring of emetic control and side effects is also imperative to ensure no adverse clinical impact. In conclusion, significant cost reductions in ondansetron use could be realized with the specification of dosing interval and treatment duration without altering dosage or patient access to the drug.
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