Erythropoietic-stimulating agent (ESA) therapy has significantly impacted the management of chemotherapy-induced anemia (CIA) by decreasing the number of red blood cell transfusions required by patients with cancer. However, managing these patients with ESA therapy has become increasingly difficult since the release of the Centers for Medicare & Medicaid Services' new National Coverage Determination document because of the disparities between this document and recommendations from expert-reviewed national clinical guidelines on the treatment of anemia. This article describes a collaborative practice agreement between pharmacists and physicians as one approach to managing CIA in hematology-oncology patients in an anemia clinic. The goal of the pharmacist-managed anemia clinic is to improve patient satisfaction and clinical outcomes associated with the treatment of CIA. This article describes the rationale for the clinic and discusses its design and implementation in managing ESA, iron, folate, and vitamin B12 therapy for CIA in hematology-oncology patients. The pharmacist's role is justified in this clinic model through increased adherence to evidence-based practice guidelines and decreased costs associated with ESA therapy.
Jeffrey A. Gilreath, Daniel S. Sageser, James A. Jorgenson and George M. Rodgers
Diana I. Brixner, Gary M. Oderda, Nancy A. Nickman, Roy Beveridge and James A. Jorgenson
Significant changes in Medicare reimbursement for outpatient oncology services were proposed as part of the Medicare Modernization Act of 2003. The purpose of this study was to identify the “true cost” associated with drug-related handling for the preparation and delivery of chemotherapy doses to estimate the impact of changing reimbursement schema by Medicare. Two academic medical outpatient infusion centers and 2 community cancer centers provided data used to estimate all costs (excluding drug cost) associated with the preparation of chemotherapy doses. The data included both fixed costs (drug storage, space, equipment, and information resources) and variable costs (insurance management, inventory, waste management, pharmacy staff payroll, supplies, and shipping). The average cost for the preparation of chemotherapy doses across all sites was $34.27 (range, $32.08–$41.23). A time-and-motion study was also performed to determine what tasks were conducted by pharmacy staff and how much time was spent in the preparation of the top 15 chemotherapeutic drugs and regimens used in the 4 sites. Data from the 4 centers was projected to show that if 3,990,495 million chemotherapy infusions were administered to a national Medicare population in 2003, when multiplied by the average cost of preparation for infusions determined by the current study ($34.27), the estimated total annual cost to Medicare for chemotherapy preparation by pharmacists is $136,754,263.65. The pharmacists spent most of their days (90% or more) performing tasks directly related to the preparation of these agents. These data provide scientific support for the consideration of appropriate reimbursement for chemotherapy services provided by pharmacists to Medicare beneficiaries.