Escalating expenditures on discretionary oncology treatments with little to no evidence of benefit (ie, overtreatment) have prompted stakeholders to propose various value frameworks to assess oncology treatments and care practices. Overtreatment is a major contributor to at least 20% of healthcare expenditures that may be classified as inefficient or wasteful.1–5 Most frameworks for value-based cancer care require an assessment of real-world benefits, including improvement in care outcomes and adherence to evidence-based standards of care.6
Recognizing that overtreatment is not without harm for patients with cancer receiving chemotherapy, the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Myeloid Growth Factors recommend febrile neutropenia (FN) prophylaxis using a colony-stimulating factor (CSF) when risk, based on the chemotherapy regimen and patient risk factors, is “high” (>20%).7 CSF prophylaxis may also be considered based on patient risk factors when the regimen-based FN risk is intermediate (10%–20%).8,9 However, several studies have reported a high proportion of possibly discretionary administration of CSF,10–15 with some reporting CSF administration as high as 30% among patients at low risk for FN.16–19 Specifically, for patients with breast cancer, as much as 50% of CSF administration was not aligned with national guidelines.16 Such findings suggest the need for additional interventions beyond the publication of clinical guidelines.20
One reason some CSF administrations do not align with guidelines stems from the challenges of incorporating patient risk factors alongside regimen-based FN risk stratifications.21 The decision to administer CSF is relatively straightforward for patients receiving chemotherapy regimens with a high risk of inducing FN. For patients receiving intermediate-risk (FN risk ≥10% to ≤20%) or low-risk (FN risk <10%) regimens, however, careful consideration must be given to patient-, disease-, and treatment-related factors.
As the heterogeneity of physician assessments on risk of FN persist in clinical practice,22 decision support tools are increasingly being implemented as part of prior authorization programs to address the challenges of incorporating multiple factors in oncology treatment decisions. Decision support tools have been reported to result in long-term improvements in practice variation.23–25 For example, adding a decision support tool to a national payer prior authorization program minimized denial rates (by approximately 1%) while reducing chemotherapy drug cost trends by 20%26; however, unintended patient outcomes or level of CSF administration were not assessed.
This study evaluated an evidence-based CSF decision support tool implemented by one national payer across 9 intervention states for patients with breast cancer. This tool was developed using NCCN and ASCO guidelines pertaining to myeloid growth factor use. We present differences in population-level changes in CSF administration between the intervention and nonintervention states. If the CSF decision support tool promoted appropriate FN risk stratification among patients with breast cancer, we hypothesized that there should be no change in population-level pre- and post-implementation FN incidence rates.
Gboyega Adeboyeje, MD, MS, contributed to study design, analysis and interpretation of results. Phil Cochetti and Zhengzheng Jiang, PhD, provided programming support. Cheryl Jones provided writing and editorial support.
Dr. Malin was an employee of Anthem, Inc. at the time of this study. Dr. Fisch is an employee of AIM Specialty Health, a wholly owned subsidiary of Anthem, Inc. Drs. Agiro, and DeVries are employees of HealthCore, a wholly owned subsidiary of Anthem, Inc.
Funding for this study was provided by Anthem, Inc.
See JNCCN.org for supplemental online content.
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