RESPONSE TO NATIONAL GUIDANCE: Information on chemotherapy use...... How can pharmacy collect better...

RESPONSE TO NATIONAL GUIDANCE:Information on chemotherapy use...

... How can pharmacy collect better data?Calum Polwart

Session Objectives

To provide an overview on why pharmacy need to collect data and how pharmacy can better collect useful data.

Session Objectives

To provide an overview on why pharmacy need to collect data and how pharmacy can better collect useful data.

Discuss how to bake a coffee cake!

WARNING:This session is interactive – you may need to stay awake!!

Scope of the session...

Identify some of the key data requirements

Discuss who and how collected, stored and reported

Won't discuss - specific systems

Before we begin...

The baking analogy!

Ask the audience!

Would you rather have a piece of Kinvara Coffee Cake or a piece of Tesco

Iced Coffee Cake...

What's Wrong with Tesco Cake?

Advantages:

Instant

Convenient

Consistent

Probably Cheaper!

What's Wrong with Tesco Cake?

Advantages:

Instant

Convenient

Consistent

Probably Cheaper!

Disadvantages:

Doesn't taste as nice!

Difficult to customise

Contains ingredients you may not want!

Short of things you do want!

Making the perfect coffee cake...

Making the perfect coffee cake...

200g Butter

200g Caster Sugar

4 eggs

200g SR Flour

1 tsp baking powder

1-2 tbl sp of instant coffee (2tbl sp in 100ml water)

50g walnuts

Add to lined baking tin

Bake 40mins in Preheated Oven 170C

Ice with 200g Butter, 200g Icing sugar & coffee

First step to making a good cake...

Get all your ingredients in order.

Small scale – measured out in bowls

Large scale – in vats and silos

Handling information... ...just like baking a cake

Information in the NHS...

PatientDemographics

Pathology Results

Pharmacy StockControl

ElectronicPrescribingCancer Waiting

Times

Accident &Emergency

Radiotherapy

PACS / Imaging

Data Silos

Before we bake the cake...

... we need to know exactly what sort of cake we are going to bake!

What information must we be already collecting?

Waiting time data – time to treatment

OPCS 4.4 / 4.5 HRG Data

Reference Cost Data (optional!)

Waiting Time Data...

Subsequent treats – chemo rarely breach

Waiting Time Data...

Subsequent treats – chemo rarely breach

Can your pharmacy system report any new chemotherapy drug started on a patient?

No Yes

OPCS HRG Data

Data entry:5Fu Mayo Regimen: X70.1 & X72.3

Intravesical Mitomycin: X70.1 & X72.3

A missed opportunity?

Coders really struggle with our terminologySo do we sometimes!

Do you even know if your trust is coding?

Reference Cost Data

Will set the future tariff for chemoGet it wrong and we loose out!

Reference Cost Data

Will set the future tariff for chemoGet it wrong and we loose out!Includes pharmacy on-costsForget to include it and we loose out!What should be in the on-costs?

Reference Cost Data

Will set the future tariff for chemoGet it wrong and we loose out!Includes pharmacy on-costsForget to include it and we loose out!What should be in the on-costs?

ConsumablesStaff (Pharm → ATO)QC, Maintenance, Cleaning? Electricity etcOutsourcing + dispensing costs

Doing the Reference Costs Right...

OPCS HRGProcurement Codes

PharmacyOn-Costs

Drug CostData


Hosp No Date Drug Cost

123456 01-Apr-09 Gemcitabine £350.00

123456 01-Apr-09 Carboplatin £45.00

123456 08-Apr-09 Gemcitabine £350.00

123456 22-Apr-09 Gemcitabine £350.00


123456 29-Apr-09 Gemcitabine £350.00

123456 13-May-09 Gemcitabine £250.00

123456 13-May-09 Carboplatin £35.00

123456 20-May-09 Gemcitabine £250.00

543210 01-Apr-09 Fluorouracil £5.00


543210 03-Apr-09 Flourouracil £5.00

Doing the Reference Costs Right...Hosp No Date Drug Cost

123456 01-Apr-09 Gemcitabine £350.00


123456 08-Apr-09 Gemcitabine £350.00

123456 22-Apr-09 Gemcitabine £350.00


123456 29-Apr-09 Gemcitabine £350.00

123456 13-May-09 Gemcitabine £250.00


123456 20-May-09 Gemcitabine £250.00





Drug On-Cost

Carboplatin £30

Docetaxel £40

Epirubicin £25

Fluorouracil £25

Gemcitabine £35

Methotrexate £25

Hosp No Date Drug Cost

123456 01-Apr-09 Gemcitabine £350.00


123456 08-Apr-09 Gemcitabine £350.00

123456 22-Apr-09 Gemcitabine £350.00


123456 29-Apr-09 Gemcitabine £350.00

123456 13-May-09 Gemcitabine £250.00


123456 20-May-09 Gemcitabine £250.00





Hosp No Date Drug Cost On-Cost Total £

123456 01-Apr-09 Gemcitabine £350.00


123456 08-Apr-09 Gemcitabine £350.00

123456 22-Apr-09 Gemcitabine £350.00


123456 29-Apr-09 Gemcitabine £350.00

123456 13-May-09 Gemcitabine £250.00


123456 20-May-09 Gemcitabine £250.00



Drug On-Cost

Carboplatin £30

Docetaxel £40

Epirubicin £25

Fluorouracil £25

Gemcitabine £35

Methotrexate £25



123456 01-Apr-09 Gemcitabine £350.00 £35 £385


123456 08-Apr-09 Gemcitabine £350.00

123456 22-Apr-09 Gemcitabine £350.00


123456 29-Apr-09 Gemcitabine £350.00

123456 13-May-09 Gemcitabine £250.00


123456 20-May-09 Gemcitabine £250.00



Drug On-Cost

Carboplatin £30

Docetaxel £40

Epirubicin £25

Fluorouracil £25

Gemcitabine £35

Methotrexate £25



123456 01-Apr-09 Gemcitabine £350.00 £35 £385

123456 01-Apr-09 Carboplatin £45.00 £30 £75

123456 08-Apr-09 Gemcitabine £350.00 £35 £385

123456 22-Apr-09 Gemcitabine £350.00 £35 £385

123456 22-Apr-09 Carboplatin £45.00 £30 £75

123456 29-Apr-09 Gemcitabine £350.00 £35 £385

123456 13-May-09 Gemcitabine £250.00 £35 £285

123456 13-May-09 Carboplatin £45.00 £30 £75

123456 20-May-09 Gemcitabine £250.00 £35 £285

543210 01-Apr-09 Fluorouracil £5.00 £25 £30

543210 02-Apr-09 Fluorouracil £5.00 £25 £30

Drug On-Cost

Carboplatin £30

Docetaxel £40

Epirubicin £25

Fluorouracil £25

Gemcitabine £35

Methotrexate £25


Hosp No Date Drug Total £

123456 01-Apr-09 Gemcitabine £385

123456 01-Apr-09 Carboplatin £75





123456 13-May-09 Gemcitabine £285

123456 13-May-09 Carboplatin £75


543210 01-Apr-09 Fluorouracil £30


543210 03-Apr-09 Flourouracil £30















Hosp No OPCS Start Date End Date Cost

123456 X71.2 01-Apr-09 21-Apr-09

123456 X71.2 22-Apr-09 12-May-09

123456 X71.2 13-May-09 03-Jun-09

543210 X71.1 01-Apr-09 14-Apr-09

543210 X71.1 15-Apr-09 29-Apr-09

678910 X71.5 02-Apr-09 28-Apr-09

678910 X71.5 29-Apr-09 31-May-09 ...
















123456 X71.2 01-Apr-09 21-Apr-09

123456 X71.2 22-Apr-09 12-May-09

123456 X71.2 13-May-09 03-Jun-09

543210 X71.1 01-Apr-09 14-Apr-09

543210 X71.1 15-Apr-09 29-Apr-09

678910 X71.5 02-Apr-09 28-Apr-09

678910 X71.5 29-Apr-09 31-May-09 ...
















123456 X71.2 01-Apr-09 21-Apr-09 £845

123456 X71.2 22-Apr-09 12-May-09

123456 X71.2 13-May-09 03-Jun-09

543210 X71.1 01-Apr-09 14-Apr-09

543210 X71.1 15-Apr-09 29-Apr-09

678910 X71.5 02-Apr-09 28-Apr-09

678910 X71.5 29-Apr-09 31-May-09 ...
















123456 X71.2 01-Apr-09 21-Apr-09 £845123456 X71.2 22-Apr-09 12-May-09 £845

123456 X71.2 13-May-09 03-Jun-09 £645

543210 X71.1 01-Apr-09 14-Apr-09 £90

543210 X71.1 15-Apr-09 29-Apr-09 ...

678910 X71.5 02-Apr-09 28-Apr-09 ...

678910 X71.5 29-Apr-09 31-May-09 ...

What information should we be collecting?

Who knows?

DH standards soon!

Includes 36 data points

Many will be common sense

This weeks questions!...

What percentage of products do we supply dose banded?



How much do we save by vial sharing?




Details of every patient who has had Pemetrexed...





...for non-small cell lung cancer

...how many cycles

...what doses





...for non-small cell lung cancer

...how many cycles

...what doses

How many patients do we treat with EOX, ECX and ECF?



How much do we save by vial sharing?Details of every patient who has had

Pemetrexed......for non-small cell lung cancer...how many cycles...what doses

How many patients do we treat with EOX, ECX and ECF?

Which wards have given chemo in the last 12 months?

Experts in medicines...

Experts in medicines...

... just don't ask us how we actually are using them!

What questions does NCAG think we should be able to answer?

How many (and what proportion of) patients with different cancers are accessing chemotherapy.

Need to know:

No of patients having chemo

Tumour Type for each patient

Overall number of patients

How chemotherapy utilisation locally compares with that in other parts of the country.

Need to know:

Chemo utilisation

Standard counting method!

National comparators

How chemotherapy utilisation locally compares with that in other parts of the country.

Also need to know – why different

PS

Co-morbidities

The indications in which chemotherapy is being used (eg curative, adjuvant or

life-prolonging/palliative).

Need to know:

Treatment intent

Do we also need to know:

Tumour type?

How many cycles of treatment patients receive and how closely this corresponds with that

expected from clinical trial findings.

Need to know:

Protocol

No of cycles delivered

Clinical detail – eg diagnosis & staging

How many cycles of treatment patients receive and how closely this corresponds with that

expected from clinical trial findings.


PS

Co-morbidities

The outcomes (eg how many patients died within a specified time of receiving treatment).

Need to know:

Protocol

Indication(diagnosis), staging

Date of Death (or Progression, or Response?)

The outcomes (eg how many patients died within a specified time of receiving treatment).


PS

Co-morbidities

People are doing this already...

...but usually manually!

Does Size Matter? An audit of Dose Intensity in Non-Small Cell Lung CancerRachel Collinson (Clinical Pharmacist, Darlington Memorial Hospital), Clive Peedell (Consultant Oncologist, James Cook University Hospital),

Calum Polwart (Pharmacy Clinical Team Manager – Cancer & Aseptic Services, Darlington Memorial Hospital)

Doublet chemotherapy is the standard treatment for Advanced Non Small Cell Lung Cancer (NSCLC) but tolerability of the regimen remains a challenge.

Luciani et al (2009) reported dose intensities less than 80% in their elderly NSCLC treatment cohort resulted in poorer outcomes.

A NSCLC patient deferring every cycle for 7 days causes the relative dose intensity (DI) to be 75% of planned.

Preventing subsequent delays by 10% dose reduction (DR) at the first delay could result in a DI of 85%.

Clinician practice varies when dealing with treatment delays and the need to formalize this to allow nurse and pharmacist led review of patients to take place prompted a protocol driven dose reduction to be implemented within our institution.

Background

Retrospective case review was used to analyse DI from a 12 month period (from Jan 08 to Jan 09) for patients receiving Carboplatin(C) & Gemcitabine(G) Chemotherapy (C- AUC 5 on d1,G- 1250mg/m2 on d1& 8, 21d cycle)

Data was retrieved from the hospital computer systems.

Relative DI was calculated for the number of cycles delivered, relative to the planned intensity over the same number of cycles (Hryniuk 1990).

Kaplan-Meier survival analysis undertaken, including Log Rank Test (p < 0.05 was assumed to show a difference).

Cockroft & Gault and Wright Equation dose variations were assessed for possible influence on results.

Method

Usable data was retrieved from 60 patients (39 Males) with NSCLC who had received GC Chemotherapy, median age 68. 20 patients had experienced Grade II+ HT after their first cycle of chemotherapy.

Results

Age is a contributing factor to likelihood of a delay due to HT and the depth of the toxicity, however, we did not observe a difference in outcome related to age.

Unlike Luciani et al we did not observe a survival disadvantage for patients with lower dose intensities. Those patients who received reduced doses had better outcomes.

We hypothesize that patient characteristics which make the patient more sensitive to chemotherapy to require DR also make their tumours more sensitive.

Small DR may improve the possibility of maintaining DI, which may be of clinical benefit to patients.

No relationship with renal function calculation method was identified.

Patients can be re-assured that small DR to optimise treatment intensity overall do not appear to have a detrimental effect on outcome and may be beneficial.

Discussion

References

11 (27.5%) patients with Grade 0-I HT who did not DR on cycle 2 did have DR on cycle 3. 3 (18%) patients with Grade II/III HT required a second DR on cycle 3, & 1 patient with Grade IV HT had a second DR.

Toxicity after 1 cycle n rCDI rGDI n > 70 years

Grade 0 / I 39 84.7% 75.4% 8 (21%)

Grade II / III 17 68.8% 65.9% 9 (53%)

Grade IV 4 62.8% 54.3% 3 (75%)

Haematological Toxicity Day 8 Day 21

Grade 0 / I Proceed Proceed with next cycle

Grade II Proceed Delay 7 days then* reduce 10%

Grade III 75% Dose Delay 7 days then* reduce 10%

Grade IV Omit Delay 7 days then* reduce 20%

*ensure counts have recovered to Grade 0/I before proceeding with treatment

Table 1: Pharmacist & Nurse driven dose reduction schedule

Table 2: Mean relative dose intensity (rDI) for Carboplatin(C) & Gemcitabine (G) by CTC Grade of Haematological Toxicity. (n = number of patients)

Aim

To audit the effectiveness of 10% dose reductions for maintaining DI, and to compare clinical outcomes.

Hryniuk WM, Goodyear M. The calculation of received dose intensity. JCO. 1990 8(12); 1936-7Luciani A, et al. Dose intensity correlate with survival in elderly patients treated with chemotherapy for advanced non-small cell lung cancer. Lung Cancer 2009 66; 94-6

National Chemotherapy Advisory Group

Patient identifiers

Tumour type

Stage of tumour

Performance status and significant co-morbidities.

Indication (curative, palliative, adjuvant and neoadjuvant)

Treatment regimen

Line of treatment

Number of cycles planned

Number of cycles delivered

Start date

Date of death

What is 'normal' for pharmacy

Patient identifiers

Tumour type

Stage of tumour



Treatment regimen

Line of treatment



Start date

Date of death

What is 'normal' for hospitals

Patient identifiers

Tumour type

Stage of tumour



Treatment regimen

Line of treatment



Start date

Date of death

What will be 'normal' for hospitals by 2010

Patient identifiers

Tumour type

Stage of tumour



Treatment regimen

Line of treatment



Start date

Date of death

National Chemotherapy Advisory Group

Patient identifiers

Tumour type

Stage of tumour


Indication (curative, palliative, adjuvant…)

Treatment regimen

Line of treatment



Start date

Date of death

Performance Status

Only decisions to be made are:

ECOG / WHO Scale (0 - 5)or

Karnofsky Scale (0 – 100)

Should we write our recipe in grams or ounces! (Can we convert?)

Indication (curative, palliative etc)

Is Indication the right terminology? Would intent not be the correct term!

Fairly simple list –Although for long term survival advantages is palliative descriptive enough?

Myeloma Intensive Arms

Treatment regimen

Hardest terminology!Is FEC and ECF the same?FEC-50, FEC-60, FEC-75, FEC-100?FEC-T, FEC then T?

Can we have a national system?

Is the OPCS Code List enough?

OPCS Coding List

REGIMEN NAME USUAL CYCLE LENGTH DAYS

OPCS PROCUREMENT CODE

OPCS DELIVERY CODE

FEC 60 / 75EPIRUBICINCYCLOPHOSPHAMIDEFLUORURACIL

21 X70.2 X72.1

FEC100EPIRUBICINCYCLOPHOSPHAMIDEFLUORURACIL

21 X70.3 X72.1

OPCS Coding List

REGIMEN NAME USUAL CYCLE LENGTH DAYS

OPCS PROCUREMENT CODE

OPCS DELIVERY CODE

FEC 60 / 75EPIRUBICINCYCLOPHOSPHAMIDEFLUORURACIL

21 X70.2 X72.1

FEC100EPIRUBICINCYCLOPHOSPHAMIDEFLUORURACIL

21 X70.3 X72.1

Procurement costs differ different entriesClinically FEC-60 and FEC-75 differ…

How can we capture Regimen?

DH: Electronic Prescribing

Pharmacy System?

Coders??

Cancer Information System

Something special?

Electronic Prescribing?

Lots of Promises – can it deliver?

Data in ≠ Data out

Still a silo! Where will you store:

Date of deathStagingCostsNon-chemo patients

Have we missed anything?

Outcomes:Survival easier than PFS Survival easier than Response

Toxicity?At least we have a standard system!Can the prescribing systems help?

Summary

Pharmacy should care about drug use dataData should be clinical not just financialElectronic Systems will be mandatoryPutting data into a silo does not mean it can come back outIf the data isn't going in it definitely can't come outBeware unproven promises

Final Thought

The home baked cake may be better than the shop bought cake...

Final Thought

The home baked cake may be better than the shop bought cake...

... but beware – not everyone's home baking is that good!

RESPONSE TO NATIONAL GUIDANCE: Information on chemotherapy use...... How can pharmacy collect better...

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