NCH's approach to more appropriate use of myeloid growth factor provides a playbook for how to change prescribing patterns.
By Dr. Andrew Hertler, Sang Chau and Jessy Delaisla
Clinical pathways are an essential part of managing oncology care, but they're just one lever for driving value. Sustained change requires multifaceted tactics for provider behavior change, combining evidence-based medicine with technology and the human touch.
New Century Health's approach to more appropriate use of myeloid growth factors (MGF) embodies this comprehensive effort. MGFs stimulate the production of white blood cells to reduce the risk of infection and help to maintain dose intensity—the schedule of chemotherapy that patients need in a curative setting for the best possible outcomes.
Where MGFs are often used inappropriately is treatment of metastatic disease, when the goals are not to achieve remission but to slow the growth of cancer. According to the American Society of Clinical Oncology (ASCO), the medical evidence does not support the need for dose intensity—survival is not improved, quality of life may suffer, and patients have a greater risk of side effects. More aggressive use of MGFs is therefore not indicated.
Yet it's still common. Some practices we've encountered before intervention have used MGFs in as many as 60% of non-curative cases, while others are closer to 10%.
NCH takes a proactive approach to educating clinicians on the appropriate use of MGFs, and to prompt them to consider alternative courses. Our first choice is that they will consider if there is an equally effective chemotherapy regimen that doesn't require an MGF or alternatively reduce the dosage and/or extend the time between doses of the selected regimen. Next, we encourage them to avoid long-acting growth factors. Most patients who do require growth factors in these settings typically receive them for five to seven days, in which case a short-acting growth factor is appropriate, and much less expensive. A long-acting MGF provides 10 days of treatment at a cost of about $3,080, while five days of a short-acting MGF costs about $1,405 ($281 per dose). Our third tool is encouraging the use of biosimilars in place of short-acting MGFs to bring similar efficacy at lower cost. One biosimilar costs $620 for five doses—a savings of 55% over the brand drug.
Among the tactics we use to encourage these decisions:
Clinical Decision Support
In June 2019, we added several non-invasive questions to our clinical pathway decision-support tool that prompt oncologists to consider alternatives to MGFs in the metastatic setting. For example: Has a dose reduction/delay been considered? Are there other treatment regimens they might select instead without compromising efficacy?
These nudges can make an impact. Across oncology practices in Florida and Arizona, requests for myeloid growth factors in metastatic disease went from 25.3% at baseline to 18.9% after implementation of this decision support tool. These are fewer cases that our utilization management team needs to review and reach out to the prescriber to understand their reasoning and explore alternatives.
Treatment requests for myeloid growth factors in metastatic cancer before and after the implementation of a clinical pathways decision support tool
We shared these results in a poster presented at an ASCO conference this fall.
Active Promotion of Biosimilars
We've learned what works to help guide providers toward the biosimilars in those cases when the provider decides to include an MGF. When regimens containing biosimilars are actively promoted—listed as a preferred choice on our high-value oncology pathways—the rate of adoption is significantly higher than when the biosimilars are passively promoted as an equal alternative.
Filgrastim-sndz was introduced in September 2015 as a biosimilar to short-acting MGF. In oncology practices where this biosimilar was listed as a preferred regimen, it took 19 months to reach a 50% utilization rate and continued climbing quickly after that. In practices that had passive promotion, however, it took 28 months to reach a 50% utilization rate, with a much more gradual increase since. Today, biosimilar utilization in practices with passive promotion remains well below that of practices with active promotion.
Utilization for short acting myeloid growth factor (SA-MGF) vs. Filgrastim-sndz biosimilar in the Passively Promoted (PP) group
Utilization for short acting myeloid growth factor (SA-MGF) vs. Filgrastim-sndz biosimilar in the Actively Promoted (AP) group
Learn more about this study, which we presented as a poster at a virtual Academy of Managed Care Pharmacy conference in the fall (Abstract appears on page S75.)
Peer Communication and Competition
As helpful as these technical changes are, person-to-person relationships are critical. When oncologists submit requests for MGFs in metastatic disease, we don't auto-approve them, but instead use it as an opportunity to consult with the provider on the patient's case. Our utilization management nurses and staff oncologists reach out, discuss the case, and educate them on the evidence surrounding MGFs in non-curative settings, as well as the cost issues. In our regular meetings with oncology practices, we also review the evidence and occasionally share data about individual providers' MGF prescribing patterns. Benchmarking their performance against their peers can be a powerful motivator to improve.
It's also key that these improvement efforts take place in an environment where oncologists are encouraged to pursue value. Rather than traditional buy-and-bill oncology drug models, in which selecting more expensive drugs results in higher practice revenues, NCH administers alternative payment models that remove these warped incentives. Providers can select high quality, lower-cost drug regimens without concern about harming their practices' financial viability.
High-value clinical pathways, clinical decision-support portals and persuasive discussions from one clinical expert to another—not to mention financial incentives—these are the tools that have helped NCH to reduce inappropriate use of MGFs. The same kinds of tactics can be used to tackle a wide range of efforts to better manage oncology care.
About the Authors
Andrew Hertler, MD, FACP is chief medical officer of New Century Health. A nationally recognized leader in oncology clinical practice, he is responsible for the advancement of the company's clinical quality and value-based strategy, utilization management policies and clinical thought leadership initiatives.
Sang Chau, PharmD, BCOP is a board-certified oncology pharmacist involved in the management, implementation and maintenance of New Century Health's high-value clinical pathways.
Jessy DelaIsla, LVN, associate director of quality improvement with New Century Health, involved with the quality and compliance oversight of NCH's utilization management program.
