Avoidable Acute Care Use Associated with Nausea and Vomiting Among Patients Receiving Highly Emetogenic Chemotherapy or Oxaliplatin

Abstract

Purpose Chemotherapy‐induced nausea and vomiting (CINV) contributes to avoidable acute care, a metric now tracked in Medicare's oncology outcome measure. CINV is preventable, yet guidelines are often not followed. We sought to quantify acute care involving CINV and other avoidable toxicities after highly emetogenic chemotherapy (HEC) to identify excess risk and assess clinician adherence to antiemesis guidelines for HEC. Materials and Methods We retrospectively evaluated U.S. electronic health records (2012‐2018) using Medicare's OP‐35 outcome measure to identify avoidable acute care involving any of 10 toxicities, including CINV, after HEC regimens relative to non‐HEC. Antiemetic guideline adherence was defined as use ofneurokinin‐1 (NKl) receptor antagonists Q5 (RAs) plus 5‐hydroxytryptamine type 3 RA+ dexamethasone at HEC initiation. Results Among 17,609 patients receiving HEC, acute care rates associated with HEC chemotherapy included 32% cisplatin, 31% carboplatin, and 21% anthracycline/cyclosphospharnide (AC), with 76% meeting the criteria as avoidable events. Oxaliplatin rates were 29%. Avoidable acute care occurred 1.83 times (95% confidence interval, 1.76‐1.91, p < .0001) as often after HEC versus non‐HEC excluding oxaliplatin; CINV‐related acute care occurred 2.29 times as often. Nonadherence to antiemesis guidelines occurred in 34% and 24% of cisplatin and AC courses, respectively, because of omission of a NKl RA. Conclusions Patients treated with HEC regimens experienced high avoidable acute care use, 1.8 times the risk seen for other chemotherapy. Nonadherence to guideline‐directed antiemetic prophylaxis highlights the need to ensure adherence to antiemetic guidelines, including the use of NKl RA in HEC. Implications for Practice After survival, perhaps the most important goal in oncology is limiting avoidable acute care, a goal now used by Medicare to impact cancer reimbursement. This study found that patients treated with highly emetogenic chemotherapy (HEC) regimens had high rates of avoidable acute care use, 1.8 times the risk seen for other chemotherapy. A substantial proportion of the avoidable acute care involved chemotherapy‐induced nausea and vomiting. Results showed that incomplete adherence to national antiemetic guidelines for HEC regimens primarily driven by omission of upfront neurokinin‐1 receptor antagonist use, suggesting that improved adherence can meaningfully resolve this gap in quality and cost of care.

A Pragmatic Study Evaluating NEPA Versus Aprepitant for Prevention of Chemotherapy-Induced Nausea and Vomiting in Patients Receiving Moderately Emetogenic Chemotherapy

“…This aligns with a recent large, retrospective study evaluating U.S. health records of 17,609 patients undergoing a variety of HEC and MEC. In this study, a substantial proportion of the avoidable acute care visits involved CINV [29].…”

Reconsidering Dexamethasone for Antiemesis when Combining Chemotherapy and Immunotherapy

“…As a result, dexamethasone is likely to be coadministered with ICIs [4], posing the question of whether its immunosuppressive effects may lessen the efficacy of ICI. Wide national variation in adoption of antiemesis guidelines [12] has prompted the U.S. Centers for Medicare and Medicaid Services to implement 30-day postchemotherapy acute care as a new performance measure [13]. In this perspective, we discuss considerations for clinical decision-making around antiemetic prescribing in patients receiving combination ICI treatments.…”

Supportive Care: Low Cost, High Value

“…However, adherence to guidelines for prevention of nausea and vomiting is still low in certain settings, 20 and nonadherence is associated with avoidable acute health care use and costs. 21 High-quality guidelines exist for most supportive care topics. Table 1 2,3, provides an overview of selected guidelines, as well as the ASCO guidelines (www.asco.org/researchguidelines/quality-guidelines/guidelines/supportive-care-andtreatment-related-issues%20), ESMO guidelines (www.esmo.…”