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Anti-CD20 Antibody Order Checks and Medication Use Evaluation Tracker Increase Hepatitis B Testing and Antiviral Treatment in VHA
Purpose: In patients initiating treatment with anti-CD20 antibodies (Ab), 20-60% with prior hepatitis B (HBV) infection not receiving HBV antiviral prophylaxis experience HBV reactivation—with hepatitis (33%), liver failure (13%), and death (5%). HBV reactivation is prevented with HBV antiviral therapy during and 12 months after anti-CD20 Ab therapy in patients with positive HBV surface antigen (HBsAg+) or HBV core antibody (HBcAb+). Our goal is to widely use anti-CD20 Ab order checks to increase testing and antiviral treatment to prevent HBV reactivation.
Background: Without HBV treatment in those at risk, fatal HBV reactivation affects 1 in 1,000 receiving rituximab. In a VHA analysis of 19,304 patients initiating anti-CD20 Ab (2002-14), > 60% of patients had HBV testing by 2014; 1 in 9 Veterans had either chronic (1-2% HBsAg+) or prior (9% HBcAb+) HBV, yet < 18% received HBV antiviral therapy. While information modestly affects behaviors, order checks with treatment algorithms can be > 95% effective.
Methods: Since 2015, our team has shared information widely, updated pharmacy criteria for use, and enabled HBV antiviral prescribing by all providers. To identify HBV testing or treatment omissions, we launched a Medication Use Evaluation Tracker (MUET), and programmed an anti- CD20 Ab order check that displays only if either HBV testing or treatment has not been done.
Results: Since 2014, HBV testing in patients initiating anti-CD20 Ab increased to 64-78% and HBV antiviral prophylaxis from < 18% to 44%. In November 2016, an anti-CD20 Ab order check was piloted at 3 sites and functional in CPRS with additional sites reporting favorable use. Additionally, a MUET was released for anti-CD20 Ab therapies providing an additional safety check.
Conclusions: VHA has increased HBV testing and antiviral treatment with anti-CD20 antibody initiation—yet more than half of patients remain at risk of HBV reactivation. Successfully used in up to 15 sites, programmed anti-CD20 Ab order checks highlight to providers when HBV testing
or antiviral prophylaxis is needed. Achieving broad use of this order check will increase HBV prophylaxis prescribing and decrease subsequent HBV reactivation. An anti-CD20 Ab MUET provides an additional safety check option for identifying at risk patient.
Purpose: In patients initiating treatment with anti-CD20 antibodies (Ab), 20-60% with prior hepatitis B (HBV) infection not receiving HBV antiviral prophylaxis experience HBV reactivation—with hepatitis (33%), liver failure (13%), and death (5%). HBV reactivation is prevented with HBV antiviral therapy during and 12 months after anti-CD20 Ab therapy in patients with positive HBV surface antigen (HBsAg+) or HBV core antibody (HBcAb+). Our goal is to widely use anti-CD20 Ab order checks to increase testing and antiviral treatment to prevent HBV reactivation.
Background: Without HBV treatment in those at risk, fatal HBV reactivation affects 1 in 1,000 receiving rituximab. In a VHA analysis of 19,304 patients initiating anti-CD20 Ab (2002-14), > 60% of patients had HBV testing by 2014; 1 in 9 Veterans had either chronic (1-2% HBsAg+) or prior (9% HBcAb+) HBV, yet < 18% received HBV antiviral therapy. While information modestly affects behaviors, order checks with treatment algorithms can be > 95% effective.
Methods: Since 2015, our team has shared information widely, updated pharmacy criteria for use, and enabled HBV antiviral prescribing by all providers. To identify HBV testing or treatment omissions, we launched a Medication Use Evaluation Tracker (MUET), and programmed an anti- CD20 Ab order check that displays only if either HBV testing or treatment has not been done.
Results: Since 2014, HBV testing in patients initiating anti-CD20 Ab increased to 64-78% and HBV antiviral prophylaxis from < 18% to 44%. In November 2016, an anti-CD20 Ab order check was piloted at 3 sites and functional in CPRS with additional sites reporting favorable use. Additionally, a MUET was released for anti-CD20 Ab therapies providing an additional safety check.
Conclusions: VHA has increased HBV testing and antiviral treatment with anti-CD20 antibody initiation—yet more than half of patients remain at risk of HBV reactivation. Successfully used in up to 15 sites, programmed anti-CD20 Ab order checks highlight to providers when HBV testing
or antiviral prophylaxis is needed. Achieving broad use of this order check will increase HBV prophylaxis prescribing and decrease subsequent HBV reactivation. An anti-CD20 Ab MUET provides an additional safety check option for identifying at risk patient.
Purpose: In patients initiating treatment with anti-CD20 antibodies (Ab), 20-60% with prior hepatitis B (HBV) infection not receiving HBV antiviral prophylaxis experience HBV reactivation—with hepatitis (33%), liver failure (13%), and death (5%). HBV reactivation is prevented with HBV antiviral therapy during and 12 months after anti-CD20 Ab therapy in patients with positive HBV surface antigen (HBsAg+) or HBV core antibody (HBcAb+). Our goal is to widely use anti-CD20 Ab order checks to increase testing and antiviral treatment to prevent HBV reactivation.
Background: Without HBV treatment in those at risk, fatal HBV reactivation affects 1 in 1,000 receiving rituximab. In a VHA analysis of 19,304 patients initiating anti-CD20 Ab (2002-14), > 60% of patients had HBV testing by 2014; 1 in 9 Veterans had either chronic (1-2% HBsAg+) or prior (9% HBcAb+) HBV, yet < 18% received HBV antiviral therapy. While information modestly affects behaviors, order checks with treatment algorithms can be > 95% effective.
Methods: Since 2015, our team has shared information widely, updated pharmacy criteria for use, and enabled HBV antiviral prescribing by all providers. To identify HBV testing or treatment omissions, we launched a Medication Use Evaluation Tracker (MUET), and programmed an anti- CD20 Ab order check that displays only if either HBV testing or treatment has not been done.
Results: Since 2014, HBV testing in patients initiating anti-CD20 Ab increased to 64-78% and HBV antiviral prophylaxis from < 18% to 44%. In November 2016, an anti-CD20 Ab order check was piloted at 3 sites and functional in CPRS with additional sites reporting favorable use. Additionally, a MUET was released for anti-CD20 Ab therapies providing an additional safety check.
Conclusions: VHA has increased HBV testing and antiviral treatment with anti-CD20 antibody initiation—yet more than half of patients remain at risk of HBV reactivation. Successfully used in up to 15 sites, programmed anti-CD20 Ab order checks highlight to providers when HBV testing
or antiviral prophylaxis is needed. Achieving broad use of this order check will increase HBV prophylaxis prescribing and decrease subsequent HBV reactivation. An anti-CD20 Ab MUET provides an additional safety check option for identifying at risk patient.
A Multidisciplinary, Multicenter Partnership Model for Breast Health Care in Women Veterans
Purpose: To demonstrate Lean Process Improvement methodologies in a multidisciplinary, multicenter model to screen for increased risk of breast cancer in Women Veterans. We strive to deliver a team-based, cross-functional model that meets the unique healthcare needs of female Veterans and results in a Veteran-centric delivery of care.
Relevant Background/ Problem: Women are the fastest growing veterans population seeking care at the VA Health Administration (VHA). There is also an increased risk of breast cancer in Women Veterans. Based on national guidelines we are developing tools to promote the use of screening for high risk breast cancer and its prevention as well as other breast health issues.
Methods: A 9 institution, multidisciplinary team including oncology, surgery, nursing, pharmacy, biostatistics, genetic counseling, mental health, and health systems engineering was launched at the 2014 AVAHO annual meeting. Since then, the group has met every 2 weeks by conference call and has developed subcommittees focusing on International Review Board approval, data collection, grant writing, survey design, and strategic planning. We have developed tools to collect data, CPRS research notes, and a multiple choice questionnaire.
Results: As a result of combined efforts, currently 5 studies are being conducted: Know your breast cancer risk factors and prevention options-pilot program currently enrolling patients at 2 sites. The preliminary data will be presented at AVAHO. Chemoprevention in VHA system: A VINCI data review from 2000-2015 VINCI data review of prophylactic mastectomies at VHA from 2000-2015. Survey for Primary Care physicians regarding awareness of increased risk breast cancer screening and prevention options. Lean Process Improvement project to roll out a program to increase the use of CVT so that VAMCs may offer screening and primary prevention for high risk breast cancer. Additionally, we are offering genetic counseling and plan to improve adherence to chemoprevention through the use of CVT.
Implications/Future Directions: Lean Process Improvement may be an effective method to coordinate clinical care in high risk breast cancer screening and awareness. This process should be considered as a model throughout the VHA system to offer care in accordance with national guidelines for our Women Veterans.
Purpose: To demonstrate Lean Process Improvement methodologies in a multidisciplinary, multicenter model to screen for increased risk of breast cancer in Women Veterans. We strive to deliver a team-based, cross-functional model that meets the unique healthcare needs of female Veterans and results in a Veteran-centric delivery of care.
Relevant Background/ Problem: Women are the fastest growing veterans population seeking care at the VA Health Administration (VHA). There is also an increased risk of breast cancer in Women Veterans. Based on national guidelines we are developing tools to promote the use of screening for high risk breast cancer and its prevention as well as other breast health issues.
Methods: A 9 institution, multidisciplinary team including oncology, surgery, nursing, pharmacy, biostatistics, genetic counseling, mental health, and health systems engineering was launched at the 2014 AVAHO annual meeting. Since then, the group has met every 2 weeks by conference call and has developed subcommittees focusing on International Review Board approval, data collection, grant writing, survey design, and strategic planning. We have developed tools to collect data, CPRS research notes, and a multiple choice questionnaire.
Results: As a result of combined efforts, currently 5 studies are being conducted: Know your breast cancer risk factors and prevention options-pilot program currently enrolling patients at 2 sites. The preliminary data will be presented at AVAHO. Chemoprevention in VHA system: A VINCI data review from 2000-2015 VINCI data review of prophylactic mastectomies at VHA from 2000-2015. Survey for Primary Care physicians regarding awareness of increased risk breast cancer screening and prevention options. Lean Process Improvement project to roll out a program to increase the use of CVT so that VAMCs may offer screening and primary prevention for high risk breast cancer. Additionally, we are offering genetic counseling and plan to improve adherence to chemoprevention through the use of CVT.
Implications/Future Directions: Lean Process Improvement may be an effective method to coordinate clinical care in high risk breast cancer screening and awareness. This process should be considered as a model throughout the VHA system to offer care in accordance with national guidelines for our Women Veterans.
Purpose: To demonstrate Lean Process Improvement methodologies in a multidisciplinary, multicenter model to screen for increased risk of breast cancer in Women Veterans. We strive to deliver a team-based, cross-functional model that meets the unique healthcare needs of female Veterans and results in a Veteran-centric delivery of care.
Relevant Background/ Problem: Women are the fastest growing veterans population seeking care at the VA Health Administration (VHA). There is also an increased risk of breast cancer in Women Veterans. Based on national guidelines we are developing tools to promote the use of screening for high risk breast cancer and its prevention as well as other breast health issues.
Methods: A 9 institution, multidisciplinary team including oncology, surgery, nursing, pharmacy, biostatistics, genetic counseling, mental health, and health systems engineering was launched at the 2014 AVAHO annual meeting. Since then, the group has met every 2 weeks by conference call and has developed subcommittees focusing on International Review Board approval, data collection, grant writing, survey design, and strategic planning. We have developed tools to collect data, CPRS research notes, and a multiple choice questionnaire.
Results: As a result of combined efforts, currently 5 studies are being conducted: Know your breast cancer risk factors and prevention options-pilot program currently enrolling patients at 2 sites. The preliminary data will be presented at AVAHO. Chemoprevention in VHA system: A VINCI data review from 2000-2015 VINCI data review of prophylactic mastectomies at VHA from 2000-2015. Survey for Primary Care physicians regarding awareness of increased risk breast cancer screening and prevention options. Lean Process Improvement project to roll out a program to increase the use of CVT so that VAMCs may offer screening and primary prevention for high risk breast cancer. Additionally, we are offering genetic counseling and plan to improve adherence to chemoprevention through the use of CVT.
Implications/Future Directions: Lean Process Improvement may be an effective method to coordinate clinical care in high risk breast cancer screening and awareness. This process should be considered as a model throughout the VHA system to offer care in accordance with national guidelines for our Women Veterans.
Breast Cancer Risk Assessment and Utilization of Prevention Options Among Female Veterans: A Feasibility Pilot Study
Purpose: To increase the appropriate breast cancer risk quantification, utilization of chemoprevention, and genetic counseling among Women Veterans at high risk for breast
cancer in accordance with national guidelines.
Background/Rationale: There are over 2 million women who constitute the fastest growing segment of eligible veterans within the VHA. The number of women diagnosed with breast cancer has more than tripled from 1995 to 2012. Chemoprevention reduces the risk of breast cancer by 50-62% in high risk patients. An estimated 10 million women in the U.S. may be eligible, but fewer than 5% of high risk women are offered chemoprevention.
Methods: This is an ongoing feasibility pilot study being conducted at 2 VAMCs (“VAMC 1” and “VAMC 2”) with plans for expansion to 7 more VAMCs. Participants were enrolled at the time of their regular visit to Women’s Health Clinics. Eligibility criteria includes: women age ≥ 35 with no history of breast cancer. After completing a 20 multiple choice questionnaire, 5-year and lifetime risk of invasive breast cancer is calculated using the Gail risk tool (BCRAT). A woman is considered high risk and eligible for chemoprevention if her 5-year risk is ≥ 1.67% or her lifetime risk is ≥ 20%. Eligibility for genetic counseling is based on the Breast Cancer Referral Screening Tool (B-RST), which includes a personal or family history of breast or ovarian cancer and Jewish ancestry.
Results: 72 females (42 at “VAMC 1” and 30 at “VAMC 2”) were enrolled and completed the questionnaire. Of these patients, 17/42 (40%) and 6/30 (20%) had Gail score of > 1.66 and were considered high risk for breast cancer. All 23 females at both facilities had Oncology clinic consultations for chemoprevention. Only 1 female at each center accepted chemoprevention with tamoxifen (“VAMC 1”) and anastrazole (“VAMC 2”). Six patients had telehealth genetic counseling consults.
Implications/Future Directions: Increasing awareness of breast cancer risk status and utilization of prevention options is a critical element in our program to increase screening and provide chemoprevention according to national guidelines in the VHA. Future directions include tool development and national spread of screening efforts.
Purpose: To increase the appropriate breast cancer risk quantification, utilization of chemoprevention, and genetic counseling among Women Veterans at high risk for breast
cancer in accordance with national guidelines.
Background/Rationale: There are over 2 million women who constitute the fastest growing segment of eligible veterans within the VHA. The number of women diagnosed with breast cancer has more than tripled from 1995 to 2012. Chemoprevention reduces the risk of breast cancer by 50-62% in high risk patients. An estimated 10 million women in the U.S. may be eligible, but fewer than 5% of high risk women are offered chemoprevention.
Methods: This is an ongoing feasibility pilot study being conducted at 2 VAMCs (“VAMC 1” and “VAMC 2”) with plans for expansion to 7 more VAMCs. Participants were enrolled at the time of their regular visit to Women’s Health Clinics. Eligibility criteria includes: women age ≥ 35 with no history of breast cancer. After completing a 20 multiple choice questionnaire, 5-year and lifetime risk of invasive breast cancer is calculated using the Gail risk tool (BCRAT). A woman is considered high risk and eligible for chemoprevention if her 5-year risk is ≥ 1.67% or her lifetime risk is ≥ 20%. Eligibility for genetic counseling is based on the Breast Cancer Referral Screening Tool (B-RST), which includes a personal or family history of breast or ovarian cancer and Jewish ancestry.
Results: 72 females (42 at “VAMC 1” and 30 at “VAMC 2”) were enrolled and completed the questionnaire. Of these patients, 17/42 (40%) and 6/30 (20%) had Gail score of > 1.66 and were considered high risk for breast cancer. All 23 females at both facilities had Oncology clinic consultations for chemoprevention. Only 1 female at each center accepted chemoprevention with tamoxifen (“VAMC 1”) and anastrazole (“VAMC 2”). Six patients had telehealth genetic counseling consults.
Implications/Future Directions: Increasing awareness of breast cancer risk status and utilization of prevention options is a critical element in our program to increase screening and provide chemoprevention according to national guidelines in the VHA. Future directions include tool development and national spread of screening efforts.
Purpose: To increase the appropriate breast cancer risk quantification, utilization of chemoprevention, and genetic counseling among Women Veterans at high risk for breast
cancer in accordance with national guidelines.
Background/Rationale: There are over 2 million women who constitute the fastest growing segment of eligible veterans within the VHA. The number of women diagnosed with breast cancer has more than tripled from 1995 to 2012. Chemoprevention reduces the risk of breast cancer by 50-62% in high risk patients. An estimated 10 million women in the U.S. may be eligible, but fewer than 5% of high risk women are offered chemoprevention.
Methods: This is an ongoing feasibility pilot study being conducted at 2 VAMCs (“VAMC 1” and “VAMC 2”) with plans for expansion to 7 more VAMCs. Participants were enrolled at the time of their regular visit to Women’s Health Clinics. Eligibility criteria includes: women age ≥ 35 with no history of breast cancer. After completing a 20 multiple choice questionnaire, 5-year and lifetime risk of invasive breast cancer is calculated using the Gail risk tool (BCRAT). A woman is considered high risk and eligible for chemoprevention if her 5-year risk is ≥ 1.67% or her lifetime risk is ≥ 20%. Eligibility for genetic counseling is based on the Breast Cancer Referral Screening Tool (B-RST), which includes a personal or family history of breast or ovarian cancer and Jewish ancestry.
Results: 72 females (42 at “VAMC 1” and 30 at “VAMC 2”) were enrolled and completed the questionnaire. Of these patients, 17/42 (40%) and 6/30 (20%) had Gail score of > 1.66 and were considered high risk for breast cancer. All 23 females at both facilities had Oncology clinic consultations for chemoprevention. Only 1 female at each center accepted chemoprevention with tamoxifen (“VAMC 1”) and anastrazole (“VAMC 2”). Six patients had telehealth genetic counseling consults.
Implications/Future Directions: Increasing awareness of breast cancer risk status and utilization of prevention options is a critical element in our program to increase screening and provide chemoprevention according to national guidelines in the VHA. Future directions include tool development and national spread of screening efforts.
Opinions of Clinical Oncology Pharmacy Specialists on Utilization and Usefulness of National Criteria for Use Documents: A Quality Improvement Pilot Project
Purpose: To evaluate the utilization of national drug Criteria for Use documents for oncologic drugs in VHA.
Background: VHA National Pharmacy Benefits Management (PBM) has been developing Criteria for Use (CFU) documents for oncologic therapies since 2001. There is no formalized mechanism to track the utilization of these documents.
Methods: A sample of clinical oncology pharmacy specialists participated in an online survey of five questions regarding recollection of CFU use. A total of 23 active CFU documents were included: 11 for oral and 12 for injectable drugs. 5 questions focused on pharmacist’s recollection of the following: 1) general use of CFU documents as a reference in the past month; 2) use of particular CFU document(s) in the past month; 3) useful document(s); 4) useless document(s); and 5) specific subsections of outdated CFU that need to be updated.
Results: Nineteen pharmacists were surveyed. Responses were provided by 11 for a response rate of 58%. The majority (70%) recall using the ibrutinib CFU in the past month, followed by use of the abiraterone CFU (60%). On average, 36% recall referring to national CFU documents 3-5 times when evaluating drug orders, and 18% recall referring to them more than 5 times. The abiraterone CFU were considered to be useful by 50% of those surveyed. Both abiraterone and enzalutamide were ranked as useful documents (Q#3, n = 10) by 50%, followed by regorafenib and ibrutinib (each 40%). Aprepitant and capecitabine documents were considered to be no longer useful (Q#4, n = 6). When asked about specific areas of the CFU that are in need of update, the overwhelming majority of question responders (Q#5, n = 5) agreed that both Inclusion Criteria (100%) and Exclusion Criteria (80%) were the areas on which to focus. CFU documents for oral therapies were used more often, compared to the injectable therapies (34 vs 15%).
Implications: This pilot highlights variance in utilization and perceived usefulness of CFU documents. Expansion of this pilot with a larger sample size can help direct improvements to increase utilization.
Purpose: To evaluate the utilization of national drug Criteria for Use documents for oncologic drugs in VHA.
Background: VHA National Pharmacy Benefits Management (PBM) has been developing Criteria for Use (CFU) documents for oncologic therapies since 2001. There is no formalized mechanism to track the utilization of these documents.
Methods: A sample of clinical oncology pharmacy specialists participated in an online survey of five questions regarding recollection of CFU use. A total of 23 active CFU documents were included: 11 for oral and 12 for injectable drugs. 5 questions focused on pharmacist’s recollection of the following: 1) general use of CFU documents as a reference in the past month; 2) use of particular CFU document(s) in the past month; 3) useful document(s); 4) useless document(s); and 5) specific subsections of outdated CFU that need to be updated.
Results: Nineteen pharmacists were surveyed. Responses were provided by 11 for a response rate of 58%. The majority (70%) recall using the ibrutinib CFU in the past month, followed by use of the abiraterone CFU (60%). On average, 36% recall referring to national CFU documents 3-5 times when evaluating drug orders, and 18% recall referring to them more than 5 times. The abiraterone CFU were considered to be useful by 50% of those surveyed. Both abiraterone and enzalutamide were ranked as useful documents (Q#3, n = 10) by 50%, followed by regorafenib and ibrutinib (each 40%). Aprepitant and capecitabine documents were considered to be no longer useful (Q#4, n = 6). When asked about specific areas of the CFU that are in need of update, the overwhelming majority of question responders (Q#5, n = 5) agreed that both Inclusion Criteria (100%) and Exclusion Criteria (80%) were the areas on which to focus. CFU documents for oral therapies were used more often, compared to the injectable therapies (34 vs 15%).
Implications: This pilot highlights variance in utilization and perceived usefulness of CFU documents. Expansion of this pilot with a larger sample size can help direct improvements to increase utilization.
Purpose: To evaluate the utilization of national drug Criteria for Use documents for oncologic drugs in VHA.
Background: VHA National Pharmacy Benefits Management (PBM) has been developing Criteria for Use (CFU) documents for oncologic therapies since 2001. There is no formalized mechanism to track the utilization of these documents.
Methods: A sample of clinical oncology pharmacy specialists participated in an online survey of five questions regarding recollection of CFU use. A total of 23 active CFU documents were included: 11 for oral and 12 for injectable drugs. 5 questions focused on pharmacist’s recollection of the following: 1) general use of CFU documents as a reference in the past month; 2) use of particular CFU document(s) in the past month; 3) useful document(s); 4) useless document(s); and 5) specific subsections of outdated CFU that need to be updated.
Results: Nineteen pharmacists were surveyed. Responses were provided by 11 for a response rate of 58%. The majority (70%) recall using the ibrutinib CFU in the past month, followed by use of the abiraterone CFU (60%). On average, 36% recall referring to national CFU documents 3-5 times when evaluating drug orders, and 18% recall referring to them more than 5 times. The abiraterone CFU were considered to be useful by 50% of those surveyed. Both abiraterone and enzalutamide were ranked as useful documents (Q#3, n = 10) by 50%, followed by regorafenib and ibrutinib (each 40%). Aprepitant and capecitabine documents were considered to be no longer useful (Q#4, n = 6). When asked about specific areas of the CFU that are in need of update, the overwhelming majority of question responders (Q#5, n = 5) agreed that both Inclusion Criteria (100%) and Exclusion Criteria (80%) were the areas on which to focus. CFU documents for oral therapies were used more often, compared to the injectable therapies (34 vs 15%).
Implications: This pilot highlights variance in utilization and perceived usefulness of CFU documents. Expansion of this pilot with a larger sample size can help direct improvements to increase utilization.