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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 1  |  Issue : 1  |  Page : 6-12

Expert-Based strategies to improve access to cancer therapeutics at the hospital level


1 Department of Oncology, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Science, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
2 Department of Pharmacy, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
3 Drug Policy and Economics Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
4 Department of Pharmacy, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
5 Department of Oncology, King Khalid University Hospital, Riyadh, Saudi Arabia
6 Department of OB and GYN, Certified Breast Cancer Center, Certified Cancer Center, Certified Endometriosis Center, Certified Dysplastic Unit, AGAPLESION Markus Krankenhaus, Frankfurt, Germany

Date of Web Publication10-Jul-2018

Correspondence Address:
Abdul Rahman Jazieh
Department of Oncology, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JQSH.JQSH_4_18

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  Abstract 


Background: Challenges related to access to cancer medications is an increasing global problem that has far-reaching impact on patients and healthcare systems. In this article, we are enlisting suggested solutions at the hospital or practice level to maximize the access to these important treatment modalities. Methods: An expert panel of practicing oncologists, clinical pharmacists, and health economists convened using a framework approach. The panelists identified individuals and entities that impact the use of cancer therapeutics and how they can improve the utilization and access to them. They enlisted the potential actions that hospital management and staff can take to enhance access to cancer therapeutics, then they grouped them into specific categories. Results: List of potential strategies and related action items were compiled into different categories including hospital leadership, drug evaluation entities, pharmacy, physicians, patients and families, and other parties. Recommendations included various actions to be considered by each group to achieve set goals. Conclusion: Our expert panel recommend multiple strategies and approaches to reduce the cost of cancer medications and improve patients' access to them. These recommendations can be adapted by the decision-makers and staff of the hospitals to their own settings and the current circumstances.

Keywords: Access to cancer therapeutics, cancer, cancer medications, cost of cancer care


How to cite this article:
Jazieh AR, Ibrahim N, Abdulkareem H, Maraiki F, Alsaleh K, Thill M. Expert-Based strategies to improve access to cancer therapeutics at the hospital level. Glob J Qual Saf Healthc 2018;1:6-12

How to cite this URL:
Jazieh AR, Ibrahim N, Abdulkareem H, Maraiki F, Alsaleh K, Thill M. Expert-Based strategies to improve access to cancer therapeutics at the hospital level. Glob J Qual Saf Healthc [serial online] 2018 [cited 2018 Dec 19];1:6-12. Available from: http://www.jqsh.org/text.asp?2018/1/1/6/236324




  Introduction Top


The cost of cancer care is rising significantly, similar to other healthcare sectors. There are many reasons for increasing the economic burden of cancer including hospital admissions, hospital visits, loss of productivity, cost of medications, and cost of cancer care.[1],[2] Cancer medications are very expensive and continue to increase exponentially.[3],[4] The cost of these medications became so prohibitive that many countries cannot afford the incoming large number of new and expensive cancer medications.[5],[6] The high cost of cancer care has been discussed and explored by many experts in the past. Reasons could be summarized within high cost of drug development, lack of true generic price check, the seriousness of the disease, the high cost of generic cancer drugs compared to those used in nonmalignant diseases, the incentive for more chemotherapy, lack of thresholds for clinical benefit, and more.[7],[8] The impact of high cost for medication is not only limited to the financial/economical impact on individuals or societies but also it may be detrimental to patient care in different ways, mainly due to the lack of access of this medications. The financial toxicity to the patients may prevent them from getting the prescribed treatment.

There are many plans and proposals to reduce the cost of medications with variable distribution of responsibilities from the pharmaceutical industry, regulatory agencies, health technology agencies, professional societies, patients' advocacy group, and healthcare professionals. Improving access to quality cancer therapy cannot be attributed to only one stakeholder. It is the responsibility of all stakeholders in the oncology ecosystem including drug manufacturers, providers, policymakers, and patient organizations. We have to call on each one to incorporate so that together we can provide high-quality cancer care.[7],[8] Regulations, strategies with clear policies, procedures, and guidelines at the national and institutional level are essential.

In this article, we enlisted various stakeholders involved in access to cancer therapeutics to determine how to can improve the access while controlling the cost at the hospital level.


  Methods Top


A team of oncology experts was assembled including senior oncologists (Abdul Rahman Jazieh, Khalid AlSaleh, and Marc Thill), pharmacists (Nagwa Ibrahim and Fatma Maraiki), and health economists (Hana Abdulkareem and Fatma Maraiki). The team members have extensive clinical, administrative, and health economics experience.

A framework analysis method was used to address the issue of access to cancer therapeutics at a hospital level.[9]

The expert panel responded to two open-ended questions:

Who is involved in acquiring, prescribing, dispensing, and using cancer medications? The second question was, what are the potential actions that these entities can take to strike a balance between improving patient's access to best evidence-based therapeutics and the significant financial impacts of these medications.

Data were collected from the panelists, and the involved entities were divided into specific categories. Potential action steps of each group were listed also and grouped into categories. Then, the panelists received the final recommendations. Although data were collected from the experts based on their own institution experience, obtaining supporting evidence from the literature was sought subsequently.


  Results Top


The panelists identified six categories of individuals/entities who can impact the use of cancer medications including hospital leadership, pharmaceutical and therapeutic committee, pharmacy, physicians, patients and families, and others. All potential actions of each group are listed and explained in [Table 1].
Table 1: Access to quality cancer therapeutic at a hospital level

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Hospital leadership

Hospital leadership plays an important role in improving access to medications wherein the aim is to provide the best care to the patient while saving money. The strategy, vision, and mission of the organization should dictate the priority of the optimal allocation of resources and budget management.

The hospital leadership should allocate the budget and resources for medications in a very structured way. The first step is to instruct end-users (department level) to request medication and justify their medication needs. Budget allocation should be based on the mission of the hospital and type of facility services, secondary or tertiary care. Evaluation of new medication should include other medications, new technology, and new therapy for comparison.

The hospital leadership has critical roles in controlling access to quality cancer medication for many reasons. We will discuss various components that leadership can work on to achieve these goals.

Strategy

  • Make strategic decisions and plans to be a value-driven organization. This will assure providing the best care while considering the cost-benefit balance. This will require setting priorities and assessing the whole process of cancer care, not only the cost of medications.
  • Evaluate all types of care provided to patients, such as diagnostic and therapeutic procedures and interventions, in addition to reviewing the work process and the attained outcome.
  • Make sure that all staff understands and buy into these concepts, so they can participate and contribute to the success of this strategy.
  • The leadership has to understand the special requirements and needs for cancer patients and put these needs into proper perspective.[10]


Budget allocations for cancer patients

There is no system, organization, or even a country that has infinite resources for the many competing needs for different patient populations. Therefore, a systematic approach is needed to tackle the budgeting issues and save scarce resources. Suggested guiding principles for budget allocations are as follows:

  • Emphasize the personalized medicine approach, where the right patient gets the right treatment. Precision medicine will pay off if utilized properly. It can improve patient outcomes and reduce the cost by limiting the unnecessary cost of treating nonresponders.[11]
  • Invest in prevention and screening programs with the coordination with the national and community entities based on hospital setting and eligible patients and other variables.[12]
  • Use the input of subspecialty physicians and consider the alternative treatment modalities for the disease
  • Establish a disease registry as plans built on actual data, not on assumptions, are more likely to be considered for budget allocation. Physicians can use a scoring system or benchmarking system for the registry.
  • Consider various methods of allocations including leaving access open for competition among various disciplines or allocate budget per disease group and let the discipline teamwork within their allocated budget.
  • Consider devices/tools and procedures in managing cancer patients, such as regional therapies and others.
  • Consider new emerging technologies/innovation in assessing new therapeutics, such as next gene sequencing, liquid biopsy, or any tests that help select the patients who are likely to benefit or local therapies such as stereotactic radiosurgery and others.


Enforcing evidence-based medicine

  • Create a system to adapt, implement, and monitor international guidelines and best practices.[13],[14],[15],[16]
  • Build capacity in evidence-based medicine (EBM). Learning guidelines adaptation is an essential skill that should be acquired by professionals in an organization that treats cancer patients. No matter how well done the national and international guidelines are, the local setting will vary, mandating the need for adapting these guidelines to the local setting. This will help in streamlining the treatment choices based on availabilities and priorities set by the organization. An example of how to adapt guidelines is published and can be used as a template for adapting other guidelines.[17]
  • Adapting guidelines is not enough unless it is accompanied by a rigorous plan of implementation and monitoring with timely feedback and corrective actions.


Building infrastructure for proper drug evaluation

  • Evaluating medications is a complex process that requires expertise and commitment of staff and resources. Historically, this task is performed by the institutional pharmacy and therapeutic committees.
  • These committees should undergo major transformation in their structure and process. They should include health and pharmaco-economics experts who will be able to do proper cost-effectiveness analysis. Involvement of the specialty experts in the discussion is paramount to bring a perspective from the frontline and end user.
  • Establishing an oncology pharmaceutical and therapeutics (PandT) sub-committee may be required in large tertiary cancer centers. This sub-committee will do more specialized drug evaluations and bring final recommendations to the general PandT committee.
  • The process for doing evaluations should be clear on how to request, review, evaluate, approve, and follow-up.
  • The evaluation process should be delivered clearly, and a well-defined framework of approving drugs should be defined including what would be acceptable or would not.


Establish disease registry/data

  • The plan should be based on actual data not assumption, and therefore, it is critical to have accurate data about the number and types of cancer cases managed at the facility and type of treatment required.
  • Patient management and outcomes should be benchmarked against international data such as the American Society of Clinical Oncology Quality Oncology Practice Initiative (ASCO QOPI) or Surveillance, Epidemiology and End Results data.[16],[18],[19],[20]


Education

  • Ownership of the idea of conserving resources is important for staff compliance and cooperation with the principles of cost-effectively. Understanding, how the decisions are made will increase the awareness of the staff and enhance their participation in various initiatives.


Pharmaceutical and therapeutics committee

Evaluation of drugs is very challenging, especially for the purpose of assessing their benefit to the patients and the economic impact on the hospital. Depending on the size of oncology service, there should be a dedicated entity, like a PandT subcommittee for oncology, to help in evaluating the cost-effectiveness and EBM of medications.[10],[21] The committee's role is to evaluate new medications, selection of medications, and approval of medications that are needed and monitor their use.

Establish an oncology-specific subcommittee

Establishing an oncology-specific subcommittee will enable the clinicians to weigh in the decision, as they are the front-line staff who are dealing with the patients and have a better grasp and feeling of the impact of the treatment on patient outcomes. They understand the whole disease impact and the available alternatives. This subcommittee will address all issues related to oncology medications, such as full clinical and economic evaluation, and guidelines for prescription and monitoring and delisting.

Establish policies and procedures

Establish clear policies and procedures for the function of the committee including the composition of the committee, which should include practicing oncologists, clinical pharmacists, and experts in health and pharmaco-economics and EBM. The process for selecting, evaluating, and approving medications should be clear. Monitoring the utilization also should be addressed.

Referral process of medications

There are multiple ways a medication is referred for review to be added to the formulary, these include:

  • Scan horizon by looking for newly approved drugs or innovative treatments and request adding them.
  • Request by individual practitioner based on emerging data in the most common scenario.
  • In rare occasions, leaders may request medications or treatment modality based on news or patients request or strategic decision.


Medication selection and approval

  • There should be the clear adoption of a particular framework, such as ASCO, European Society of Medical Oncology, National Comprehensive Cancer Network, or others to evaluate medication.[17],[22],[23],[24]
  • Consider alternatives such as biosimilar or generics.[25]


Price negotiation

There are multiple approaches to get a discounted price on medications dependent on the indication, the benefits, and the availabilities of other options (competitors). One of the basic requirements is to have a system of interacting with suppliers in open and transparent way and be able to interact directly with them to negotiate the best deals. A risk-sharing approach is usually welcome by many major pharmaceutical companies, and it may take different approaches.

Direct discount is the first step, especially if the evaluation revealed the lack of cost-effectiveness of a particular medication. The hospital may get further discounts or risk sharing for other products that are already on the formulary, which will result in cost savings that can be utilized to get more products.

Enforce patient education and public awareness

Education of patients and public awareness may help in many ways to address issues related to access, such as understanding that not all medications available in the market will be suitable for them and alternatives should be discussed with them to make a choice. Patient advocacy groups may help facilitate access to medication through policymakers.[26]

Monitoring

The addition of medication to the formulary, even for use as a nonformulary, should be monitored by the organization to make sure that the medication is used per indications and for the right patients.

Delisting

There should be a regular systematic review of the formulary to delist the unused medications and unneeded medications that were replaced by better medications. This may require a class review to determine the best choices for the institution, such as tyrosine kinase inhibitors in lung cancer.

Pharmacy

Pharmacy staff play a major role in providing quality access to cancer medication and contributing to cost savings, including the following.

Monitoring utilization/medication control

  • Adhere to clinical guidelines and algorithm and capture any new deviation from the guidelines.
  • Report deviations to the leadership of the department and devise plans to address them.


Managing inventory/supply chain

This ranges from selecting the right vendors and requesting the right amount of drug to monitoring inventory and shelf life of medications.

Minimize waste

  • There should be access to a policy on dispensing medication and avoid waste.
  • Monitor waste systematically and implement quality projects to reduce waste.


Exchange program

  • Establish agreement with other hospitals to share expensive or rarely used medication or medication needed with short supply.


Control refills

  • The pharmacy should dispense a supply for one cycle only and request patients to bring back leftover or empty boxes to be reviewed and assure adherence to treatment.


Ensure education

  • Counsel patients and their families about the proper use of medications, the importance of proper storage, and the importance of returning all remaining medicines.


Physicians

Physicians are the main gatekeepers in the utilization of cancer medications, as they are the ones who will have the clinical expertise and the responsibility to discuss with patients their treatment options and then prescribe them. Physicians should be supportive of cost-effectiveness data use.[27]

Adhering to guidelines

  • Internationally accepted guidelines should be adapted to the hospital setting in a multidisciplinary fashion to assure selection of the best choice for their settings. The guidelines and pathways should be implemented and monitored to assure adherence to these guidelines.


Encourage delisting

  • When requesting the new addition of a medication, a decision about existing medication should be made and encouraged to eliminate redundancy.


Do proper clinical trials

  • Clinical trials are one ways to have access to new agents and should participation be encouraged. However, marketing studies with no added value should be avoided.
  • Clear policy and agreement regarding post-trial access to medications should be addressed.


Patients and families

Having educational training, information sharing, and counseling of the patient and families will be very helpful in the access to medications.

    Proper use of medication


  • Ensuring the education of the patients and families about the goals of care and the proper use of medication can lead reduce waste. Encouraging patients to bring the leftovers will help evaluate compliance and can also help other patients in need based on the specific medications and existing policies.


  • Make your voice heard (advocacy)

    • The patient representative should have a say in the process of obtaining certain medication and also contribute to the societal debate about the distribution of healthcare resources and services/medication made available to patients.
    • Patients and families should be advised to raise their concerns about medications through the proper channels.


    Pharmacovigilance

    Establishing pharmacovigilance in the institution by creating a hotline or mobile application for the patient and healthcare provider to use is a good way of accessing the information related to management, indication, and medication prescription.


      Conclusion Top


    Access to quality cancer therapeutics requires a multilevel, multidiscipline approach to optimize the results. This article will serve as a guide for these individuals and entities. The roles of each stakeholder are listed, and having a comprehensive approach will assure better utilization of these recommendations.

    Recommendations

    The expert panel recommends that facilities that offer cancer treatment should assemble a team from stakeholders and decision-makers listed in this article to review all suggested interventions and adapt what is appropriate to their own setting and circumstances.

    Monitoring certain indications and key performance indicators for each major activity are important to assure continuous improvement and containment of the expenditure.

    Financial support and sponsorship

    The authors disclosed no funding related to this study.

    Conflicts of interest

    The authors disclosed no conflicts of interest.



     
      References Top

    1.
    Kolodziej M, Hoverman JR, Garey JS, Espirito J, Sheth S, Ginsburg A, et al . Benchmarks for value in cancer care: An analysis of a large commercial population. J Oncol Pract 2011;7:301-6.  Back to cited text no. 1
        
    2.
    Sullivan R, Peppercorn J, Sikora K, Zalcberg J, Meropol NJ, Amir E, et al . Delivering affordable cancer care in high-income countries. Lancet Oncol 2011;12:933-80.  Back to cited text no. 2
        
    3.
    Light DW, Kantarjian H. Market spiral pricing of cancer drugs. Cancer 2013;119:3900-2.  Back to cited text no. 3
        
    4.
    Kantarjian H, Steensma D, Rius Sanjuan J, Elshaug A, Light D. High cancer drug prices in the United States: Reasons and proposed solutions. J Oncol Pract 2014;10:e208-11.  Back to cited text no. 4
        
    5.
    Luengo-Fernandez R, Leal J, Gray A, Sullivan R. Economic burden of cancer across the European Union: A population-based cost analysis. Lancet Oncol 2013;14:1165-74.  Back to cited text no. 5
        
    6.
    Lopes Gde L Jr., de Souza JA, Barrios C. Access to cancer medications in low – And middle-income countries. Nat Rev Clin Oncol 2013;10:314-22.  Back to cited text no. 6
        
    7.
    Siddiqui M, Rajkumar SV. The high cost of cancer drugs and what we can do about it. Mayo Clin Proc 2012;87:935-43.  Back to cited text no. 7
        
    8.
    Marsland T, Robbins G, Marks A, Cassell R, Philips DG, King K, et al . Reducing cancer costs and improving quality through collaboration with payers: A proposal from the Florida society of clinical oncology. J Oncol Pract 2010;6:265-9.  Back to cited text no. 8
        
    9.
    Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol 2013;13:117.  Back to cited text no. 9
        
    10.
    Tyler LS, Cole SW, May JR, Millares M, Valentino MA, Vermeulen LC Jr., et al . ASHP guidelines on the pharmacy and therapeutics committee and the formulary system. Am J Health Syst Pharm 2008;65:1272-83.  Back to cited text no. 10
        
    11.
    Shomron N. Prioritizing personalized medicine. Genet Res (Camb) 2014;96:e007.  Back to cited text no. 11
        
    12.
    Cohen JT, Neumann PJ, Weinstein MC. Does preventive care save money? Health economics and the presidential candidates. N Engl J Med 2008;358:661-3.  Back to cited text no. 12
        
    13.
    Zon RT, Frame JN, Neuss MN, Page RD, Wollins DS, Stranne S, et al . American society of clinical oncology policy statement on clinical pathways in oncology. J Oncol Pract 2016;12:261-6.  Back to cited text no. 13
        
    14.
    Greenhalgh J, Dwan K, Boland A, Bates V, Vecchio F, Dundar Y, et al. First-line treatment of advanced epidermal growth factor receptor (EGFR) mutation positive non-squamous non-small cell lung cancer. The Cochrane Library 2016.  Back to cited text no. 14
        
    15.
    Jazieh AR, Jaafar H, Jaloudi M, Mustafa RS, Rasul K, Zekri J, et al . Patterns of epidermal growth factor receptor mutation in non-small-cell lung cancers in the Gulf region. Mol Clin Oncol 2015;3:1371-4.  Back to cited text no. 15
        
    16.
    Gerber DE, Gandhi L, Costa DB. Management and future directions in non-small cell lung cancer with known activating mutations. Am Soc Clin Oncol Educ Book 2014;34:e353-65.  Back to cited text no. 16
        
    17.
    Jazieh AR, McClure JS, Carlson RW. Implementation framework for NCCN guidelines. J Natl Compr Canc Netw 2017;15:1180-5.  Back to cited text no. 17
        
    18.
    Dangi-Garimella S. QOPI, the ASCO initiative, improves compliance and promotes quality of patient care. Am J Manag Care 2014;20:E1.  Back to cited text no. 18
        
    19.
    Jacobson JO, Neuss MN, Hauser R. Measuring and improving value of care in oncology practices: ASCO programs from quality oncology practice initiative to the rapid learning system. Am Soc Clin Oncol Educ Book 2012; p.e70-6.  Back to cited text no. 19
        
    20.
    Travis WD, Brambilla E, Noguchi M, Nicholson AG, Geisinger KR, Yatabe Y, et al . International association for the study of lung cancer/American thoracic society/european respiratory society international multidisciplinary classification of lung adenocarcinoma. J Thorac Oncol 2011;6:244-85.  Back to cited text no. 20
        
    21.
    Holloway K, Green T, World Health Organization. Drug and therapeutics committees: A practical guide.  Back to cited text no. 21
        
    22.
    Cherny NI, Dafni U, Bogaerts J, Latino NJ, Pentheroudakis G, Douillard JY, et al . ESMO-magnitude of clinical benefit scale version 1.1. Ann Oncol 2017;28:2340-66.  Back to cited text no. 22
        
    23.
    Schnipper LE, Bastian A. New frameworks to assess value of cancer care: Strengths and limitations. Oncologist 2016;21:654-8.  Back to cited text no. 23
        
    24.
    Schnipper LE, Davidson NE, Wollins DS, Tyne C, Blayney DW, Blum D, et al . American society of clinical oncology statement: A Conceptual framework to assess the value of cancer treatment options. J Clin Oncol 2015;33:2563-77.  Back to cited text no. 24
        
    25.
    American Society of Clinical Oncology. American society of clinical oncology position statement on addressing the affordability of cancer drugs. J Oncol Pract 2018;14:187-92.  Back to cited text no. 25
        
    26.
    Borman P, Yaman A, Yasrebi S, Özdemir O. The importance of awareness and education in patients with breast cancer-related lymphedema. J Cancer Educ 2017;32:629-33.  Back to cited text no. 26
        
    27.
    Berry SR, Bell CM, Ubel PA, Evans WK, Nadler E, Strevel EL, et al . Continental divide? The attitudes of US and Canadian oncologists on the costs, cost-effectiveness, and health policies associated with new cancer drugs. J Clin Oncol 2010;28:4149-53.  Back to cited text no. 27
        



     
     
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