Affronti, M.L., Schneider, S.M., Herndon II, J.E., Schlundt, S., & Friedman, H.S. (2014). Adherence to antiemetic guidelines in patients with malignant glioma: A quality improvement project to translate evidence into practice. Supportive Care in Cancer, 22, 1897–1905.

DOI Link

Study Purpose

To determine if the intervention used would increase adherence to National Comprehensive Cancer Network (NCCN), Multinational Association of Supportive Care in Cancer, and American Society of Clinical Oncology guidelines in patients receiving moderately emetogenic chemotherapy (MEC) for glioma

Intervention Characteristics/Basic Study Process

This quality improvement project implemented evidence-based order sets for patients with malignant glioma receiving MEC. Order sets were based on NCCN guidelines recommending palonosetron and dexamethasone for the prevention of acute and delayed chemotherapy-induced nausea and vomiting (CINV). A secondary aim of this study was to maximize prescribers’ adherence to the order sets. Interventions consisted of a provider education program on NCCN antiemetic guidelines, the implementation of standardized order sets to manage acute and delayed CINV including a risk-assessment tool, and a monthly audit feedback strategy.

Sample Characteristics

N = 14 providers, 36 patients
AGE = Not provided
MALES: 36%, FEMALES: 64%
KEY DISEASE CHARACTERISTICS: Included six physicians and eight APNs who ordered antiemetics; all patients had glioma and were receiving at least moderately emetogenic chemotherapy
OTHER KEY SAMPLE CHARACTERISTICS: Median clinical experience was 6.5 years with a range of 1–31 years. Providers were trained in neurology (n = 7) or oncology (n = 7).

Setting

SITE: Single site
SETTING TYPE: Outpatient
LOCATION: Duke University Preston Robert Tisch Brain Tumor Center

Phase of Care and Clinical Applications

PHASE OF CARE: Active antitumor treatment

Study Design

One-sample, binomial, quasi-experimental design measuring pre- and postintervention data for adherence and patient outcomes

Measurement Instruments/Methods

The retrieval of providers’ computerized prescriptive records and existing assessment tools was used to assess patient CINV rates and quality of life. The CINV complete response rate (CR) for both acute and delayed phases was defined as no emetic episode and no use of rescue medication. CINV CR was defined as no vomiting or use of medication for vomiting, and CINV CR as absence of need for medication for nausea.
Osoba survey for quality of life
Functional Assessment of Chronic Illness Therapy–Brain (FACIT–B)
Functional Assessment of Chronic Illness Therapy–Fatigue (FACIT–F)
Adherence was defined as the ratio of antiemetic orders with palonosetron and dexamethasone to total orders.

Results

Providers used standardized order sets more often, which was associated with fewer patient reports of nausea and vomiting. Of 61 orders, adherence to guidelines was seen in 58%. Over time, adherence ultimately increased to 92%. There was a significant increase in acute (p < 0.05, 75% CR) and delayed (p < 0.05, 84% CR) CINV rates. Nausea was less controlled, and CR rates for nausea only improved by 3%–4%. No significant changes in quality of life were identified.

Conclusions

Patients with improved adherence also reported less nausea and vomiting and better quality of life.

Limitations

Small sample (< 100)
Risk of bias (no control group)
Risk of bias (no random assignment)
Findings not generalizable
Other limitations/explanation: There was no discrimination for duplicate data (same provider writing orders for same patients on multiple visits).

Nursing Implications

These findings supported the use of standardized order sets for all prescribers, including nurses, who order antiemetics for patients receiving chemotherapy within a single institution. It also supports using NCCN guidelines (specifically palonosetron and dexamethasone recommendations) for patients with malignant gliomas receiving moderately emetogenic chemotherapies.