Patil, V.M., Noronha, V., Joshi, A., Ramaswamy, A., Gupta, S., Sahu, A., . . . Prabhash, K. (2017). Adherence to and implementation of ASCO antiemetic guidelines in routine practice in a tertiary cancer center in India. Journal of Oncology Practice, 13, e574–e581.

To evaluate adherence to ASCO guidelines and to improve quality of antiemetic prescriptions.

An initial audit of 1,211 consecutive prescriptions for adult patients with solid tumors receiving outpatient chemotherapy were characterized based on consistency with ASCO guidelines.  

• Adherent to CINV prophylaxis
• Overadherent to guideline with addition of an additional antiemetic.  
• Nonadherent with two criteria identified: major deviation if the regimen had omitted an antiemetic either totally or in part, minor deviation if all appropriate medications utilized, but at lower than recommended dosing.

If a patient vomited, they were classified as having CINV if this occurred within five days after completion of chemotherapy and there was no other causation. Education was offered to clinicians regarding results of the audit. Review of the antiemetic policy was revised according to ASCO guidelines. A second audit occurred and included 201 patients.

• N: 1,211 prescriptions for antiemetics for adult patients with solid tumors between July and August 2015. This was repeated with another 201 prescriptions between September and October 2016.
• AGE: 18 to older than 60
• MALES: 49.5%  
• FEMALES: 50.5%
• CURRENT TREATMENT: Chemotherapy, combination radiation and chemotherapy
• KEY DISEASE CHARACTERISTICS: Head and neck cancer, 183 (15.1%); ovarian, 197 (16.3%); lung, 132 (10.9%); gall bladder, 128 (10.6%); rectum, 124 (10.3%); cervix, 100 (8.2%); stomach, 77 (6.3%); colon, 57 (4.7%); esophagus, 27 (2.2%); prostate, 25 (2.1%); urinary bladder, 17 (1.4%); sarcoma, 11 (0.9%); endometrium, 10 (0.8%); and other, 123 (10.2%)
• OTHER KEY SAMPLE CHARACTERISTICS: Antiemetic potential: High, 404 (33.4%); moderate, 586 (48.4%); low, 220 (18.2%); minimal, 1 (0.1%). Chemotherapy regimen: only chemotherapy, 1,005 (83%); single drug, 223 (35.4%); combination, 782 (64.6%). Chemotherapy: concurrent with radiation, 206 (17%); single drug, 183 (15.1%); combination, 23 (1.9%).

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: Tertiary Cancer Center in India

• PHASE OF CARE: Active anti-tumor treatment
• APPLICATIONS: Elder care, palliative care

Retrospective study

Measuring incidence of vomiting, emergency visits, and hospitalizations using Descriptive statistics and Fisher exact test

Patient incidence of CINV with adherence to guidelines had a lower rate of vomiting, 6.6% versus 21.9% (p < 0.001), emergency visits, 2.6% versus 5.8%, p = 0.006 and hospitalization for emesis, 0.9% versus 4.9%, p < 0.001. In ASCO adherent guidelines, the proportion of prescriptions at initial audit was 63.6% and at reassessment was 98.5% (p < 0.001). Proportion of overuse was 41.3% at re-audit, and 68.3% before the intervention (p = 0.001). Post-audit intervention included education of providers regarding guideline and policy.

• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)

Use of guidelines enhances patient outcomes by significantly reducing the occurrence of CINV. Use of semi-rigid corrective actions lead to substantial improvement in adherence rates at this institution. This study demonstrates the importance of using guidelines in clinical care.