Institutional Initiatives

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

• 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).

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

• PHASE OF CARE: Active antitumor treatment

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

• 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.

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.

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

• 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).

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.

To determine whether an intervention could improve antiemetic guideline adherence and the control of chemotherapy-induced nausea and vomiting (CINV)

Evidence-based antiemetic medication information was provided as notification to physicians in a view format. The description of the intervention was not clear, and it was presumed that the notification was provided in some manner through the electronic medical record system. CINV control after the intervention was compared to CINV control in a cohort of patients treated prior to the intervention.

• N = 125 (64 in intervention group)
• MEAN AGE = 64.2 years
• MALES: 71%, FEMALES: 29%
• KEY DISEASE CHARACTERISTICS: All patients had colorectal cancer and were receiving moderately emetogenic chemotherapy.

• SITE: Single site  
• SETTING TYPE: Outpatient    
• LOCATION: Japan

• PHASE OF CARE: Active antitumor treatment

Cohort comparison

• Complete protection in the acute and delayed periods was defined as no vomiting and protection from nausea.

The dosage of oxaliplatin or irinotecan was higher in the intervention group (p < 0.01). In the observational group, adherence to guidelines was 100% in the acute phase and 6.6% in the delayed phase. Nonadherence was caused by the lack of a prescription of dexamethasone on days 2 and 3. After the intervention, adherence to the administration of dexamethasone was 89%. In the intervention group, the complete protection rate was 20% higher after the intervention (p < 0.05), but adherence during the acute phase dropped and was significantly lower in the intervention group (p < 0.01). The incidence of leukopenia was higher in the intervention group (42.2% versus 23%, p = 0.024). There were no other differences in toxicity.

The intervention used in this study had mixed results in terms of adherence to CINV antiemetic guidelines and control of CINV in acute and delayed phases.

• Small sample (< 100)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Key sample group differences that could influence results
• Measurement validity/reliability questionable
• Other limitations/explanation: The intervention group was significantly older. The exact intervention was not well described. The definition and method of measurement of CINV outcomes were not well described.

In this study, an organizational intervention had mixed results in improving adherence to antiemetic guidelines and patient CINV outcomes. The findings were limited by the lack of detail regarding the specific intervention used, but it appears to have been a notification in the medical record with no other action. Organizational initiatives to improve practice are not all created equally, and such studies need to provide sufficient detail about the actual intervention to determine if approaches that are effective in creating practice changes and improvements in patient outcomes.