title: Reduction of Inappropriate Prophylactic Pegylated Granulocyte Colony-Stimulating Factor Use for Patients With Non-Small-Cell Lung Cancer Who Receive Chemotherapy: An ASCO Quality Training Program Project of the Cleveland Clinic Taussig Cancer Institute.
abstract: OBJECTIVE
  Routine prophylactic pegylated granulocyte colony-stimulating factor (pGCSF) administration for patients receiving chemotherapy regimens associated with low risk (< 10%) for neutropenic fever (LRNF) is not recommended. Inappropriate use of pGCSF increases patient morbidity and health care costs.
  
  
  METHODS
  A multidisciplinary team reviewed the charts of patients with non-small-cell lung cancer (NSCLC) at the Taussig Cancer Institute in whom a new chemotherapy regimen was initiated from April through November 2013. pGCSF use was identified and deemed appropriate if prescribed for chemotherapy associated with high risk of neutropenic fever (> 20%) or intermediate risk (10% to 20%) if other risk factors for neutropenic fever were present. Use with LRNF chemotherapy was recorded as inappropriate.
  
  
  RESULTS
  One hundred eighty patients with NSCLC received a new chemotherapy regimen during the specified time period. Thirty-four of 119 patients (28%) treated with LRNF chemotherapy received pGCSF. Each patient received an average of 2.6 doses of pGCSF (total, 89 doses). We implemented three plan-do-study-act cycles: education of providers, development of Taussig Cancer Institute consensus guidelines for pGCSF in NSCLC, and removal of standing pGCSF orders from LRNF chemotherapy in the electronic medical record. Analysis during the change period revealed 4% of patients with NSCLC treated with LRNF chemotherapy received pGCSF. Cost analysis showed an 84% decrease in billed charges per month. No increase in neutropenic fever admissions was found.
  
  
  CONCLUSIONS
  pGCSF was excessively prescribed for patients with NSCLC. Factors contributing to inappropriate use included provider lack of familiarity with guidelines and knowledge with regard to the risk of neutropenic fever for individual chemotherapy regimens, and electronic medical record chemotherapy templates that contain standing GCSF orders. Interventions to address these gaps quickly produced improved compliance with guidelines and led to significant cost savings.
authors.affiliation: Cleveland Clinic, Cleveland, OH; and Dana-Farber Cancer Institute, Boston, MA goodmal2@ccf.org.
authors.forename: Lindsey Martin
authors.initials: LM
authors.lastname: Goodman
authors.affiliation: Cleveland Clinic, Cleveland, OH; and Dana-Farber Cancer Institute, Boston, MA.
authors.forename: Machelle B
authors.initials: MB
authors.lastname: Moeller
authors.affiliation: Cleveland Clinic, Cleveland, OH; and Dana-Farber Cancer Institute, Boston, MA.
authors.forename: Abdel-Ghani
authors.initials: AG
authors.lastname: Azzouqa
authors.affiliation: Cleveland Clinic, Cleveland, OH; and Dana-Farber Cancer Institute, Boston, MA.
authors.forename: Amy E
authors.initials: AE
authors.lastname: Guthrie
authors.affiliation: Cleveland Clinic, Cleveland, OH; and Dana-Farber Cancer Institute, Boston, MA.
authors.forename: Carole K
authors.initials: CK
authors.lastname: Dalby
authors.affiliation: Cleveland Clinic, Cleveland, OH; and Dana-Farber Cancer Institute, Boston, MA.
authors.forename: Marc A
authors.initials: MA
authors.lastname: Earl
authors.affiliation: Cleveland Clinic, Cleveland, OH; and Dana-Farber Cancer Institute, Boston, MA.
authors.forename: Connie
authors.initials: C
authors.lastname: Cheng
authors.affiliation: Cleveland Clinic, Cleveland, OH; and Dana-Farber Cancer Institute, Boston, MA.
authors.forename: Nathan A
authors.initials: NA
authors.lastname: Pennell
authors.affiliation: Cleveland Clinic, Cleveland, OH; and Dana-Farber Cancer Institute, Boston, MA.
authors.forename: Marc
authors.initials: M
authors.lastname: Shapiro
authors.affiliation: Cleveland Clinic, Cleveland, OH; and Dana-Farber Cancer Institute, Boston, MA.
authors.forename: Vamsidhar
authors.initials: V
authors.lastname: Velcheti
authors.affiliation: Cleveland Clinic, Cleveland, OH; and Dana-Farber Cancer Institute, Boston, MA.
authors.forename: James P
authors.initials: JP
authors.lastname: Stevenson
mesh_terms: D000971:Antineoplastic Combined Chemotherapy Protocols / Q000009:adverse effects* / Q000627:therapeutic use; D002289:Carcinoma, Non-Small-Cell Lung / Q000150:complications* / Q000188:drug therapy; D064146:Chemotherapy-Induced Febrile Neutropenia / Q000517:prevention & control*; D032921:Consensus; D016179:Granulocyte Colony-Stimulating Factor / Q000008:administration & dosage / Q000627:therapeutic use*; D006801:Humans; D008175:Lung Neoplasms / Q000150:complications* / Q000188:drug therapy; D011092:Polyethylene Glycols / Q000008:administration & dosage / Q000627:therapeutic use*; D017410:Practice Guidelines as Topic; D011292:Premedication; D000067490:Prescription Drug Overuse / Q000517:prevention & control; D058996:Quality Improvement; D011787:Quality of Health Care / Q000592:standards; D011994:Recombinant Proteins / Q000008:administration & dosage / Q000627:therapeutic use
chemical_list: D011994:Recombinant Proteins; D016179:Granulocyte Colony-Stimulating Factor; D011092:Polyethylene Glycols; C423652:pegylated granulocyte colony-stimulating factor