This retrospective analysis evaluated the conversion from administration of fosaprepitant to aprepitant IV at RMCC. Over an 18-month period after initiating utilization of aprepitant IV, RMCC had administered nearly 13,000 doses of aprepitant in 13 infusion clinics. Within 9 months of initial aprepitant IV utilization, percent utilization of aprepitant IV compared to fosaprepitant reached 90%, signifying a successful conversion within the practice. Only 1 out of 13 clinics (80%) did not achieve a 90% utilization of aprepitant IV by the end of the 18-month analysis. This potentially could have been due to payer preference, nursing preference, change resistance (patient preference or intolerance to aprepitant), or simply because this clinic was limited by being the farthest physical distance from pharmacy leadership. Preparation of aprepitant as an IV push compared to an infusion yielded decrease in supply cost savings per preparation ($1.99/unit, from $2.51 to $0.52). A greater impact was observed on the overall time saved; 90% (33 min per unit, 36.5 min to 3.5 min) when preparing and administering aprepitant as a 2-min IV push rather than a 30-min infusion. This time savings translated to freeing up approximately 60 workdays of combined pharmacist and nursing time for RMCC monthly.
Successful conversion was attributed to multiple routes of education and communication with key stakeholders: providers, schedulers, PFCs, pharmacists, pharmacy technicians, and infusion nurses. Prior to administering the initial dose of aprepitant, the RMCC Pharmacy Team met with key stakeholders to gauge interest in selecting aprepitant as the preferred NK1-RA, and to discuss creation of a specific plan for how to successfully roll out its use within the clinics. RMCC began by collecting economic and clinical data and then presented this information to both the Managed Care and Clinical Quality committees for buy-in and approval. These committees were made up of physicians, advanced practice practitioners (APPs), pharmacists, and practice and nursing leadership. Other key decision makers included the Director of Operations, Controller, and billing team. After factoring in positive clinical outcomes, time savings, drug shortage concerns, and multiple delivery options, the key stakeholders agreed to move forward with selecting aprepitant as the preferred NK-1 RA.
The utilization of aprepitant IV as the preferred NK-1 RA at RMCC began in June of 2018. One critical factor in the successful conversion was the favorable safety profile of aprepitant IV compared to fosaprepitant. Clinical trials have shown that the use of fosaprepitant has been associated with infusion-site adverse events (ISAEs) , including infusion-site pain, erythema, swelling, venous hardening or induration, and phlebitis or thrombophlebitis. These ISAEs may be associated with the formulation of fosaprepitant, which contains the synthetic nonionic surfactant polysorbate 80 , an excipient composed of fatty acid esters and polyoxymethylene sorbitan . Polysorbate 80 is a biologically and pharmacologically active compound that does not alter the pharmacologic properties of the drug with which it is formulated, but is itself associated with a number of adverse events (AEs). Aprepitant is free of synthetic surfactants and polysorbate 80, has demonstrated bioequivalence to fosaprepitant, and is associated with a lower risk for injection-site adverse and hypersensitivity reactions over injectable fosaprepitant when administered via a 30-min infusion [23, 24].
Aprepitant currently represents the only NK-1 RA that can be administered as both a 2-min IV push and a 30-min infusion. Consistent with presenting a tolerable safety profile when administered as a 30-min infusion [23,24,25,26,27], aprepitant administered as a 2-min IV push was well tolerated in healthy volunteers  and in patients with various cancer types receiving a range of HEC and MEC chemotherapy regimens [26, 29, 30]. The 2-min IV push administration of aprepitant offers a convenient method of administering an NK-1 RA for CINV prophylaxis, which has multifold implications. It addresses significant infusion bag shortages and complies with the ASHP recommendation of switching the administration of parenterally administered products to IV push whenever possible . More importantly, and in line with findings of this study, this mode of administration confers operational advantages to pharmacies and infusion clinics. In the pharmacy, a 2-min IV push of aprepitant saves on preparation time, supplies (bags, tubing, etc.), and transit time to the infusion clinic. In the infusion clinic, the 2-min IV push administration of aprepitant allows savings on chair time that can be used for other purposes. Infusion clinics within RMCC have become increasingly busy despite the implementation of decoupling visits (labs/office visits held on a separate day than scheduled treatment) and streamlining the scheduling process. More than 20% of revenue generated in oncology practices comes from infusions , so the extra chair time saved could be reused for other billable procedures likely to be beneficial to the practice. Hence, all the saved time within the infusion clinics would allow for greater efficiency and prevent complicated bottlenecks and may allow each practice to see and treat a greater number of patients in a timelier fashion. As a practice that is almost entirely tied to value-based care (approximately 94% of payer contracts) and being the only Oncology Care Model (OCM) practice within the state of Colorado, this conversion supported RMCC’s mission and strategic initiatives of improving the overall value and care that patients receive, while minimizing the impact of patient cost.
Looking more specifically into time saved, in terms of the pharmacist, it was determined that for RMCC, the impact was minimal when administering aprepitant as an IV push. Regardless of route of administration, a pharmacist must review and verify correct order entry. The current EMR allows for nursing to adjust aprepitant orders for preference (i.e., IV push or IV infusion). If premedications such as antiemetics were prepared in a primary engineering control (PEC) by a technician and then verified by a pharmacist, then switching to IV push administration would save substantial amounts of time. Approximately 7–10 min could be saved per preparation if made individually and not part of a batch. All additional time saved on the nursing side (whether via more efficient preparation or more efficient administration) was redirected toward focus on the patient and documentation within the patient EMR.
Despite requiring a great deal of effort and time to plan this conversion, it was ultimately a success and provided the pharmacy team with a high level of knowledge in determining overall positive impact to clinic workflows and identifying a best practice approach for implementing a new drug within a practice that could be replicated for future drug implementation initiatives. RMCC learned that by strategizing with larger committees and further collaborating with key stakeholders to gain necessary buy-in, the chances of a successful drug implementation initiative were greatly improved. Given the level of reach this initiative involved, it was imperative that pharmacy create a robust process for involvement, planning, communication, tracking, follow-up, and reporting. Careful planning and developing an implementation strategy allowed RMCC to successfully convert from administration of fosaprepitant infusions to IV push of aprepitant in a timely manner.
The transition to aprepitant IV as RMCC’s preferred NK-1 RA was an active conversion, and all usage of aprepitant IV during the data collection period was intentional. RMCC did participate in two small, separate drug buy-ins during the 18-month period, which totaled 615 vials (approximately 4.7% of total purchases). This is mentioned since having extra vials of drug on hand could have sped up utilization for some clinics.
RMCC did not collect a baseline of AEs related to fosaprepitant prior to the conversion, so no determination could be made whether a decrease in AEs to aprepitant IV was seen. However, RMCC did not notice a higher reporting of documented AEs related to aprepitant IV during the data collection period.