Utilization of Pegfilgrastim In the Community Setting: Observation From 22 Practices In South Florida and the Effect of Monitoring and Education

Cytotoxic chemotherapy often causes neutropenia, which in severe cases may result in potentially fatal infection. Pegfilgrastim is FDA approved to decrease the incidence of infection, as manifested by neutropenic fever, in patients with non-myeloid malignancies receiving chemotherapy that has a clinically significant incidence of febrile neutropenia. ASCO and NCCN have provided guidelines on the appropriate use of white blood cell growth factors. Both guidelines strongly recommend primary prophylactic growth factors if the risk of neutropenic complications is considered high (>20%), and to evaluate other risk factors, such as age, performance status, and indication for therapy (curative versus palliative), when considering growth factors for primary prophylaxis if the risk of neutropenic complications is considered intermediate (10-20%). Among patients at low risk of neutropenic complications (<10%), growth factors should be used as secondary prophylaxis. Despite the availability of guidelines, the current usage pattern of growth factors, including pegfilgrastim, in the community oncology setting is not known. We attempted to address this issue by collecting and analyzing paid claims across three different calendar quarters. After establishing a baseline, we initiated a prospective review and education program to determine if prior-review may have the potential to alter practice patterns.

Paid claims data on all chemotherapy and supportive care medications for 97,000 Medicare HMO members in Broward and Palm Beach counties, Fl, were reviewed from the fourth quarter of 2009, and the first 2 quarters of 2010. Commencing March 2010, a prior review system was initiated for pegfilgrastim. If the prescribed chemotherapy protocol was deemed to have a low risk (<10%) for neutropenic complications, then the treating physician was contacted and informed that the treatment plan was associated with a low risk of neutropenic complications, and that neither NCCN nor ASCO recommend the routine use of pegfilgrastim in low risk situations. If requested, a reference to the ASCO and NCCN guidelines was provided as well as the neutropenic complication data from the chemotherapy regimen in question.

Among the 22 practices analyzed, a total of 80 units (1 U = 6mg) of pegfilgrastim was paid in 4 Q 2009, 68 units in 1 Q 2010 and 53 units in 2 Q 2010. Out of these 54 (67.5%), 42(61.8%) and 23 (43.4%) were used in conjunction with chemotherapy regimens deemed to be low risk in 4 Q 2009, 1 Q 2010 and 2 Q 2010, respectively (Table 1). Looking at the utilization of pegfilgrastim in intermediate/high risk chemotherapy cycles, the utilization across the three quarters remained similar (26 units 4 Q 2009, 26 units 1 Q 2010, 30 units 2 Q 2010). The utilization among chemotherapy cycles deemed low risk decreased across the quarters (54 Units 4 Q 2009, 42 Units 1 Q 2010 [77.7% of 4 Q 2009], 23 Units 2 Q 2010[42.6% of 4 Q 2009]). There have been no episodes of neutropenic fever in the group of patients that did not receive pegfilgrastim as a result of the prior-review system.

These data suggest that a significant proportion of pegfilgrastim utilization occurs in chemotherapy cycles which have a low risk (<10%) of neutropenic complications, despite ASCO and NCCN guidelines which state that primary prophylaxis in patients at low risk for neutropenic complications is usually not necessary. These data also suggest that monitoring and education can alter the utilization of pegfilgrastim in chemotherapy regimens at low risk for neutropenic complications without any adverse effect on clinical outcomes. Additional work is needed to better understand how providers utilize growth factors to prevent neutropenic complications.

No relevant conflicts of interest to declare.