Reducing inappropriate rasburicase use to promote cost-effective care.

Abstract

312 Background: Rasburicase is recommended for treating established Tumor lysis syndrome (TLS) and patients at high-risk for TLS. Unfortunately, it is an expensive medication and unnecessary use contributes to expenses. Methods: A multidisciplinary quality improvement team reviewed the process of ordering rasburicase and its prescription patterns at Parkland Heath and Hospital System, Dallas, TX between 10/2015-9/2017. Use was determined as appropriate/ inappropriate based on internally approved indications (laboratory TLS, at-risk for TLS, acute kidney injury and hyperuricemia, failure of or inability to administer allopurinol). Quality improvement interventions were implemented based on weaknesses identified. Results: 65 doses of rasburicase were administered during the 2-year baseline period; 21 (32.3%) of these were grossly inappropriate. The most common ordering providers were oncologists (23 orders, 35%), hospitalists (16 orders, 25%), intensivists (11 orders, 17%), and emergency physicians (8 orders, 12%). Ordering process review identified several pitfalls: one-click ready to sign order, auto-population of dosage, no hard-stop requiring providers to review rasburicase indications, and no pharmacy oversight. We aimed to reduce the percentage of inappropriate rasburicase orders from a baseline of 32.3% to 10% over 3 months. In 2/2018, we implemented PDSA cycle 1 including introducing a best practice advisory requiring providers to select an approved indication for medication use and changed auto-population of rasburicase dosage to 3 mg. A mandatory secondary review by pharmacy prior to dispensing the medication was implemented. Over a 3-month period post-change (2/2018- 5/2018), 11 of 11 rasburicase administered doses have been appropriate (0% inappropriate). Conclusions: A multidisciplinary team and classic quality improvement methodology was able to reduce inappropriate rasburicase use from 32.3% to 0%, with significant cost savings. Straightforward electronic medical record interventions and increased pharmacy oversight are effective interventions in curbing medication overuse. We will periodically re-assess utilization patterns and refine PDSA cycles as needed.