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Improving the Care of Patients With Regard to Chemotherapy-Induced Nausea and Emesis: The Effect of Feedback to Clinicians on Adherence to Antiemetic Prescribing Guidelines

Wilson C. Mertens, Donald J. Higby, David Brown, Regina Parisi, Janice Fitzgerald, Evan M. Benjamin, Peter K. Lindenauer

From the Baystate Regional Cancer Program, Divisions of Hematology Oncology and Healthcare Quality, Baystate Medical Center, Springfield, MA, and Tufts University School of Medicine, Boston, MA.

Address reprint requests to Wilson C. Mertens, MD, Baystate Regional Cancer Program, 3400 Main St, Springfield, MA 01107; email: wilson.mertens{at}bhs.org.

Purpose: To evaluate the effect of performance and outcomes feedback on adherence to clinical practice guidelines regarding chemotherapy-induced nausea and emesis (CINE).

Methods: Institutional CINE clinical practice guidelines were developed based on American Society of Clinical Oncology guidelines. Consecutive administrations of moderately/highly emetogenic chemotherapy were assessed for errors. Baseline statistical process control (SPC) charts were created and mean errors per administration were calculated. Prospective SPC charts were used to measure the effect of guideline development and distribution, a visiting lecturer, and ongoing feedback regarding compliance with guidelines employing SPC charts. Patients were surveyed regarding the extent and severity of CINE for 5 days postadministration. These outcomes were then shared with physicians.

Results: Baseline compliance was poor (mean, 0.87 omissions per chemotherapy administration), largely because of inadequate adherence to recommendations for delayed CINE management. Most patients experienced delayed nausea, particularly on day 3 postchemotherapy. Physician prescribing performance did not undergo sustained improvement despite guideline development or distribution, a lecture by a visiting expert, or sharing of adherence data with clinicians. Once patient outcomes were shared, physicians accepted the need for compliance and instituted nurse practitioner antiemetic prescribing, with almost complete compliance and concurrent measurable reduction in day 3 nausea. SPC charts documented improvements in both outcomes.

Conclusions: SPC charts effectively monitor ongoing compliance and patient symptoms and represent appropriate outcome measurement and change facilitation tools. However, physician participation in guideline development and evidence of poor compliance alone did not improve prescribing performance. Only evidence of patient CINE experience coupled with noncompliance improved results.

Presented in part at the Annual Meeting of the American Society of Clinical Oncology, Orlando, FL, May 2002.

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