Implementing evidence based antiemetic guidelines in the oncology setting: results of a 4-month prospective intervention study

There is a considerable gap between obtaining results in randomized trials and implementing them into practice. This is particularly relevant with the high-cost 5HT3 antiemetics, which include ondansetron, dolasetron and granisetron. Randomized trial data suggests that they should be used as a single daily dose during only the first 24 h of chemotherapy because they offer little benefit over less costly agents beyond this period. In this study, six intervention methods (i.e. multifaceted approach) were combined to change physicians' 5HT3 prescribing patterns to comply with evidence-based antiemetic guidelines. A six-step implementation process was adopted, consisting of guideline dissemination, the use of opinion leaders, interactive educational workshops, therapeutic reminders in the form of preprinted orders, clinical interventions by pharmacists for the event of inappropriate antiemetic orders, and physician audit and feedback. Once implemented, the control of emesis was collected in all patients who were enrolled in the intervention program. Multivariable regression analysis was then used to assess whether prescribing within antiemetic guidelines compromised patient care. A total of 195 inpatients were enrolled in the study over the 4-month intervention period. Overall, 88.7% of granisetron prescriptions fulfilled the guidelines with respect to appropriate indication, dosage, and duration of therapy. The multivariable analysis suggested that granisetron prescribing within guidelines did not compromise the control of acute and delayed emesis. In addition, patients who received evidence-based antiemetic therapy experienced a significant reduction in the severity of acute nausea [risk ratio (RR) = 0.69; P=0.03]. The results of this guideline implementation study revealed that a pharmacist-driven multifaceted intervention program for such high-cost agents as 5HT3 antiemetics can promote their use in a clinically appropriate manner and can save unnecessary drug costs without compromising the quality of patient care.