Kirstin Schmidt, RN

THE CURRENT FOCUS ON value-based health care is driving myriad efforts to ensure that patients receive the best care at the lowest cost. Invariably, this is a challenging proposition, particularly in the setting of special populations, such as patients with hemophilia, who require extremely costly treatments.

However, new research on patients receiving home infusion of life-saving factor VIII demonstrates that it is achievable when patients receive high-quality clinical management and collaborative coordination of care. Indeed, research presented by Option Care at the 2016 World Federation of Hemophilia meeting demonstrates that this approach could reduce costs without sacrificing outcomes.

Hemophilia is a genetic disorder that affects approximately 1 in 10,000 people.

 Those with hemophilia are deficient in a protein in the blood necessary for normal clotting to occur. They are, therefore, at higher risk of spontaneous or trauma-induced bleeding, as well as excessive bleeding from surgery or an invasive procedure.

These patients may experience excessive bruising, bleeding into joints or muscles, and internal bleeding. As children with hemophilia become more active, they often begin to experience more bleeding episodes, including joint bleeds. Repeat bleeds into the joints leads to permanent joint damage; therefore, people with hemophilia are at high risk of needing joint replacement surgery. This not only negatively affects quality of life, but any surgery increases the risk of additional bleeding and infection.

The majority of people with hemophilia (80%) have hemophilia A.

The standard of care treatment consists of infusions of factor VIII, 2 to 5 times per week to prevent bleeds. If bleeding does occur, additional doses of factor VIII may be needed to control the bleeding and decrease the amount of damage to the joints, muscles, and organs.

Timely administration leads to quicker resolution of the bleed, fewer complications, and less factor consumption. Prophylactic treatment success is evaluated by assessing the annual bleed rate (ABR). The fewer the bleeds, the more successful the treatment. Reduced bleeding translates into reduced joint damage, which can help prevent, or delay, joint replacement surgery. Therefore, keeping the ABR as low as possible is vital.

Hemophilia treatment is costly, averaging approximately $200,000 per year per patient.

 However, Option Care data demonstrate that costs can be contained through high-quality clinical management that benefits all stakeholders, from patients and health systems to providers and payers.

The study included 77 hemophilia A patients receiving home infusion of factor VIII. Per Option Care’s clinical management, patients received an average of 102 units of factor VIII per week. Compared with the national average of 108 units per week, this translates into a cost savings of $21,165 per patient per year. More importantly, the average ABR for these patients was 1.7, less than the average ABR, which ranges from 2 to 5.

These data demonstrate that even for high-cost conditions, such as hemophilia, both positive outcomes and cost savings are achievable when treatment is managed by a home infusion provider that offers high-quality clinical management and coordination across the continuum of care.

For example, the Option Care Bleeding Disorders (BDs) Home Infusion Plus program features a multidisciplinary team approach to care, including a dedicated BD-certified nurse and pharmacist. Personalized clinical care begins with close coordination with the Hemophilia Treatment Center, and collaboration with the patient, physician, nurse, and home infusion provider. The first step is to develop a customized patient-specific care plan, based entirely on meeting the needs of the patient, and his or her care team.

Therapy management and medication oversight are crucial and include frequent contact with the patient and family to continually assess the patient’s weight, activity level, and number of bleeds. Home infusion providers are in frequent contact with the patient and family and can relay vital information to the patient’s physician team.

A quality home infusion provider shares detailed reports with the patient’s physician team on health care status, including location and severity of bleeding, treatment outcomes, and adherence. Additionally, the home infusion provider relays timely vital information to the physician team regarding changes in weight or activity level, which may necessitate an adjustment to the treatment dose.

A quality home infusion provider offers prompt access to medications and supplies, and coordinates adjunctive treatment, such as physical therapy. Education is vital to ensuring successful treatment of patients with hemophilia. Most patients self-infuse, in some cases with parental support.

That is why the infusion provider works with the patient and care provider—whether a parent, spouse, friend or grandparent&mdash;to learn how to identify bleeds and treat them promptly. Another key is ensuring patients and their families understand the risks of delaying treatment.

In cases where the patient is not able to self-infuse independently, nurses provide the infusion, as well as direction and support at the level necessary to ensure successful treatment. Additionally, it is vital to provide 24-hour support that includes access to nursing, pharmacy staff, delivery of needed medication, and Spanish translators.

Currently, factor is reimbursed on a per-unit basis. This gives financial incentive to the infusion provider to order more product, which may not translate into superior care. Providing high-caliber clinical management ensures that patients receive only the factor they require.

The savings accrue through the optimization of treatment dosage to ensure the patient receives what is prescribed, while avoiding overdispensing. Quality clinical management means coordinating care with the physician to provide insight into how much factor is needed, which prevents over- or under-prescribing. It also means not shipping more factor than necessary, which increases wasteful spending.

This level of care results in secondary cost savings, as well. For example, quality clinical management ensures patients have the factor and supplies in the home to keep them healthy, and helps them avoid emergency department (ED) visits for infusions. ED evaluation is warranted if the patient experiences a trauma or another serious health concern, however.

If the patient does require hospitalization, quality home infusion providers offer support that can help get patients out of the hospital sooner, and avoid readmission. Option Care’s history of low readmissions after hospitalization—less than 1% among infusion patients overall (based on nearly 200,000 patients treated)&mdash;is a testament to this excellent care.

Clearly, this level of high-touch, high-quality home infusion care is beneficial all around. Patients enjoy better quality of life; physicians can rest assured that their patients are being well cared for; hospitals benefit by avoiding the provision of extra days of costly factor and the lower likelihood of readmissions; and payers benefit through the careful management and dispensing of factor.

Health care costs have skyrocketed, in part, due to providing extremely costly treatments for conditions such as hemophilia. These data demonstrate that it is possible to contain these costs, while ensuring patients get the very best care. Further, these findings are readily applicable to other high-cost-care specialty patients who require infusion therapy.&ensp;

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High-quality clinical management of home infusion hemophilia patients reduces costs and maintains outcomes.
