Defining Value in Care For Patients With MPNs


The panel offers effective practices to establish value-based and pathway-driven care for patients with MPNs.

Ryan Haumschild, PharmD, MS, MBA: Speaking of the EMR [electronic medical record], I’m going to ask you about your patients with PV [polycythemia vera]. With those who are at high risk for thrombosis, how are you leveraging the EMR? Are you identifying them a specific way? Are you putting them in the care plans there? I’d love for you to tease that out. What’s the importance of keeping the hematocrit less than 45%? How are you accomplishing that through this initiative?

Sharita Howe, PharmD: With patients with high-risk PV, we’re looking at 3 different things. We’re utilizing the EMR, but only to get patient-specific factors. We’re going to look at their age, if they’ve had a history of thrombosis, and genetic mutations. If they’re JAK2-positive, they may have a disease that can eventually have more of an incidence of thrombosis. We’re teasing that out of the EMR, and then from there, we’re treating them with standard therapy.

Our patients are started on low-dose aspirin as an antiplatelet therapy or on hydroxyurea [Hydrea] or Jakafi [ruxolitinib], depending on if they’re more resistant or refractory to the initial therapy. We’re using Pegasys [peginterferon alfa-2a] in some of our patients if they’re of childbearing age, want to pursue that avenue, are younger, or if they want a different type of therapy if the hydroxyurea isn’t something that they’re too keen on doing. Sometimes we’ll use the pegylated interferon. That’s how we’re initially treating these patients. Some patients opt for a phlebotomy, so we’ll do any of these medications in combination with phlebotomy.

It’s important to make sure we’re hitting that goal of keeping hematocrit less than 45%. It was discussed in the CYTO-PV trial. They looked at keeping patients at a hematocrit less than 45% or between 45% and 50%. They saw more cardiovascular events in the group that was 45% to 50%, and that’s why we’re using that cutoff of 45%. But with these patients, we’re just treating them using standard of care and not running into any issues. There are no access issues with Hydrea. When we start to add ruxolitinib, we’re running into some financial toxicity and access issues, but we don’t see those issues if we’re starting with Hydrea or Pegasys.

With Pegasys, we might run into some issues determining whether it’s covered on their pharmacy benefit or through their medical benefit. If it’s covered in medical, they can come in and can get it in the office. But if it’s covered in pharmacy, we may have to worry about co-pay assistance, and we’ll also have to make sure patients are receiving the teaching to be able to inject at home. Those are some of the things that we’re looking at.

Jeff A. Gilreath, PharmD: It’s tricky and depends on where you treat patients. In Salt Lake City at the University of Utah, our center is roughly 4000 ft above sea level, so the hematocrit might be a little higher due to hypoxia. It may not translate exactly depending on where you are. We have allowed some people to drift a little above that because that may be their normal at that altitude. We also pay attention to the white blood cell count as a possible risk factor for thrombosis, and we’ll aggressively treat that, because the picture is a little less clear and a little more cloudy for us at elevation.

Ryan Haumschild, PharmD, MS, MBA: I like those considerations of patient-specific laboratory values as well. As someone who just went skiing in Utah, I was hypoxic myself, so I can relate to that directly. But I think that’s unique how you’re adapting your treatment strategy to your unique patient population.

When I summarize this, one of the key takeaways that I keep thinking about is also pathway-driven care. Pathways are important because you want to make sure you’re having somewhat of a standardized approach to patients, especially at large integrated delivery networks. It’s important to be thoughtful that a patient shouldn’t have to go to some main academic center just to get the best care for MPNs [myeloproliferative neoplasms].

We recognize hematologists need to manage it. We have subspecialist practices and community practices. But how do we roll out more best approaches to care when we’re thinking about hematocrit and what therapy we start someone on? Do we start them on aspirin or hydroxyurea? Do we have them step through to a JAK [inhibitor] if they aren’t responding well? Or do we consider an interferon-based care strategy with adverse effect management built into that?

The important piece that we’re seeing is pharmacists being more involved. Because these are high-touch therapies, they require someone to have some of that patient-specific knowledge as we develop therapies and pathways, whether we build them into our EMR or pathways for adverse effect management, having a pharmacist build that out, bring it to the team, and get their blessing on it. That allows better and more comprehensive care. When you’re utilizing that same pathway maybe through an academic arm as a community practice, you’re providing great consistency of care.

When I think about value-based care and where we’re headed in the future, when you have great pathways that were developed through shared decision-making and a pharmacist is able to manage those, we’re going to have best practice across the board and you’re going to be well prepared to formulate best outcomes and perform well on value-based arrangements in the future. That’s one of the last things I want to bring in there, having that efficient care where those adverse effect management medications are built in, where you have those dose reductions built in. It makes it a lot easier on that physician, advanced practice practitioner, or pharmacist when dose adjustments or titrations in treatment are needed.

Transcripts edited for clarity.

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