How to Implement Subcutaneous Immuno-Oncology for Providers

Experts discuss practical considerations for implementing subcutaneous immunotherapy in melanoma care, including workflow integration, operational planning, and patient access.

Roxana Dronca, MD (00:12): Good evening, everyone. Thank you for joining us for our chapter on how to implement subcutaneous immunotherapy options for providers, even when clinicians recognize the value of the option implementation can falter when practices lack a clear path to operationalize it. So with this, I'm going to invite my colleagues to comment on how can we operationalize in a way that preserves clinic workflow and minimizes disruption. Jen, would you like to comment?

Jennifer Hunze, MSN, RN (00:46): Great. Thank you for kicking us off, Dr Dronca. Talking about sub-q administration of some of these medications that have been IV route has been a game changer for our healthcare systems, but more importantly for our patients. With the implementation of this new practice for delivery, we really did have to work with our pharmacy colleagues. Actually, Lucia and I partnered to launch a nivolumab sub-q injection that we were able to provide in the home. And with that, she was able to provide us with some techniques and some literature to understand the difference between how to give this injection versus how we would normally provide IV treatment. And honestly, there wasn't a whole lot to learn. These nurses are all experienced with sub-q injections and it was pretty seamless, which is exciting, honestly. It's very exciting when you can implement something that's going to be so impactful to patients, but doesn't take a huge lift from the actual providers administering the medication. Lucia, what would you add?

Lucia Nolan, PharmD, BCSP (02:07): Yeah, I'm really excited to talk about this topic. There's a lot of logistics considerations to take into account here. I would say prior to even medication delivery, one of the first things that we have to think about is ordering capabilities. And so in many institutions, there is an informatics component where you do have to implement some new ordering capabilities. Your treatment plans have to be updated, you have to create a new medication record build. And so that does come with some lift, particularly with these IO therapies that do have many different options, and many different health systems might have several different treatment plans available for provider ordering.

So one of the considerations is how are you even going to get this into your electronic health record? And that can be a little bit of a hurdle that we have to face and decide as an institution, "How are we going to be able to effectively get access to our providers?" One of the other things and one of the other considerations as you're bringing this on board is, "In what context?" Do we open this up holistically to every provider to be able to order for every indication or do we need to consider things like formulary preferred biosimilars that may or may not become available sooner rather than later? And so that is a topic of conversation at many institutions is how to strategically implement this process when a couple years down the road, patients may be faced with formulary-induced preferences by their insurance companies.

When it comes to the actual rollout, though, in your actual workflow, I think you do realize a lot of benefits, and that is obviously going to be instituted, dependent on how efficient your operations already are. But as we've previously talked about interoperability between some of these agents and amongst different disease states, there was an adept trial that was actually studying this exact effect within a health system implementing an IV versus subcutaneous formulation of sub-trastuzumab to be able to identify, "What are the benefits realized?"

So from a patient perspective, the time in the chair was over an hour and the overall time that they spent within the institution was almost an hour and a half. And from the pharmacy perspective, it was also very similar, hour to an hour and a half timeframe. And so if you look at all of those efficiencies gained, you are able to streamline your process to be able to facilitate patients in and out of your health system. And to Sam's comments in our previous session, that time makes a huge difference, especially when you compound it with travel distances, parking requirements, things like that. And so I think that's really important to consider as we tackle these conversations of how to implement these within an institution, how to overcome those barriers of ordering and formulary considerations, that this really does have some benefit to patients that is realized in real time.

Dronca (05:36): Thank you very much to both of you. So I think key learnings in a way from this workflow and what you both have mentioned are the fact that subcutaneous administration can shorten visit length, creating more scheduling flexibility for patients, as well as for institutions. You both have mentioned streamlining this process. I think some practices like ours are considering creating maybe an injection clinic that may not even be located in the infusion unit, but be located in the same clinic area where we see patients in such a way that patients can stay in the room and they can have the injection done without checking in and out of different areas of the clinic. I think shorter chair time can improve our infusion center throughput.

Jen has mentioned previously the fact that many patients now fortunately have lots of treatment options available. They live a lot longer than they used to with same diagnosis often by undergoing subsequent lines of treatment. More patients are diagnosed, unfortunately, with cancer. Our population is growing. Population is also aging. So we really need a lot of capacity in our infusion centers, in our clinics and hospitals to be able to see patients. So anything that we can do to streamline that process is very important. I think you both mentioned that we need logistical updates to be able to handle this new, I think, process, but those are things that I think in a practice that implements these in a structured way can be done.

Jen, you mentioned nurse training on subcutaneous administration, which I would imagine for nurses is bread and butter to their, I think, jobs and job description. We talked about injection site management and how to counsel patients, how to advise patients on what to do, should they experience these type of injection reactions. And finally, financial and authorization workflows and how to determine feasibility, and making sure that we have early coordination with the patients' insurance companies and financial advocacy teams that all of these are very important.

So with this, I would like to thank you all for watching our series. I encourage you to go back and listen to some chapters that you may have missed and thank you, everyone, for listening.