Strategies to improve CINV outcomes in managed care.

Managing chemotherapy-induced nausea and vomiting (CINV) is an opportunity for better clinical, economic, and humanistic outcomes. Clinicians working in managed care settings must understand background information about CINV's causes, likelihood, and treatment. They need to understand how CINV creates collateral damage (eg, psychological effects, electrolyte disturbances, dehydration, malnutrition, and esophageal injury). Patients with CINV are costly to treat and may be unable or unwilling to continue chemotherapy at doses needed. Several guidelines offer recommendations for selecting appropriate antiemetic medications. Most managed care organizations use or encourage their oncology staffs to use established guidelines. A trend is to tailor guidelines to address institution-specific policies, procedures, and idiosyncrasies. Patients receiving guideline-directed care for CINV tend to have better outcomes. Prophylaxis and treatment for CINV must be patient specific and consider risk factors that increase the likelihood of nausea and vomiting or, conversely, decrease the likelihood. Managed care clinicians should know that most of the guidelines do not include patient-specific factors in their prediction models for CINV. Although research has indicated that clinicians tend to underestimate and undertreat CINV, some research has indicated that clinicians can be too aggressive when providing prophylaxis for various types of CINV. Patient education is the cornerstone of good treatment planning, and educating patients on how and when to report symptoms is critical. Tools are available to help patients track symptoms. The multidisciplinary team must ensure that patients receive prophylaxis and appropriate treatment for their diagnoses, as well as treatment plans.