Improved Adherence Rates and Clinical Outcomes of an Integrated, Closed-Loop, Pharmacist-Led Oral Chemotherapy Management Program

Purpose: To address the growing use of oral anticancer therapy, an integrated, closed-loop, pharmacist-led oral chemotherapy management program was created within an academic medical center. Methods: An integrated, closed-loop, pharmacy-led oral chemotherapy management program was established. From September 2014 until June 2015, demographic information, rates of adherence, patient understanding of treatment, pharmacist interventions, patient and provider satisfaction, and molecular response rates in patients with chronic myeloid leukemia (CML) were collected. Results: After full implementation, 107 patients were enrolled in our oral chemotherapy management program from September 2014 until June 2015. All patients were educated before starting oral chemotherapy, and using pre- and postassessment tests, comprehension of oral chemotherapy treatment increased from 43% to 95%. Patient-reported adherence was 86% and 94.7% for the GI/breast and malignant hematology patient populations, respectively, and these were validated with medication possession ratio, revealing adherence rates of 85% and 93.9% for the GI/breast and malignant hematology patient populations, respectively. A total of 350 encounters with a clinical pharmacist and 318 adverse effects were reported, which led to 235 interventions. This program led to a higher major molecular response rate (83%) in our CML population compared with published clinical trials (average major molecular response rates, 40% and 60% with 1- and 2-year follow-up, respectively). Conclusion: An innovative model was developed and resulted in improved patient knowledge regarding oral chemotherapy, improved adherence rates that exceeded nationally established thresholds, and superior major molecular response outcomes for patients with CML compared with published literature. As a result, this model has produced the gold standard in managing patients receiving oral chemotherapy.

Download Full-text

Patients’ perspectives and outcomes on an oral chemotherapy education and electronic monitoring program.

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.15_suppl.e18007 ◽

2019 ◽

Vol 37 (15_suppl) ◽

pp. e18007-e18007

Author(s):

Noah Xavier Tocci ◽

Jim Doolin ◽

Daniel Aaron Roberts ◽

Christina Cibotti ◽

Rebekah A Hartwell ◽

...

Keyword(s):

Electronic Monitoring ◽

Medical Center ◽

Academic Medical Center ◽

Monitoring Program ◽

Management Program ◽

Oral Chemotherapy ◽

P Value ◽

Online Tool ◽

Significant Difference ◽

Patient Reported

e18007 Background: Patients on oral chemotherapy (OC) often lack consistent education and monitoring, risking toxicity and poor adherence. We developed an OC management program including education and an online tool for active outreach. Methods: In November 2017, we initiated pharmacist-led education for patients newly prescribed OC at a community practice and in the gastrointestinal oncology group at an academic medical center (AMC). An online tool assessing adherence, symptoms, and financial toxicity was emailed to patients three days after starting OC. Non-responders were contacted for phone interviews. A random sample of 28 patients newly started on OC at both sites before the intervention in 2017 was analyzed at baseline. A retrospective chart analysis was done to collect time to symptom assessment, identification and action. A report generated date of first emergency department (ED) visit or hospitalization within the AMC. We conducted a Mann Whitney U-Test, using a one-sided p value of 0.025 with Bonferroni correction. Results: Sixty-nine of 106 eligible patients (66%) received education, of whom 36 (52.1%) received the online tool, and 13 (36.1%) responded. There was a significant difference between the intervention and baseline median times to first new/worsening symptoms (p = 0.0105) but otherwise there were no outcome improvements. Eight of 23 patients who did not respond to the electronic tool were interviewed and indicated that their illness impeded their ability to check email (n = 2), and that they never check email (n = 2). Conclusions: This OC management program improved time to detect new/worsening symptoms and could potentially improve outcomes after further patient accrual. Future investigation should examine ways to improve patient responsiveness to electronic patient-reported symptom tools. [Table: see text]

Download Full-text

Electronic monitoring of patient-reported adherence and symptoms on oral chemotherapy at an academic and a community site.

Journal of Clinical Oncology ◽

10.1200/jco.2018.36.30_suppl.283 ◽

2018 ◽

Vol 36 (30_suppl) ◽

pp. 283-283

Author(s):

Jim Doolin ◽

Daniel Aaron Roberts ◽

Christina Cibotti ◽

Scott M Devlin ◽

Holly Dowling ◽

...

Keyword(s):

Median Time ◽

Medical Center ◽

Academic Medical Center ◽

Symptom Assessment ◽

Oral Chemotherapy ◽

Community Practice ◽

Financial Toxicity ◽

Online Tool ◽

Academic Medical ◽

Patient Reported

283 Background: Monitoring of toxicity and adherence is often lacking for patients recently started on oral chemotherapy. National guidelines recommend active outreach to patients within a week after treatment start. We developed an online tool to actively reach out to patients newly started on oral chemotherapy at one academic medical center and community practice. Methods: A multi-disciplinary team, including patients, developed an online oral chemotherapy adherence, symptom, and financial toxicity assessment tool within REDCap. We implemented this tool for new oral chemotherapy prescriptions in May 2018 in the gastrointestinal oncology group of an academic medical center and a general community practice. To quantify the impact of this tool on symptom management, we completed a retrospective analysis of patients receiving new oral chemotherapy prescriptions at these same sites, in the 13 months immediately preceding clinical implementation of the online tool, May 2017 to May 2018. Results: In the pre-intervention historical cohort (n = 58) the median time to first symptom assessment by a clinician was 7 days (range 1 – 41 days, SD 7 days), median time to identifying a new or worsening symptom was 10 days (range 1-55 days, SD 10 days), and median time to clinical action regarding a new or worsening symptom was 10 days (range 1-104, SD 20 days). Our first intervention patient used the online tool in May 2018 to report symptoms of “nausea and fatigue,” 4 days after starting oral chemotherapy. This resulted in an oncology clinical nurse calling the patient to review symptom management by phone. Conclusions: The median time to first symptom assessment in our historical control cohort is 7 days, with standard deviation of 7 days, suggesting potential room for improvement. Thus far, the online tool has been completed by one patient. Further data will be reported regarding the uptake of this tool, the tool’s impact on quality measures, and patient reported symptoms, adherence, and financial toxicity.

Download Full-text

Application of a Computer Vision Tool for Automated Glottic Tracking to Vocal Fold Paralysis Patients

Otolaryngology ◽

10.1177/0194599821989608 ◽

2021 ◽

pp. 019459982198960

Author(s):

Tiffany V. Wang ◽

Nat Adamian ◽

Phillip C. Song ◽

Ramon A. Franco ◽

Molly N. Huston ◽

...

Keyword(s):

Vocal Fold ◽

Assessment Tool ◽

Medical Center ◽

Characteristic Curve ◽

Academic Medical Center ◽

Vocal Fold Paralysis ◽

Control Group ◽

Large Patient ◽

Patient Reported ◽

Before And After

Objectives (1) Demonstrate true vocal fold (TVF) tracking software (AGATI [Automated Glottic Action Tracking by artificial Intelligence]) as a quantitative assessment of unilateral vocal fold paralysis (UVFP) in a large patient cohort. (2) Correlate patient-reported metrics with AGATI measurements of TVF anterior glottic angles, before and after procedural intervention. Study Design Retrospective cohort study. Setting Academic medical center. Methods AGATI was used to analyze videolaryngoscopy from healthy adults (n = 72) and patients with UVFP (n = 70). Minimum, 3rd percentile, 97th percentile, and maximum anterior glottic angles (AGAs) were computed for each patient. In patients with UVFP, patient-reported outcomes (Voice Handicap Index 10, Dyspnea Index, and Eating Assessment Tool 10) were assessed, before and after procedural intervention (injection or medialization laryngoplasty). A receiver operating characteristic curve for the logistic fit of paralysis vs control group was used to determine AGA cutoff values for defining UVFP. Results Mean (SD) 3rd percentile AGA (in degrees) was 2.67 (3.21) in control and 5.64 (5.42) in patients with UVFP ( P < .001); mean (SD) 97th percentile AGA was 57.08 (11.14) in control and 42.59 (12.37) in patients with UVFP ( P < .001). For patients with UVFP who underwent procedural intervention, the mean 97th percentile AGA decreased by 5 degrees from pre- to postprocedure ( P = .026). The difference between the 97th and 3rd percentile AGA predicted UVFP with 77% sensitivity and 92% specificity ( P < .0001). There was no correlation between AGA measurements and patient-reported outcome scores. Conclusions AGATI demonstrated a difference in AGA measurements between paralysis and control patients. AGATI can predict UVFP with 77% sensitivity and 92% specificity.

Download Full-text

Comparison of rates of adherence to oral chemotherapy medications filled through an internal health-system specialty pharmacy vs external specialty pharmacies

American Journal of Health-System Pharmacy ◽

10.1093/ajhp/zxaa135 ◽

2020 ◽

Vol 77 (14) ◽

pp. 1118-1127

Author(s):

Colleen C McCabe ◽

Meagan S Barbee ◽

Marley L Watson ◽

Alyssa Billmeyer ◽

Collin E Lee ◽

...

Keyword(s):

Health System ◽

Multiple Regression ◽

Patient Adherence ◽

Medical Center ◽

Academic Medical Center ◽

Medication Possession Ratio ◽

Primary Objective ◽

Wilcoxon Test ◽

Tumor Type ◽

Specialty Pharmacy

Abstract Purpose The primary objective of the study described here was to compare rates of patient adherence to anticancer medications filled at an internal health system specialty pharmacy (HSSP) vs external specialty pharmacies. The primary outcome was the medication possession ratio (MPR), and the secondary outcomes included proportion of days covered (PDC), and time to treatment (TTT). Methods A retrospective chart review was conducted to compare the MPR, PDC, and TTT for patients who received oral anticancer therapy using prescriptions claim data. A t test or Wilcoxon test was used to explore the effect of demographic and other factors on adherence and TTT. A multiple regression model with backward elimination was used to analyze significant factors to identify covariates significantly associated with the outcomes. Results Of the 300 patients screened for study inclusion, 204 patients whose records had complete MPR and PDC data and 164 whose records had TTT data were included in the analysis. There were significant between-group differences in mean MPR and mean PDC with patient use of the HSSP vs external pharmacies (1.00 vs 0.75 [P < 0.001] and 0.95 vs 0.7 [P < 0.001], respectively). Pharmacy type (P = 0.024) and tumor type (P = 0.048) were significantly associated with TTT. Conclusion The multiple regression analysis indicated that oncology patients who filled their anticancer medication precriptions at an internal HSSP at an academic medical center had significantly higher adherence, as measured by MPR and PDC, and quicker TTT than those who filled their prescriptions at an external specialty pharmacy.

Download Full-text

Integration of Patient-reported Outcomes in a Total Joint Arthroplasty Program at a High-volume Academic Medical Center

JAAOS Global Research and Reviews ◽

10.5435/jaaosglobal-d-20-00034 ◽

2020 ◽

Vol 4 (5) ◽

pp. e20.00034 ◽

Cited By ~ 1

Author(s):

Surabhi Bhatt ◽

Kristina Davis ◽

David W. Manning ◽

Cynthia Barnard ◽

Terrance D. Peabody ◽

...

Keyword(s):

Total Joint Arthroplasty ◽

Patient Reported Outcomes ◽

Medical Center ◽

Academic Medical Center ◽

High Volume ◽

Joint Arthroplasty ◽

Academic Medical ◽

Patient Reported

Download Full-text

Integrating Oncology Massage Into Chemoinfusion Suites: A Program Evaluation

Journal of Oncology Practice ◽

10.1200/jop.2016.015081 ◽

2017 ◽

Vol 13 (3) ◽

pp. e207-e216 ◽

Cited By ~ 6

Author(s):

Jun J. Mao ◽

Karen E. Wagner ◽

Christina M. Seluzicki ◽

Audra Hugo ◽

Laura K. Galindez ◽

...

Keyword(s):

Breast Cancer ◽

Program Evaluation ◽

Clinical Oncology ◽

Medical Center ◽

Symptom Control ◽

Academic Medical Center ◽

Distress Thermometer ◽

Integrative Approach ◽

Patient Reported ◽

Oncology Massage

Objective: This article reports on the development, implementation, and evaluation of an integrative clinical oncology massage program for patients undergoing chemotherapy for breast cancer in a large academic medical center. Materials and Methods: We describe the development and implementation of an oncology massage program embedded into chemoinfusion suites. We used deidentified program evaluation data to identify specific reasons individuals refuse massage and to evaluate the immediate impact of massage treatments on patient-reported outcomes using a modified version of the Distress Thermometer delivered via iPad. We analyzed premassage and postmassage data from the Distress Thermometer using paired t test and derived qualitative data from participants who provided written feedback on their massage experiences. Results: Of the 1,090 massages offered, 692 (63%) were accepted. We observed a significant decrease in self-reported anxiety (from 3.9 to 1.7), nausea (from 2.5 to 1.2), pain (from 3.3 to 1.9), and fatigue (from 4.8 to 3.0) premassage and postmassage, respectively (all P < .001). We found that 642 survey participants (93%) were satisfied with their massage, and 649 (94%) would recommend it to another patient undergoing treatment. Spontaneous patient responses overwhelmingly endorsed the massage as relaxing. No adverse events were reported. Among the 398 patients (36%) who declined a massage, top reasons were time concerns and lack of interest. Conclusion: A clinical oncology massage program can be safely and effectively integrated into chemoinfusion units to provide symptom control for patients with breast cancer. This integrative approach overcomes patient-level barriers of cost, time, and travel, and addresses the institutional-level barrier of space.

Download Full-text

Oral chemotherapy education: Hitting the mark?

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.29_suppl.221 ◽

2020 ◽

Vol 38 (29_suppl) ◽

pp. 221-221

Author(s):

Jonathan L Berry ◽

Jim W Doolin ◽

Garrett Diltz ◽

Tenzin Dechen ◽

Natalia Forbath ◽

...

Keyword(s):

Formal Education ◽

Medical Center ◽

Academic Medical Center ◽

Hematologic Malignancies ◽

Oral Chemotherapy ◽

Community Practice ◽

Medication Persistence ◽

Process Measures ◽

Education Group ◽

Oncology Practice

221 Background: ASCO’s Quality Oncology Practice Initiative (QOPI) includes process measures on oral chemotherapy education. Whether achievement of these measures has an impact on clinical outcomes and if an intervention to improve these measures can improve outcomes is not yet known. Methods: A retrospective analysis was conducted of patients initiated on oral chemotherapy in an academic medical center site and a community oncology practice between January 2016 and October 2019. The primary aim was to compare the time to emergency department (ED) within 90 days from initiation of oral chemotherapy of patients who met the QOPI process measure through an intervention of pharmacist-driven education with a comparison group of patients who had not received formal education. A secondary aim was to assess for a difference in oral chemotherapy medication persistence. Data were also analyzed by demographics, concurrent parenteral therapy, intent of therapy, and disease group. Results: 285 patients in the education group and 284 patients in the non-education group were analyzed. The education group had a higher proportion of patients with gastrointestinal and gynecologic cancers, and a lower proportion of patients with hematologic malignancies, compared to the non-education group. The education group also had a higher proportion of patients treated at the community practice compared to the non-education group. There was no statistical difference in median time-to-ED, with 49 days (IQR 37-74) in the education group and 59 days (IQR 41-60) in the non-education group (p=0.15). Conclusions: In patients receiving oral chemotherapy, pharmacist-driven education with improvement in QOPI process measures did not result in an improvement in time to ED. One factor contributing to this result may be that only 20% of patients required ED-level care within 90 days of starting oral We continue to collect data regarding medication persistence, which may be a more sensitive outcome measure. At this point, further work is needed to determine if achievement or modification of the QOPI oral chemotherapy process measures results in a clinically significant change in outcome. [Table: see text]

Download Full-text

Electrosclerotherapy for capillary malformations: study protocol for a randomised within-patient controlled pilot trial

BMJ Open ◽

10.1136/bmjopen-2017-016401 ◽

2017 ◽

Vol 7 (11) ◽

pp. e016401 ◽

Cited By ~ 3

Author(s):

Sophie E R Horbach ◽

Albert Wolkerstorfer ◽

Daniel Martijn de Bruin ◽

Chantal M A M van der Horst

Keyword(s):

Study Protocol ◽

Medical Center ◽

Academic Medical Center ◽

Pilot Trial ◽

Small Diameter ◽

Laser Speckle ◽

Alternative Treatment Option ◽

Study Results ◽

Patient Reported ◽

Scientific Meetings

IntroductionThe current state-of-the-art treatment modality for hypertrophic capillary malformations (CMs), laser therapy, has a considerable rate of non-responders and recurrence. Intralesional bleomycin injections (or ‘sclerotherapy’) are commonly used to treat venous and lymphatic malformations with an excellent effect, but these intravascular injections are not possible in CMs due to the small diameter of the vessels. Electroporation—an electric field applied to the tissue—could increase the permeability of endothelial cells, which could theoretically facilitate targeted localised bleomycin delivery. We therefore hypothesise that bleomycin injections in combination with electroporation—‘electrosclerotherapy’ (EST), also known as ‘electrochemotherapy’—could potentially be a novel alternative treatment option for CMs.Methods and analysisIn this randomised within-patient controlled pilot trial, 20 patients with hypertrophic CMs will be enrolled. Three regions of interest (ROIs) within the CM will be randomly allocated for treatment with (A) EST, (B) bleomycin sclerotherapy without electroporation and (C) no treatment. Patients and outcome assessors are blinded for the treatment allocation. Treatment outcome for each ROI will be measured approximately 7 weeks after the treatment procedure, using patient-reported and physician-reported global assessment scores, colorimetry, laser speckle imaging and reporting of adverse events.Ethics and disseminationThe study protocol is approved by the ethics review committee of the Academic Medical Center, Amsterdam. Results will be published in peer-reviewed medical journals and will be presented at international conferences and scientific meetings. Study results will be fed back to the patient population through website and social media notifications.Trial registration numberNCT02883023;Pre-results. NTR6169.

Download Full-text

Organization- and System-Level Factors Influencing Implementation Overview of Case Studies

10.1093/med/9780190647421.003.0020 ◽

2018 ◽

Author(s):

Stephanie B. Wheeler

Keyword(s):

Case Studies ◽

Psychosocial Support ◽

Medical Center ◽

Academic Medical Center ◽

System Level ◽

Differential Outcomes ◽

System P ◽

Academic Medical ◽

Patient Reported ◽

Integrated Health Care System

Organization- and health system-level determinants of cancer outcomes are critical to understand. Studies focusing only on individual- or provider-level factors contributing to differential outcomes may mask the important, and often far-reaching, influence of organizational and system-wide structures, policies, norms, and behaviors that drive outcomes. This chapter explores case studies including implementation of patient reported outcomes symptom monitoring within a large academic medical center; cancer patient navigation programs to reduce social, economic, cultural, and system barriers to timely cancer care; how psychosocial support has been integrated into community-based and Veterans Administration (VA) oncology programs; and implementing Lynch syndrome testing within a VA integrated health care system.

Download Full-text

Phalangeal Osteotomy…To Perform or Not to Perform

Foot & Ankle Orthopaedics ◽

10.1177/2473011417s000128 ◽

2017 ◽

Vol 2 (3) ◽

pp. 2473011417S0001

Author(s):

Monique Chambers ◽

MaCalus Hogan ◽

Dukens LaBaze

Keyword(s):

Failure Rate ◽

Medical Center ◽

Academic Medical Center ◽

Bone Cyst ◽

Cyst Formation ◽

Hallux Rigidus ◽

Reconstructive Procedures ◽

Hallux Valgus Deformity ◽

Patient Reported ◽

Decreasing Failure Rate

Category: Bunion Introduction/Purpose: As the hallux valgus deformity progresses, patients can get mild to moderate arthritis of the metatarsophalangeal (MTP) joint. The degenerative process of MTP arthritis results in reactive tissue formation and proliferation of osseous and cartilaginous structures. For some patients, the results in dorsal bone spurs and pain with great toe dorsiflexion of irritation from shoes. Reconstructive procedures provide a surgical option for patients to address pain and functional limitations, prior to subchondral bone cyst formation and loss of joint space. Patients who underwent cheilectomy alone have been shown to have a high failure rate and progress to advanced disease. A phalangeal dorsiflexion osteotomy has become increasingly more popular amongst foot and ankle surgeons with the hopes of decreasing failure rate and improving early outcomes. Methods: This study was a retrospective review of prospectively collected data from 385 patients treated for hallux rigidus at a large academic medical center between July 2015 and November 2016. All patients underwent either a cheilectomy or cheilectomy with phalangeal osteotomy of the MTP joint. Collected patient reported outcomes (PROs) included in this study were SF12 M, SF12P, FAAM, VAS and PASS scores. Mann-Whitney t-test was performed using GraphPad Prism version 7.0b for Mac to compare procedure groups. Exclusion criteria included poly-trauma, revision of same procedure, and lack of pre or post- operative. Results: Eighteen patients met criteria, 8 underwent cheilectomy and 10 had a cheilectomy with osteotomy procedure. The average age was 51.9 amongst the cohort, with a total of 13 female and 5 males. Patients who underwent cheilectomy with osteotomy procedure had better outcomes across all outcome measure scores. When comparing postoperative scores, cheilectomy with osteotomy patients showed significantly higher scores compared to cheilectomy alone patients: SF12-M (56 vs 36, respectively; p=0.0333), and SF12P (52 vs 30, respectively p=0.0095). VAS scores and FAAM scores showed no statistical difference between the two cohorts. Despite surgical intervention, 50% of patients who received cheilectomy alone reported more pain post-operatively compared to no reports of worsening pain in patients who received cheilectomy with osteotomy. Conclusion: Patients with moderate to severe hallux rigidus demonstrate improved functional outcomes with phalangeal osteotomy in conjunction with cheilectomy compared to cheilectomy alone. Further research with larger cohorts would be beneficial to confirm the reports of this study and expand upon aspects of care that contribute to patient satisfaction and performance.

Download Full-text