The impact of medication reconciliation and review in patients using oral chemotherapy

Background and aim Verifying and reviewing a patients medication list can detect and reduce drug related problems (DRPs). However little is known about its effects in patients using oral chemotherapy. The aim of this study was to evaluate the impact of these interventions and the adapted Medication Appropriateness Index (aMAI) as a tool to carry out a medication review. Methods A case-control study was carried out. The hospital pharmacist performed a medication reconciliation and medication review, using the aMAI tool, in 54 patients starting oral chemotherapy. Discrepancies, DRP's and associated pharmaceutical interventions were reported via the electronic patient record (EPR). After one month, the acceptance rate was measured and the aMAI score recalculated. Kappa statistics were used to test intra- and interrater reliability. Results The medication list in the EPR was incomplete in 74,1% of patients with an average of 2.4 errors per patient. After medication review, the aMAI score decreased significantly from 7.2 to 5.4 (SD = 4,7; p <0.001), indicating an improvement in the appropriateness of the drugs patients were taking. Acceptance rates were 41,4% and 53,2% for advices resulting from medication reconciliation and medication review respectively. Kappa values of 0.90 and 0.70 respectively indicate good intra- and interrater reliability. Discussion and conclusion The study shows that medication reconciliation can identify and address discrepancies. Furthermore, medication review seems to ensure that drug treatment better meets patient needs. The aMAI was a reliable tool. Future research will have to determine the clinical relevance of these interventions.

Patients’ knowledge and awareness of safe handling of oral anticancer agents at Sultan Qaboos University Hospital in Oman

Background Safe handling of oral anticancer agents is of great concern. There is a lack of clear, national guidelines on how patients can safely handle and dispose of unwanted medications. We aimed to evaluate the safe handling, storage, and disposal of oral anticancer drugs among cancer patients and caregivers at home. Method This cross-sectional survey of adult cancer patients (or their adult caregivers) used a closed-ended questionnaire from May 2019 to March 2020. Results A total of 257 patients (50 ± 15 years; range: 18–93 years) were enrolled; however, only 91% (233/257) reported self-administering oral anticancer medications. Caregivers were more likely to administer oral anticancer agents for patients ≥60 years than those <40 years old (63% vs. 8%; P = 0.001). Most patients (52%; 133/257) did not wash their hands after administering the drug; 74% (164/222) of the respondents reported that their medications were kept in a bedroom cabinet, while 18% (40/222) stored their medications in a refrigerator, and 5% (12/222) in a kitchen cabinet. A total of 55% (68/124) of patients returned their excess oral chemotherapy medications to the hospitals; however, 36% (45/124) disposed of their unused oral chemotherapy drugs in a household garbage container. Conclusion While two-thirds of patients stored their oral anticancer medications properly, more than half used inappropriate handling procedures. Disposal practices were inconsistent and did not adhere to the reported international guidelines.

Implementation of an oral chemotherapy adherence tool at an NCCN comprehensive cancer center.

265 Background: Adherence to oral chemotherapy (OC) is a critical factor in achieving optimal oncologic outcomes. Correct dosing, education, and symptom management are essential to maximizing adherence. As part of the 2020 Quality Oncology Practice Initiative Certification Program Fox Chase Cancer Center (FCCC), a NCCN Comprehensive Cancer Center, learned that only 33% of patients on OC had a documented OC plan, 7% were assessed for adherence, and 0% had documentation reflecting efforts to address non-adherence. Methods: Our goal was to create and implement an electronic medical record (EMR) tool (Oral Chemo Smart Form) to address the variance and deficiencies in monitoring adherence to OC. The Smart Form (SF) was designed to include fields to document the OC plan (drug, indication, dose, schedule, duration of cycle, initial start/end date) as well as provide a standard for documentation of education, management of toxicity and non-adherence. We integrated the SF into nursing, pharmacy, and physician workflows to capitalize on shared EMR tools. A series of Plan-Do-Study-Act cycles were conducted over 8 weeks within pilot clinics. Weekly review of the SF and feedback forms generated real-time progress reports which were serially appraised and shared with stakeholders. Results: Two oncologists (piloted in Genitourinary and Breast Cancer clinics), two pharmacists, and several nurses used the SF March 15, 2021 to May 7, 2021. Over these 8 weeks, 223 patients on OC were seen in clinic. If the OC was dispensed from FCCC, pharmacists were to complete the SF at the time of initial OC prescription, 7 days after dispensing, and with each refill. Pharmacists also identified patients receiving OC through a specialty pharmacy and routed a message to clinic nurses via an EMR message pool. The message became the trigger for nurses to call patients within two weeks to troubleshoot dispensing issues and/or complete the SF. Oncologists were to complete the SF with each clinic visit for a patient on OC. Feedback from the clinical and pharmacy teams motivated changes in the content fields of the SF and workflow. Ultimately, 45% of patients on OC had the SF completed. An OC plan was documented in 41% of patients, compared to 33% at baseline; 87% had an administration schedule compared to 81%. There was an increase in the number of patients contacted following start of OC, 35% from 4%. Medication adherence was assessed in 35% of patients, up from 7%. Documented discussions addressing medication adherence increased to 78%, from 0%. Conclusions: Introduction of the Oral Chemo SF in pilot clinics improved documented OC plans and administration schedules. Its use introduced a standard process for monitoring safety, assessing and addressing non-adherence, while troubleshooting specialty pharmacy dispensing issues. The SF will be implemented throughout FCCC and further evaluated with efforts focused on adopting and streamlining this as standard work.

Sustaining safety and delivery of oral chemotherapy utilizing lean methodology.

218 Background: An oral chemotherapy safety event in 2017 prompted analysis of related workflows utilizing lean quality improvement methodology. Three kaizen workshops utilizing lean methodology with primary objectives to 1) develop safety standards for oral chemotherapy as rigorous as those for intravenous chemotherapy; 2) improve efficiency; and 3) design workflows that enable data collection and process control were conducted. Since 2017, our goal has been to sustain developed workflows to ensure oral chemotherapy patients have the right oral chemotherapy agent, at the right dose, at the right time, with independent and efficient safety checks by all care providers. Methods: After multidisciplinary teams participated in three kaizen workshops to develop workflows, education plans were developed and results were incorporated into the lean management system. The lean production method of Training Within Industry (TWI) was used to train physician, nursing, and pharmacy teams to the workflows. Results were communicated to key stakeholders weekly to monitor progress on workflow creation, spread, and process metrics designed to signal defects in the workflow. When processes were deemed ‘out of control,’ clinical team members provided regular and targeted interventions. Safety data were collected and correlated to surrogate outcomes for long-term impact assessment. Results: Interventions resulted in the following outcomes: 62 consecutive weeks with 99% reduction in oral chemotherapy defects reaching pharmacy. 86 consecutive weeks with 51% error reduction processing oral chemotherapy though a single EMR workflow. 57 consecutive weeks with 62% error reduction processing oral chemotherapy though a single EMR workflow. No serious safety events have occurred since 2017. Conclusions: Comprehensive quality improvement in our oral chemotherapy process has resulted in sustained safety, efficiency, and a data collection to signal when process defects occur. Multidisciplinary teams utilizing established lean methodology were critical to success.

Improving oral chemotherapy compliance and documentation in a safety-net oncology clinic.

263 Background: Barriers to safe delivery of oral chemotherapy in a safety net hospital population include lack of health insurance, delays in medication delivery, and language barriers. Baseline chart review at the Lyndon B. Johnson Hospital oncology clinic revealed sparse documentation of oral chemotherapy education and compliance. Our team conducted the present quality improvement project to improve documentation of toxicity assessment, patient education, and compliance with the oral chemotherapy agents capecitabine, palbociclib, and sorafenib by 25% from October through December 2020. Methods: A set of standardized questions designed to assess for the above domains were generated in the form of an auto-populated electronic medical record phrase ("dot phrase," see Figure 1). Using weekly timed email notifications, physicians were reminded to incorporate these questions in their documentation during clinic visits. Chart review was performed to assess usage frequency of the dot phrase. A post-intervention survey was administered to assess providers' experience with use of the dot phrase, and assess barriers to consistent documentation. Results: 41 patients over 3 months were identified as taking the oral chemotherapy drugs capecitabine (68%), palbociclib (29%) or sorafenib (3%). 63% were non-English speakers. 49% had breast cancer, 39% GI cancers, and 12% other cancers. 12% of clinic visits correctly incorporated use of the dot phrase. Education on the dosing and schedule for oral chemo was addressed for 48% of patients, documentation of adverse effects was performed for 34% of patients, and assessment of medication adherence was documented for 22% of patients. While 73% of providers felt that documentation of oral chemotherapy compliance is important, 70% cited failure to remember to incorporate the dot phrase in real time as the primary reason for failure to use the dot phrase for oral chemotherapy documentation. Conclusions: Despite providers' view of documentation of oral chemotherapy toxicities and compliance as important, low uptake of the dot phrase was observed. The main barrier to use of the dot phrase was providers' forgetting to incorporate the dot phrase prior to and during their clinic charting. Future efforts should focus on automated reminders and regular assessments to increase compliance to this important quality domain. [Table: see text]

Health-system specialty pharmacy impact on oral chemotherapy outcomes.

240 Background: Oral chemotherapy usage has grown significantly over the years as it provides a more convenient and less invasive administrative option for patients.In 2019, 89% of large hospitals owned and operated their own Health System Specialty Pharmacies (HSSP)1.Pharmacist-led medication therapy management services are crucial to provide patient education, monitoring of medication adherence and adverse effect management. With the current vertical integration of health plans and pharmacy benefit managers (PBMs) increasing their dominance over specialty dispensing channels, HSSP are often excluded from specialty networks. The objective of this study is to compare outcomes of oncology patients filling their oral chemotherapy at Cedars Sinai Medical Center (CSMC) Specialty Pharmacy versus those who are filling their medications at outside specialty pharmacies (OSP). Methods: Electronic health records were used to conduct a retrospective chart review of patients started on oral chemotherapy at CSMC between January 2019 to January 2021. Primary endpoints included time to treatment (TTT) and proportion of days covered (PDC). Secondary endpoints included drug-related problems (DRPs) and treatment-related ED visits and hospitalizations. DRPs were categorized by severity and type of intervention. Results: There were 100 patients included in the study: CSMC group (n = 50) and OSP group (n = 50). Patients in the CMSC group had significantly shorter TTT compared to OSP group (4 days vs. 9.5 days, respectively [P < 0.0026]), as well as a higher PDC (99.5% vs 91%, respectively [P < 0.0005]). Pharmacists identified and resolved 31 DRPs in CSMC arm with 19 DRPs categorized as serious and 1 DRP categorized as life-threatening. For the OSP group, 23 preventable DRPs were identified with 12 DRPs categorized as serious and 1 DRP categorized as life-threatening. There were no treatment-related ED visits or hospitalizations in either group. Conclusions: Patients filling their oral chemotherapy at CSMC Specialty Pharmacy had significantly quicker TTT and higher adherence rates as measured by PDC. Numerous DRPs were identified for OSP patients; potential pharmacist-interventions could have led to optimized and safer medication therapy if filled at a HSSP. Continued research comparing treatment outcomes and interventions made between HSSP and OSP can create a strong argument for health plans and PBMs to consider inclusion of HSSPs into their specialty networks. References: Pedersen CA, Schneider PJ, Ganio MC, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Prescribing and transcribing—2019. American Journal of Health-System Pharmacy. 2020;77(13):1026-1050. doi:10.1093/ajhp/zxaa104

A systematic approach to improving oral chemotherapy consent compliance in a rural cancer center.

206 Background: Ensuring quality and comprehensive cancer care for our patients, families and our communities have been goals for the Cancer Center since its inception. To achieve these goals we must encourage collaborative decision-making, patient autonomy and promote a culture of patient safety with regards to all aspects of care, including treatment planning. Oral chemotherapy consent compliance has been a measured monthly Quality metric by the Cancer Center since 2018. A steady decline in compliance began in June 2019. 38% of all patients prescribed new oral chemotherapy did not sign an Informed Consent prior to beginning therapy. Lack of compliance may compromise patient safety and autonomy. In order to ensure our patients are fully informed regarding recommended treatment options, we evaluated our compliance to ASCO’s Quality Oncology Practice Initiative (QOPI) Core Module, Measure 14 which requires a signed patient consent for chemotherapy. This project was initiated during the 2020 Quality Training Program (QTP) in Alexandria, Virginia and progressed through the COVID-19 pandemic. Methods: Using the systematic approach and quality improvement tools taught during the QTP, we engaged a multidisciplinary Quality Improvement (QI) team to assist in gathering, organizing and interpreting data. The QI team sought input from all providers, their associated teams and Navigators regarding current processes and barriers. Process maps were created for each team; with both variables and percent of consent compliance being compared. The QI team identified common barriers to obtaining consent. A Cause and Effect Diagram, Pareto Chart and Prioritization Matrix were used narrowing the focus for the changes developed for improvement. Two quarterly Plan-Do-Study-Act (PDSA) cycles were conducted from March through September 2020. Results: PDSA cycle one was implemented in March of 2020 immediately prior to the COVID-19 pandemic affecting our area. Despite the competing priority of COVID Pandemic, results improved to 76% compliance over a 4 month period. PDSA cycle 2 was implemented at the end of July 2020. Following PDSA cycle 2, compliance rates improved to 91%. With no additional process changes, compliance continues to maintain through April of 2021 at 92%. Conclusions: The use of the QTP systematic approach improved oral chemotherapy consent compliance to just short of our 92% improvement goal. In spite of the obstacles brought about by COVID-19, compliance rates for August-October 2020 increased to 91%. As a result of the study process, we are now more cognizant of the variability in practices among our providers. This awareness will aid us in development and success of future processes. We continue to monitor compliance and adjust processes related to oral chemotherapy informed consent to accommodate on-going COVID-19 implications, staffing variances and ever-changing approved chemotherapy regimens.

Implementation and outcomes of a pharmacist-led oral chemotherapy clinic at VA Maine Healthcare System

Background Patients undergoing intravenous chemotherapy tend to receive more structured follow-up and closer monitoring than those taking oral chemotherapy. The management of oral chemotherapy at our facility was historically segmented and weighed heavily on veteran self-advocacy. It was hypothesized that routine check-ins with a clinical pharmacy specialist with a scope of practice would allow for a more proactive, supportive approach to care. Objective The primary purpose of this quality improvement project is to ascertain the impacts of a pharmacist-led oral chemotherapy clinic at the VA Maine Healthcare System. Methods: Starting January 7, 2019, all patients filling an oral medication(s) for cancer treatment were considered for enrollment into the pharmacist-run clinic at the time of medication approval. The pharmacist contacted each patient by phone at patient-specific intervals determined by drug-specific lab monitoring requirements, side effect prevalence, refill due date, and overall patient preference. The total number of interventions was tallied by intervention category. Medication adherence was assessed as a secondary outcome by comparing medication possession ratios preclinic and postclinic implementation. Results From January 7, 2019, to January 5, 2020, there were a total of 698 interventions made by the clinical pharmacist. These impacts are a composite of pharmacologic ( n = 141), nonpharmacologic ( n = 115), and surveillance ( n = 442) interventions. Medication possession increased from 92% to 96% ( p < 0.05). Conclusion A pharmacist-led oral chemotherapy clinic allows for a variety of clinically significant interventions and improved monitoring of patients on oral anticancer medication(s). Providing proactive follow-up with a scoped pharmacist improved medication compliance and improved the quality of care for our veterans.