Pharmacy-Led Intervention Improved Tyrosine Kinase Inhibitor Adherence and Monitoring

TOP - May 2017, Vol 10, No 2 - NCCN News
Audrey Andrews

Orlando, FL—A pharmacist-led outreach program at Magellan Rx Management improved adherence to tyrosine kinase inhibitors (TKIs), and compliance with polymerase chain reaction (PCR) testing in patients with chronic myeloid leukemia (CML).

A study of the program’s results was reported by YuQian Liu, PharmD, Manager, Specialty Clinical Programs, Magellan Health, Scottsdale, AZ, at the National Comprehensive Cancer Network (NCCN) 22nd Annual Conference.

The intervention led to an 8.5% relative increase in the proportion of patients who were able to achieve target adherence, as well as an increase in patients who underwent the recommended monitoring.

The key to good outcomes in CML is adherence to treatment with TKIs. Current guidelines recommend routine PCR testing to measure total leukemia cell mass and the degree to which BCR-ABL transcripts are reduced by treatment. The recommendation is for PCR testing every 3 months for the first 2 years after the patient achieves BCR-ABL 0.1% to <1%, and every 3 to 6 months thereafter.

Previous studies demonstrated that patients who received at least 3 to 4 PCR tests a year had a lower risk for disease progression and incurred fewer inpatient admissions compared with patients who did not receive the tests, Dr Liu and colleagues reported. Despite recommendations, testing and monitoring are significantly underused in patients with CML, which may lead to worsened clinical outcomes.

Details of Assessment and Intervention

Dr Liu and colleagues instituted their CML Adherence and Assessment Program in a regional health plan that covers approximately 700,000 patients, among whom they identified patients with CML who were receiving TKIs. They determined treatment adherence by calculating the proportion of days covered, from the date of the first TKI fill to the end of the specified evaluation period.

The 1-year intervention period involved telephone outreach by pharmacists to patients monthly, and to providers every 3 months, to discuss and resolve adherence barriers to TKI therapy and PCR testing. Providers were also sent quarterly reports summarizing trends in their patients’ adherence to TKI therapy and PCR testing.

To assess the impact on adherence and use of PCR testing, Dr Liu and colleagues analyzed pharmacy and medical claims data 1 year before and 1 year after the study initiation date.

Frequently Identified Barriers

During patient outreach, the pharmacists identified adherence barriers to TKI therapy and to PCR testing.

Approximately 72% of patients reported having ≥1 barriers to treatment adherence, which were, in order from most to least frequent, adverse effects (eg, nausea, vomiting, gastrointestinal discomfort, muscle soreness, fatigue), forgetfulness, pharmacy-related issues (eg, delay in treatment), cost, and delay in prior authorization approval.

Approximately 26% of patients reported experiencing ≥1 barriers to PCR testing, including cost of testing, prescriber’s lack of awareness of testing recommendations or presumption that the test would not be covered, and transportation issues.

According to the information reported by providers, 71% of patients should have received PCR testing every 3 months; however, based on claims analysis, only 56% of providers ordered the recommended testing, and only 22% of patients received this testing.

Effect of Intervention

The adherence goal was proportion of days covered ≥85%, which was met after the intervention. The average proportion of days covered for all patients was 83% before the intervention and 85% after the intervention.

The proportion of patients with proportion of days covered ≥85% rose from 68% at baseline to 74% with intervention. By TKI brand, the change from baseline was 8% for ponatinib, 2% for imatinib, 8% for dasatinib, and 8% for nilotinib. Bosutinib was not included in the analysis because of its low use. The drug with the highest average proportion of days covered was ponatinib, with 97% adherence following the intervention.

The percentage of members using the NCCN–recommended number of PCR tests also increased. After the intervention, the percentage of patients receiving ≥2 tests increased from 67% at baseline to 69%, and those receiving ≥4 tests increased from 18% to 22%.

Dr Liu and colleagues acknowledged that although the proportion of patients who received ≥4 annual PCR tests increased, many patients were still not being tested as frequently as is recommended by the guidelines.

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Last modified: May 10, 2017