Chicago, IL—Oral chemotherapy pharmacists face unique hurdles when reporting patient outcomes, according to Alison Palumbo, PharmD, MPH, BCOP, Clinical Oncology Pharmacist, Oregon Health and Science University (OHSU) Hospital, Portland. There are currently no standard reporting metrics in place, so various reporting strategies are used. in addition, there have been few robust studies in oral chemotherapy specifically.
In response to these gaps in the literature, Dr Palumbo and her colleagues sought to evaluate whether patient-centered therapy management software, in conjunction with use of electronic medical records (EMRs), would be valuable in completing pharmacist activities and capturing patient outcomes.
The researchers conducted a retrospective, observational chart review study using data from EMRs, a patient-centered therapy management software program, and patient satisfaction surveys, and presented their findings at the Hematology/Oncology Pharmacy Association (HOPA) 2018 Practice Management Conference.
Gaps in the Literature
The researchers’ primary objective was to describe patient care activities completed by oncology pharmacists, including clinical interventions, drug interactions identified, and medication reconciliations. The study’s secondary objective was to describe the effect of oncology pharmacists on patient outcomes in the realms of adherence, toxicity management, and satisfaction.
Patients with cancer in this study were aged between 18 and 85 years and were receiving oral chemotherapy from an OHSU specialty pharmacy between October 2016 and April 2018. The investigators excluded patients who were receiving their prescriptions at an OHSU specialty pharmacy but who were not being treated by OHSU physicians.
A total of 139 patients were included in the study, with 78 patients evaluable for follow-up assessment. The majority of patients were women, with a mean age of 62 years, and the majority of all study participants were treated at OHSU community oncology sites. Approximately 50% of the study’s participants were patients with breast cancer, followed by leukemia and prostate cancer. The most commonly prescribed oral chemotherapy agents were anastrozole (Arimidex), letrozole (Femara), and capecitabine (Xeloda).
Pharmacists spent a little under half an hour on average with each assessment (initial and follow-up). Medication reconciliation was performed on 71% of patients initially, but that figure dropped to approximately 44% going into follow-up.
“However, it is hard to say if this is an accurate number, because the number of unreported incidents was higher on follow-up,” Dr Palumbo noted. Medication reconciliations were initially unreported 22% of the time, compared with about half of the time at follow-up.
The researchers also looked at whether clinical interventions were completed. Dr Palumbo noted that the numbers were quite low (3.4% initially and 1.4% at follow-up), possibly caused by documentation errors and duplication of efforts.
However, in terms of the clinical interventions that the researchers did observe, pharmacists conducted activities such as monitoring (ie, recommending baseline electrocardiogram or echocardiogram for patients starting osimertinib [Tagrisso]), symptom management (ie, recommending granisetron in place of ondansetron [Zofran]), and care planning interventions (ie, discussing reinitiating oral chemotherapy, in this case, ibrutinib [Imbruvica]).
The researchers then evaluated the drug interactions identified by pharmacists. They found that on initial assessment, drug interactions were not reported 13% of the time, and at follow-up they went unreported 60% of the time.
“Underreporting was quite an issue with the software,” Dr Palumbo said.
In contrast to pharmacist activities, patient outcomes were only underreported approximately 10% of the time initially and at follow-up. Most of the time, side effects did not require an intervention, but at follow-up, the interventions required were slightly more severe. For example, <1% of patients required a drug holiday at initial assessment, compared with 3% at follow-up.
Adherence was high; more than 80% of the time patients were taking 100% of their drug and, if not, the majority were taking their drug >95% of the time. Underreporting, again, was <10% on initial assessment and at follow-up, although the degree of nonadherence was worse at follow-up; 3.2% of patients had <80% adherence at follow-up, compared with none at initial assessment, most likely attributed to side effects, she noted.
According to Dr Palumbo, patient satisfaction survey results revealed that patients were extremely satisfied with the program, but possible areas of improvement included patient education and pharmacist–patient communication. Survey results also showed that all patients either got their prescriptions on time or before the expected date, and the vast majority of patients felt that the refill reminders were helpful.
Dr Palumbo said that some strengths of using the software included the relative simplicity of running reports, the ease of use (when questions were answered consistently), and the ability to track follow-up dates. Also, using it allowed their program to maintain its accreditation with the Utilization Review Accreditation Commission.
The limitations, however, were quite numerous, she added. The program is costly, and it requires double documentation, which is not ideal. It separates data by drug, not diagnosis, creating extra paperwork if a pharmacist makes amendments to a patient’s general oncology assessment. Software updates may result in patient data being lost, and not all drugs were initially included in the software (additional packages must be purchased to unlock access to all oncology drugs). Accounting for all of these limitations can be quite time-consuming, she noted.
Based on these findings, Dr Palumbo recommends moving all documentation into one place (ie, EMRs). She noted that the type of software used in this study was not actually required to maintain accreditation, because it can be maintained through a variety of reporting mechanisms. Moving forward, she suggests making certain assessments required to minimize underreporting, which may require the pharmacist to answer a question in the EMR before moving on, and improving the documentation of pharmacist interventions.
“These are all things we can do to help improve the documentation of our patient outcomes, especially if we’re going to use this type of software,” Dr Palumbo concluded.—MB