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Collaborative Drug Therapy Management in the Oncology Setting

Peter Campbell, PharmD BCOP
Clinical Pharmacy Manager, Hematology/Oncology
New York–Presbyterian Hospital, Columbia University Medical Center
New York, NY


Collaborative practice agreements (CPAs) allow pharmacists to contribute toward a team-based healthcare model, as well as improve medication safety and achieve cost savings.1,2 The concept of collaborative drug therapy management (CDTM) is not new: the first position statement on the topic was issued by the American College of Clinical Pharmacy in 1997.3 As the projected shortage of oncologists increases each year, the need for CDTM agreements grows. A 2014 study published by the American Society of Clinical Oncology projects that by the year 2025, about 2,400 fewer oncologists may be practicing than are needed.4 As the projected shortage of healthcare providers, and specifically oncologists, increases, pharmacists are in a position to help improve access to healthcare in the oncology setting.5

Although CDTM is not universally permitted, 48 states currently have laws and regulations in place allowing its implementation. The pharmacy services that are allowed under CPAs vary by state and may include such functions as modifying medication therapy, initiating and discontinuing medication therapy, and ordering and interpreting laboratory studies. Although CDTM agreements traditionally exist between pharmacists and physicians, a number of states have allowed CDTM agreements to expand and include other healthcare providers such as nurse practitioners. The scope of practice of the collaborating pharmacist also will vary depending on each state’s laws and regulations. Many states allow the pharmacist to make patient-care interventions according to preselected protocols and guidelines or for specific drug classes or drugs. Some states, however, allow the pharmacist to make patient-care interventions without the use of protocols, providing a more autonomous scope of practice.6

Much of the literature on CPAs that has been published to date has focused on chronic disease states, with numerous studies showing clinical benefits in such disease states as diabetes, hypertension, and hyperlipidemia.7,8 Currently, limited data are available to document the clinical or economic benefits of CDTM in the oncology setting. Hansen and colleagues reported the outcomes of CDTM agreements for the management of chemotherapy-related symptom management in a gynecologic oncology clinic. The CDTM agreements contained treatment algorithms for the management of chemotherapy-induced nausea and vomiting, chemotherapy-induced peripheral neuropathy, vasomotor symptoms, vaginal dryness, and bone health. This CDTM pilot study showed favorable results in patient and physician satisfaction surveys, as well as improvements in patient symptom scores compared to baseline.9 Valgus and colleagues described the implementation of a pharmacist-led interdisciplinary care model in an outpatient oncology clinic serving gynecologic, radiation, medical, and surgical oncology patients. The majority of medication interventions pertained to pain management, with the other symptoms commonly managed consisting of nausea and vomiting, constipation, and anxiety. Reductions in patient-reported symptoms were seen after the first visit, and reductions were sustained over an average of three visits.10

Though numerous studies of the clinical outcomes associated with CPAs have been conducted, some studies have detailed their economic benefits. Schumock and colleagues conducted a systematic literature review of articles that evaluated the economic impact of clinical pharmacy services. This review identified pharmacy interventions in a wide range of clinical settings, including government clinics, hospital-associated clinics, community hospitals, university hospitals, and physicians’ offices. A mean benefit-to-cost ratio of 4.68 to 1 was shown with the addition of clinical pharmacy services.2 The financial impact of clinical pharmacy services was also reported by Lee and colleagues in a study that evaluated the economic impact of pharmacists’ recommendations.11 This review evaluated 600 medication recommendations by pharmacists in a variety of settings, including inpatient and outpatient facilities and nursing homes. A total of 1,511 recommendations were made, with a physician acceptance rate of 92.4%. The mean medication cost avoidance was increased in the inpatient setting as compared to the outpatient setting or nursing homes, but the mean total medication cost avoidance was $420,155.11 Although the financial impact will vary depending on the practice setting and clinical scenario, this study shows that pharmacists’ interventions can lead to substantial cost savings. A Cochrane Database review of 25 studies showed that pharmacists’ collaborative practice resulted in a decrease in the overall use of drugs, as well as the cost.12 Despite the fact that studies have shown the positive effect of pharmacists’ interventions on healthcare costs, reimbursement and funding for these services are limited. Without adequate compensation, the implementation of CDTM may be severely limited, and this limit may be a barrier to optimizing healthcare outcomes.1

The documentation of pharmacy services is an important component of CDTM and can help further the development of collaborative agreements. Although not all states have laws and regulations requiring documentation of pharmacists’ activities, many require that pharmacists record and track interventions and that collaborating prescribers review these documents at routine intervals.4 The documentation of activities can allow collaborating prescribers to monitor and approve of interventions, but it also allows tracking to be used for financial and research purposes. Future research supporting the financial and clinical impact of CDTM on the healthcare system will require thorough records and evaluation of pharmacists’ interventions. These documents may be in the form of electronic medical records or in a format tailored to the practice setting and CPA. A study by Sledge and colleagues reported on the use of a daily pharmacy progress note in the surgical intensive care unit. In a 2-month period, 462 daily pharmacy progress notes resulted in 1,055 therapy changes and the avoidance of one sentinel event.13 This study showed that the documentation of pharmacy services not only provides evidence of the pharmacist’s involvement in the multidisciplinary team but also improves patient outcomes.

Despite the many proven benefits of CDTM, many providers are hesitant to sign a CPA. Many reasons for this concern exist, such as not understanding the pharmacist’s credentialing, experience level, or scope of practice.6 Thus, it is important that the pharmacist has established a trustworthy relationship with the providers with whom they request entrance into a CPA. Snyder and colleagues reported on the importance of trustworthiness in the success of CDTM agreements in the community setting. It was shown that physicians scored pharmacists higher on a Pharmacist-Physician Collaborative Index when they had frequent face-to-face communications and when the pharmacist made consistent contributions that improved patient care.14 Also, healthcare providers who have a strong working relationship with a pharmacist are more likely to have success in improving clinical outcomes.

Although many states require pharmacists to possess specific education and training in order to participate in CPAs, physicians and other healthcare providers may not be familiar with pharmacists’ credentials. One way to alleviate this problem would be to educate the prescriber on the credentialing process for pharmacists and explain any experience the pharmacist may have within the given field of practice.

The development of CPAs between pharmacists and healthcare providers has been shown to improve clinical and economic outcomes, increase access to health care, and improve medication safety. Given the projected shortage of physicians, and specifically oncologists, pharmacists are in a position to improve oncology patients’ access to the healthcare system. Pharmacists should therefore work closely with their collaborating prescribers to develop trustworthy relationships and limit any potential barriers to CDTM implementation. Routine documentation of pharmacy activities can help demonstrate the clinical and financial impact of CDTM and may provide a basis for reimbursement for services in future healthcare models.  

References

  1. Giberson S, Yoder S, Lee MP. Improving patient and health system outcomes through advanced pharmacy practice. A report to the U.S. Surgeon General. Office of the Chief Pharmacist. U.S. Public Health Service. Dec 2011.
  2. Schumock GT, Butler MG, Meek PD, et al. Evidence of the economic benefit of clinical pharmacy services: 1996-2000. Pharmacotherapy. 2003;23(1):113-132.
  3. Carmichael JM, O’Connell MB, Devine B, et al. Collaborative drug therapy management by pharmacists. Pharmacotherapy. 1997;17(5):1050-1061.
  4. Yang Y, Williams JH, Hogan PF, et al. Projected supply of and demand for oncologists and radiation oncologists through 2025: an aging, better-insured population will result in shortage. J Oncol Pract. 2014;10(1):39-45.
  5. Manolakis PG, Skelton JB. Pharmacists’ contributions to primary care in the United States collaborating to address unmet patient care needs: the emerging role for pharmacists to address the shortage of primary care providers. Am J Pharm Ed. 2010;74(10):S7.
  6. Centers for Disease Control and Prevention. Advancing Team-Based Care Through Collaborative Practice Agreements: A Resource and Implementation Guide for Adding Pharmacists to the Care Team. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2017.
  7. McBane SE, Dopp AL, Abe A, et al. Collaborative drug therapy management and comprehensive medication management–2015. Pharmacotherapy. 2015;35(4):e39-e50.
  8. Doucette WR, McDonough RP, Klepser D, McCarthy R. Comprehensive medication therapy management: identifying and resolving drug-related issues in a community pharmacy. Clin Ther. 2005;27:1104-1111.
  9. Hansen EA, Pietkiewicz JM, Blum BL. Evaluation of the feasibility and utility of a pharmacist-centered collaborative drug-therapy management program for oncology-based symptom management. J Pharmacy Pract. 2016;29(3):206-211.
  10. Valgus J, Jarr S, Schwartz R, et al. Pharmacist-led, interdisciplinary model for delivery of supportive care in the ambulatory cancer clinic setting. J Oncol Pract. 2010;6(6):e1-e4.
  11. Lee AJ, Boro MS, Knapp KK, et al. Clinical and economic outcomes of pharmacist recommendations in a Veterans Affairs medical center. Am J Health-Syst Pharm. 2002;59:2070-2077.
  12. Beney J, Bero LA, Bond C. Expanding the roles of outpatient pharmacists: effects on health services utilization, costs, and patient outcomes. Cochrane Database Syst Rev. 2000;(3):CD000336.
  13. Sledge T, Lonardo N, Simons H, Shipley W. Implementing the use of pharmacist progress notes in the surgical ICU. Hosp Pharm. 2016;51(7):577-584.
  14. Snyder ME, Zillich AJ, Primack BA, et al. Exploring successful community pharmacist-physician collaborative working relationships using mixed methods. Res Social Adm Pharm. 2010;6:307-323.
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