Pharmacist-Led Oral Chemotherapy Management Program: Improved Adherence Rates and Clinical Outcomes
Cathy Y. Cao, PharmD BCOP
Dana-Farber Cancer Institute
Oral anticancer therapies are becoming a main treatment option for many types of cancer. Most of these medications are distributed through a few specialty pharmacies, and most specialty pharmacies remain entities separate from ambulatory care clinics. This stand-alone practice model can lead to operational challenges because of segregated communication channels with patient care teams. To integrate specialty pharmacy into patient care, the University of North Carolina Medical Center (UNCMC) started its own specialty pharmacy. The internal specialty pharmacy filled and dispensed specialty prescriptions, in addition to providing medication assistance. Muluneh and colleagues developed and implemented a closed-loop pharmacist-led oral chemotherapy management program through the specialty pharmacy to manage patients who were prescribed oral chemotherapy by UNCMC oncologists.1 They recently published their experiences and results of the program in the Journal of Oncology Practice.
The oral chemotherapy management program services included patient counseling on oral anticancer therapy, adherence monitoring, and medication management. With this combination of specialty pharmacy and clinical pharmacy services, UNCMC was able to provide a full spectrum of pharmacy services, including dispensing, counseling, refilling, clinical monitoring, and management of patients on oral chemotherapy. The pharmacists who participated in this oral chemotherapy management were credentialed as clinical pharmacist practitioners (CPPs) by the North Carolina Board of Medicine and Pharmacy. This credential allowed licensed pharmacists to provide drug therapy management under a collaborative practice agreement with a licensed physician in the state of North Carolina.
The program was first implemented in the hematology, breast, and gastrointestinal (GI) oncology clinics at UNCMC. The study measured several endpoints, including the impact of a specialty pharmacy and pharmacist-led program on patient knowledge, drug adherence, service satisfaction, and clinical outcomes. Patient knowledge of oral chemotherapy was measured with a 5-question test before and after pharmacist-led counseling. The adherence rates were calculated on the basis of medication possession rate (MPR), a validated scale, with goals of greater than 90% adherence for the hematology clinic and greater than 80% for the breast and GI clinics. Patient and physician satisfaction ratings of the specialty pharmacy and clinical pharmacy services were assessed using a 5-point Likert scale. Last, the study compared molecular response rates of patients with chronic myeloid leukemia (CML) who were treated with oral chemotherapy before and after the implementation of this program.
Research data were collected from September 2014 to June 2015. A total of 107 patients (70 hematology and 37 breast or GI patients) enrolled in the program. The internal specialty pharmacy captured 263 new prescriptions, 257 refills, and 413 clinical interactions (refill follow-up and adherence monitoring). The CPPs counseled 100% of the patients enrolled. The average pretest score was 43% versus 95% for posttest score (p =.0058). In the first 90 days of therapy, each patient had an average of 3.5 encounters with a CPP, including the initial counseling encounter. The CPPs documented 350 follow-up encounters in clinic or by telephone, 318 adverse drug reactions, and 238 total interventions. The most common interventions were management of adverse effects (57%) and dose modification recommendations (16%).
The average self-reported adherence rates for hematology patients and breast/GI patients were 94.7% and 86%, respectively. The MPRs verified for hematology and breast/GI patients were 93.9% and 85%, respectively. According to the patient survey results, 97.8% of the patients reported that the teaching provided at the beginning of therapy was “good” or “excellent.” Most patients (97.5%) agreed or strongly agreed that they will continue to use the internal specialty pharmacy in the future. The physician survey had a 45% response rate, and results showed that the physicians valued the education provided by the CPPs and felt that they were knowledgeable. With the CML patients, more patients achieved an early molecular response (EMR) or major molecular response (MMR) at 12 months than the historic preintervention cohort of patients (EMR, 88.9% vs. 54.8%; p = .0138; MMR, 83.3% vs. 57.6%; p = .0575, respectively), indicating a statistically significant improvement in clinical outcome.
A closed-loop pharmacist-led oral chemotherapy management program greatly improved patients’ understanding of oral chemotherapy, maintained best-practice adherence rates, and received high satisfaction scores from both patients and physicians. In addition, this study showed a significant improvement in CML patient outcomes for patients enrolled in this program when compared to UNCMC’s own historical data. This pharmacist-led model disrupted the traditional stand-alone specialty practice and demonstrated that integration and collaboration within cancer treatment teams led to outstanding results and patient experiences.
- Muluneh B, Schneider M, Faso A, et al. Improved adherence rates and clinical outcomes of an integrated, closed-loop, pharmacist-led oral chemotherapy management program. J Oncol Pract. 2018 May 25. doi:10.1200/JOP.17.00039. [Epub ahead of print]