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Asia-Pacific Journal of Clinical Oncology 2014
doi: 10.1111/ajco.12267
ORIGINAL ARTICLE
Impact of a specialist clinical cancer pharmacist at a multidisciplinary lung cancer clinic Clare WALTER,1* James D MELLOR,1*† Carol RICE,1 Sue KIRSA,1 David BALL,2 Mary DUFFY,3 Alan HERSCHTAL4 and Linda MILESHKIN5,6 1
Pharmacy Department, 2Division of Radiation Oncology, 3Division of Cancer Allied Health, Nursing and Support, 4Centre for Biostatistics and Clinical Trials, 5Division of Cancer Medicine, Peter MacCallum Cancer Centre, St Andrew’s Place, East Melbourne and 6University of Melbourne, Parkville, Victoria, Australia
Abstract Aim: Medication misadventure contributes to unplanned hospital admissions. General practitioners (GPs) may lack experience in managing problems involving complex cancer-related medication. A previous survey explored the unmet needs of lung cancer outpatients and highlighted their desire for more medication information. Inpatient clinical pharmacy services positively impact on patient care. This study evaluated the effects of extending this service to outpatients. Method: A specialist cancer pharmacist joined the lung cancer clinic team for 6 months. Patients completed assessments of their medication adherence and their satisfaction with the provision of medicine information (at baseline and repeated within 30 days of initial pharmacist review). Following review, a medication list and plan (detailing recommendations/interventions) were provided to patients and their health care providers. Interventions were categorized and graded according to risk avoided. Unplanned admissions and clinic attendance rates were compared with the previous year. GPs’ opinion of the service was also evaluated. Results: Forty-eight patients participated in the study. Medication adherence (P = 0.007) and patient satisfaction (P < 0.001) significantly improved. A total of 154 pharmacist interventions were made: 4.5% extreme risk and 43.5% high risk. The mean number of unplanned admissions and clinic attendances per patient decreased from 0.3 to 0.26 (P = 0.265) and from 3.32 to 2.98 (P = 0.004), respectively. Seventy-four percent of surveyed GPs found the service useful. Conclusions: Adding a specialist cancer pharmacist to the outpatient lung cancer team led to significant improvements in patient medication adherence. Both patients and GPs were highly satisfied with the service. Medication misadventure and clinic attendances were reduced. Key words: adherence, lung cancer, medication, outpatient clinic, pharmacist.
Correspondence: Mrs Clare Walter B.Pharm, Pharmacy Department, Peter MacCallum Cancer Centre, Locked Bag 1, A’Beckett Street, Vic. 8006, Australia. Email: [email protected] *Joint first authors. † Present address: Dan Mellor, Roche Products Pty Ltd., 108 Power Street, Hawthorn, Vic. 3122, Australia. Conflict of interest: Roche Pharmaceuticals was not involved in the conception, design, and conduct or reporting of this study. Subsequent to this study, Dr Dan Mellor became employed by Roche Pharmaceuticals Accepted for publication 20 July 2014.
© 2014 Wiley Publishing Asia Pty Ltd
INTRODUCTION Patients with chronic diseases are known to have a high rate of unplanned hospital admissions, and medication misadventure is a known contributor.1–3 In Australia, 25% of patients in the community who have been designated as “high-risk” report experiencing an adverse drug event.3 High-risk patients include: older people, those with serious health conditions, those taking multiple medications, those using high-risk medicines (such as warfarin) and those being transferred between
2
community and hospital care. Many lung cancer patients meet the high-risk criteria, often for multiple reasons.3 A patient survey conducted in 2007 explored the unmet needs of lung cancer outpatients at our tertiary cancer center.4 A key finding was the desire of patients for more information regarding their medication. The survey (n = 197) found that 53% [95% CI 46–60%] of patients wanted more information on possible side effects of their medication, 27% [95% CI 21–34%] wanted more information on complementary and alternative medications (CAMs) and 26% [95% CI 20–33%] wanted more information regarding their medication in general. Lung cancer patients and their caregivers may be faced with an overwhelming number of new medications prescribed by an array of different physicians giving rise to complicated medication regimes. In our experience, it is not uncommon for a lung cancer patient to be commenced on 5–10 new medications in the course of a few months. Community-based general practitioners (GPs) and pharmacists, although experienced in dealing with patients’ regular medications, may lack the experience or expertise to identify and act on problems involving complex cancer-related medication. Documentation errors occur between the hospital and primary caregivers, with 52–88% of transfer documents containing an error, leaving both the hospital practitioners and GPs unaware of their patients’ current medications.3 The value of medication reviews in assisting patients and their carers to manage medications appropriately has been demonstrated in patients with chronic diseases who are taking multiple medications.5–9 Previous studies have highlighted the problems that arise due to the lack of continuity of care when patients are discharged from the hospital.3,6,7,10 Community liaison programs have been successfully developed by hospital pharmacists for acute medical11 and palliative care patients12; however, a literature search failed to identify any program in Australia developed specifically for cancer patients. Clinical pharmacy services are the standard of care for admitted hospital patients and pharmacist interventions have been shown to significantly impact on patient care, length of hospital stay and hospital costs.13 An experienced cancer pharmacist possesses the specific knowledge about the medications used in the care of cancer patients and has been shown to obtain more accurate medication histories than doctors or nurses in the hospital setting.2 However, this service is not currently standard of care for ambulatory oncology patients in
© 2014 Wiley Publishing Asia Pty Ltd
C Walter et al.
Australia. The aim of this study was to provide a clinical pharmacy and community liaison service to ambulatory patients in the lung cancer clinic and evaluate what benefits are seen in this population.
METHODS This was a single-center, nonrandomized quality improvement project designed to assess the impact of providing a specialist clinical cancer pharmacist to address the specific medication management and information needs of ambulatory lung cancer patients in the outpatient setting. The project was approved by the Peter MacCallum Cancer Centre ethics committee. Eligible patients were identified by the lung team from clinic lists over a 6-month period. Patients provided verbal consent to take part in this study. Inclusion criteria were as follows: ≥18 years of age; diagnosis of lung cancer and receiving chemotherapy, radiotherapy, surgery or palliative care at our center; ability to participate in a telephone interview; ability to complete an adherence assessment tool; and ability to possess one or more of the following risk factors: ≥55 years of age, taking three or more medications, drug regimens altered during hospitalization, admitted to hospital because of medication misadventure/misuse, newly trained in the use of pharmaceutical devices (e.g. inhalers or compliance aids), requiring drug-related monitoring, dexterity problems, impaired vision, housebound, living alone. Exclusion criteria included patients who: were unwilling to give consent, had hearing impairment, were unable to communicate by telephone or in English, and were residents of a residential care facility. A baseline adherence assessment survey was conducted using the Morisky adherence tool14 (a structured four-item self-reported adherence measure) and a satisfaction rating (on a 10-point scale) regarding the information provided about their medication was obtained from the patients before the pharmacist medication review commenced. The review included an assessment of all of the patients’ medications (including over the counter and CAM), and verbal and written advice about optimal medicine use and side effects. When recommendations involved a change of prescription medication, the patient’s prescribers (hospital and community) were contacted either in person or by telephone on the day of review. The undertaking of the medication changes and any ongoing monitoring depended upon the particular medication(s) involved; if it was oncology related then the hospital doctor had made the required changes, if
Asia-Pac J Clin Oncol 2014
3
Pharmacist in lung cancer clinic
related to a primary care condition (e.g. hypertension) then it became the GP’s responsibility. A medication list and medication action plan (MAP) was developed for the patient. The MAP identified any medication-related problems and included recommendations for ongoing drug therapy, side effects, medication changes, new therapeutic devices, details of the recommended treatment plan and any ongoing monitoring requirements. The MAP was posted to the patients and faxed to their nominated GPs and community pharmacists within 24 h of clinic review. The MAP was also filed in the patients’ electronic hospital medical records. Patients were contacted by telephone 7 days after the initial review to discuss their adherence with current medications, assess adequacy of symptom control and identify potential monitoring problems or supply issues. If required, the MAP was modified and resent to all relevant parties. At the next hospital visit (within 30 days), the patient was again asked to complete the Morisky adherence tool and satisfaction rating. If the patient did not attend the hospital within the 30-day time frame, the interview was conducted via telephone. Details of medication changes brought about by the pharmacist review (defined as “interventions”) were recorded, categorized and graded according to the level of risk avoided. This risk level was determined using a nationally recognized grading tool for pharmacist interventions.15 The tool measured the consequence or impact of the outcome that may have occurred if the intervention had not been made. The likelihood of that consequence actually occurring was then measured. The classification of risk (extreme, high, moderate or low) was determined by looking at the point of intersection of the two individual measurements on a table plotting consequence against likelihood. The number of unplanned admissions (unexpected urgent hospitalizations) and clinic attendances of patients treated by the lung service was recorded and compared with the same period the previous year. At the conclusion of the study, GPs were contacted and asked to complete a short survey evaluating the information they received from the pharmacist: (i) Do you recall receiving the information sent to you by the pharmacist? (ii) Was it useful for you? (iii) If the service became available on a long-term basis, would you like to continue receiving this information about your patients?
Statistical analysis Each of the four questions comprising the Morisky medication adherence tool was coded as Boolean
Asia-Pac J Clin Oncol 2014
response (yes or no). Each question was considered individually, with baseline and post-review results compared using an exact McNemar’s test. The questions were then considered collectively by summing the number of positive responses across the four questions for each patient both at baseline and post-review, and baseline results were compared with post-review results using the nonparametric matched pairs Wilcoxon test. Patient satisfaction with medicine information was measured on a scale from 1 to 10, and was also compared using a Wilcoxon two-sample matched pairs test for difference between assessments (baseline vs post-review). The rates of unplanned admissions and clinic attendances were compared with the same period in the previous year and analyzed using the rate ratio test assuming Poisson counts.
RESULTS A total of 48 patients were recruited over 6 months. All the patients approached agreed to participate. The age ranged from 51 to 88 years, with a mean and median age of 67 years. Twenty-five of the patients were female, and 23 were male. All of the patients were competent at reading in English. Two patients were lost to follow-up (despite three attempts to contact them).
Medication adherence A reply of “yes” to any of the four questions in the Morisky tool is associated with poor medication adherence. A decrease in the number of “yes” responses was seen for all questions between the baseline and postreview assessments. Questions 1 and 3 showed a statistically significant reduction, while questions 2 and 4 showed a positive trend. Using the sum of the “no” replies for each patient as an overall measure of medication adherence, the Wilcoxon matched pairs test demonstrated a significant improvement in medication adherence (P-value
Asia-Pacific Journal of Clinical Oncology 2014
doi: 10.1111/ajco.12267
ORIGINAL ARTICLE
Impact of a specialist clinical cancer pharmacist at a multidisciplinary lung cancer clinic Clare WALTER,1* James D MELLOR,1*† Carol RICE,1 Sue KIRSA,1 David BALL,2 Mary DUFFY,3 Alan HERSCHTAL4 and Linda MILESHKIN5,6 1
Pharmacy Department, 2Division of Radiation Oncology, 3Division of Cancer Allied Health, Nursing and Support, 4Centre for Biostatistics and Clinical Trials, 5Division of Cancer Medicine, Peter MacCallum Cancer Centre, St Andrew’s Place, East Melbourne and 6University of Melbourne, Parkville, Victoria, Australia
Abstract Aim: Medication misadventure contributes to unplanned hospital admissions. General practitioners (GPs) may lack experience in managing problems involving complex cancer-related medication. A previous survey explored the unmet needs of lung cancer outpatients and highlighted their desire for more medication information. Inpatient clinical pharmacy services positively impact on patient care. This study evaluated the effects of extending this service to outpatients. Method: A specialist cancer pharmacist joined the lung cancer clinic team for 6 months. Patients completed assessments of their medication adherence and their satisfaction with the provision of medicine information (at baseline and repeated within 30 days of initial pharmacist review). Following review, a medication list and plan (detailing recommendations/interventions) were provided to patients and their health care providers. Interventions were categorized and graded according to risk avoided. Unplanned admissions and clinic attendance rates were compared with the previous year. GPs’ opinion of the service was also evaluated. Results: Forty-eight patients participated in the study. Medication adherence (P = 0.007) and patient satisfaction (P < 0.001) significantly improved. A total of 154 pharmacist interventions were made: 4.5% extreme risk and 43.5% high risk. The mean number of unplanned admissions and clinic attendances per patient decreased from 0.3 to 0.26 (P = 0.265) and from 3.32 to 2.98 (P = 0.004), respectively. Seventy-four percent of surveyed GPs found the service useful. Conclusions: Adding a specialist cancer pharmacist to the outpatient lung cancer team led to significant improvements in patient medication adherence. Both patients and GPs were highly satisfied with the service. Medication misadventure and clinic attendances were reduced. Key words: adherence, lung cancer, medication, outpatient clinic, pharmacist.
Correspondence: Mrs Clare Walter B.Pharm, Pharmacy Department, Peter MacCallum Cancer Centre, Locked Bag 1, A’Beckett Street, Vic. 8006, Australia. Email: [email protected] *Joint first authors. † Present address: Dan Mellor, Roche Products Pty Ltd., 108 Power Street, Hawthorn, Vic. 3122, Australia. Conflict of interest: Roche Pharmaceuticals was not involved in the conception, design, and conduct or reporting of this study. Subsequent to this study, Dr Dan Mellor became employed by Roche Pharmaceuticals Accepted for publication 20 July 2014.
© 2014 Wiley Publishing Asia Pty Ltd
INTRODUCTION Patients with chronic diseases are known to have a high rate of unplanned hospital admissions, and medication misadventure is a known contributor.1–3 In Australia, 25% of patients in the community who have been designated as “high-risk” report experiencing an adverse drug event.3 High-risk patients include: older people, those with serious health conditions, those taking multiple medications, those using high-risk medicines (such as warfarin) and those being transferred between
2
community and hospital care. Many lung cancer patients meet the high-risk criteria, often for multiple reasons.3 A patient survey conducted in 2007 explored the unmet needs of lung cancer outpatients at our tertiary cancer center.4 A key finding was the desire of patients for more information regarding their medication. The survey (n = 197) found that 53% [95% CI 46–60%] of patients wanted more information on possible side effects of their medication, 27% [95% CI 21–34%] wanted more information on complementary and alternative medications (CAMs) and 26% [95% CI 20–33%] wanted more information regarding their medication in general. Lung cancer patients and their caregivers may be faced with an overwhelming number of new medications prescribed by an array of different physicians giving rise to complicated medication regimes. In our experience, it is not uncommon for a lung cancer patient to be commenced on 5–10 new medications in the course of a few months. Community-based general practitioners (GPs) and pharmacists, although experienced in dealing with patients’ regular medications, may lack the experience or expertise to identify and act on problems involving complex cancer-related medication. Documentation errors occur between the hospital and primary caregivers, with 52–88% of transfer documents containing an error, leaving both the hospital practitioners and GPs unaware of their patients’ current medications.3 The value of medication reviews in assisting patients and their carers to manage medications appropriately has been demonstrated in patients with chronic diseases who are taking multiple medications.5–9 Previous studies have highlighted the problems that arise due to the lack of continuity of care when patients are discharged from the hospital.3,6,7,10 Community liaison programs have been successfully developed by hospital pharmacists for acute medical11 and palliative care patients12; however, a literature search failed to identify any program in Australia developed specifically for cancer patients. Clinical pharmacy services are the standard of care for admitted hospital patients and pharmacist interventions have been shown to significantly impact on patient care, length of hospital stay and hospital costs.13 An experienced cancer pharmacist possesses the specific knowledge about the medications used in the care of cancer patients and has been shown to obtain more accurate medication histories than doctors or nurses in the hospital setting.2 However, this service is not currently standard of care for ambulatory oncology patients in
© 2014 Wiley Publishing Asia Pty Ltd
C Walter et al.
Australia. The aim of this study was to provide a clinical pharmacy and community liaison service to ambulatory patients in the lung cancer clinic and evaluate what benefits are seen in this population.
METHODS This was a single-center, nonrandomized quality improvement project designed to assess the impact of providing a specialist clinical cancer pharmacist to address the specific medication management and information needs of ambulatory lung cancer patients in the outpatient setting. The project was approved by the Peter MacCallum Cancer Centre ethics committee. Eligible patients were identified by the lung team from clinic lists over a 6-month period. Patients provided verbal consent to take part in this study. Inclusion criteria were as follows: ≥18 years of age; diagnosis of lung cancer and receiving chemotherapy, radiotherapy, surgery or palliative care at our center; ability to participate in a telephone interview; ability to complete an adherence assessment tool; and ability to possess one or more of the following risk factors: ≥55 years of age, taking three or more medications, drug regimens altered during hospitalization, admitted to hospital because of medication misadventure/misuse, newly trained in the use of pharmaceutical devices (e.g. inhalers or compliance aids), requiring drug-related monitoring, dexterity problems, impaired vision, housebound, living alone. Exclusion criteria included patients who: were unwilling to give consent, had hearing impairment, were unable to communicate by telephone or in English, and were residents of a residential care facility. A baseline adherence assessment survey was conducted using the Morisky adherence tool14 (a structured four-item self-reported adherence measure) and a satisfaction rating (on a 10-point scale) regarding the information provided about their medication was obtained from the patients before the pharmacist medication review commenced. The review included an assessment of all of the patients’ medications (including over the counter and CAM), and verbal and written advice about optimal medicine use and side effects. When recommendations involved a change of prescription medication, the patient’s prescribers (hospital and community) were contacted either in person or by telephone on the day of review. The undertaking of the medication changes and any ongoing monitoring depended upon the particular medication(s) involved; if it was oncology related then the hospital doctor had made the required changes, if
Asia-Pac J Clin Oncol 2014
3
Pharmacist in lung cancer clinic
related to a primary care condition (e.g. hypertension) then it became the GP’s responsibility. A medication list and medication action plan (MAP) was developed for the patient. The MAP identified any medication-related problems and included recommendations for ongoing drug therapy, side effects, medication changes, new therapeutic devices, details of the recommended treatment plan and any ongoing monitoring requirements. The MAP was posted to the patients and faxed to their nominated GPs and community pharmacists within 24 h of clinic review. The MAP was also filed in the patients’ electronic hospital medical records. Patients were contacted by telephone 7 days after the initial review to discuss their adherence with current medications, assess adequacy of symptom control and identify potential monitoring problems or supply issues. If required, the MAP was modified and resent to all relevant parties. At the next hospital visit (within 30 days), the patient was again asked to complete the Morisky adherence tool and satisfaction rating. If the patient did not attend the hospital within the 30-day time frame, the interview was conducted via telephone. Details of medication changes brought about by the pharmacist review (defined as “interventions”) were recorded, categorized and graded according to the level of risk avoided. This risk level was determined using a nationally recognized grading tool for pharmacist interventions.15 The tool measured the consequence or impact of the outcome that may have occurred if the intervention had not been made. The likelihood of that consequence actually occurring was then measured. The classification of risk (extreme, high, moderate or low) was determined by looking at the point of intersection of the two individual measurements on a table plotting consequence against likelihood. The number of unplanned admissions (unexpected urgent hospitalizations) and clinic attendances of patients treated by the lung service was recorded and compared with the same period the previous year. At the conclusion of the study, GPs were contacted and asked to complete a short survey evaluating the information they received from the pharmacist: (i) Do you recall receiving the information sent to you by the pharmacist? (ii) Was it useful for you? (iii) If the service became available on a long-term basis, would you like to continue receiving this information about your patients?
Statistical analysis Each of the four questions comprising the Morisky medication adherence tool was coded as Boolean
Asia-Pac J Clin Oncol 2014
response (yes or no). Each question was considered individually, with baseline and post-review results compared using an exact McNemar’s test. The questions were then considered collectively by summing the number of positive responses across the four questions for each patient both at baseline and post-review, and baseline results were compared with post-review results using the nonparametric matched pairs Wilcoxon test. Patient satisfaction with medicine information was measured on a scale from 1 to 10, and was also compared using a Wilcoxon two-sample matched pairs test for difference between assessments (baseline vs post-review). The rates of unplanned admissions and clinic attendances were compared with the same period in the previous year and analyzed using the rate ratio test assuming Poisson counts.
RESULTS A total of 48 patients were recruited over 6 months. All the patients approached agreed to participate. The age ranged from 51 to 88 years, with a mean and median age of 67 years. Twenty-five of the patients were female, and 23 were male. All of the patients were competent at reading in English. Two patients were lost to follow-up (despite three attempts to contact them).
Medication adherence A reply of “yes” to any of the four questions in the Morisky tool is associated with poor medication adherence. A decrease in the number of “yes” responses was seen for all questions between the baseline and postreview assessments. Questions 1 and 3 showed a statistically significant reduction, while questions 2 and 4 showed a positive trend. Using the sum of the “no” replies for each patient as an overall measure of medication adherence, the Wilcoxon matched pairs test demonstrated a significant improvement in medication adherence (P-value
