Oral Chemotherapy Prescription Research Articles

Patient-reported outcomes in patients with gastrointestinal cancer on oral chemotherapy.

732 Background: Over the last several years, patient reported outcomes (PROs) have been demonstrated to address patient symptoms, improve outcomes, and reduce health care utilization. We aim to provide an electronic PRO (ePRO) tool for gastrointestinal (GI) oncology patients with the goals of improving adherence, reducing toxicity, and enhancing patient access to the clinical team. Methods: Patients are provided an ePRO tool consisting of a cellphone app integrated into the electronic health record with questions on adherence and 10 questions on symptoms adapted from the NCI PRO-CTCAE for local use. Emails are sent to the clinical team for nonadherence, new or worsening symptoms, or patient requested callback. Outcomes including time to first symptom assessment, emergency department (ED) visit and/or hospitalization at 30 and 90 days from enrollment will be compared with historical controls. Other outcomes including adherence and patient-reported access to the clinic will be assessed. Results: Six patients have been enrolled between May 1, 2023 and September 4, 2023. Five patients were newly starting oral chemotherapy agents and one patient had already been on therapy. Types of cancers included colon cancers (2), rectal cancer (1), pancreatic cancer (1), GIST (1), and cholangiocarcinoma (1). Types of oral chemotherapy included capecitabine (4), olaparib (1), and imatinib (1). Five patients have submitted a total of ten responses. Of the five who completed the ePROs, patients responded a median of one time (range 1-5). Reported symptoms were fatigue (4), pain (2), nausea (1), diarrhea (1), other symptoms (2) and a request callback (1). Seven (70%) responses have prompted emails alerts for clinical symptoms and one (10%) for adherence concerns. All alerts were resolved; average time to alert response 1.6 calendar days (range 1-3). Among historical controls, time to first symptom assessment after a new oral chemotherapy prescription was seven days, 30-day rate for ED and/or hospitalizations was 12%, and 90-day rate of ED visits and/or hospitalizations was 28%. Conclusions: Early data suggests a new process to manage ePROs can provide timely responses to email alerts. Of the responses thus far, 70% prompted email alerts due to clinical symptoms and 10% reported nonadherence, suggesting a high need for ongoing ePRO tools. Results are forthcoming on outcomes including time to symptom assessment/clinical action, ED visit/hospitalization and access.

Making sense of the dollars: Evaluation of financial toxicity in patients of breast medicine receiving oral chemotherapy at Roswell Park.

e18519 Background: Increasing costs of oral chemotherapy have become a significant barrier to cancer care with the potential to cause treatment abandonment and noncompliance. The primary objective of this study is to evaluate the financial toxicity of oral chemotherapy in the Breast Medicine Service at Roswell Park Comprehensive Cancer Center (RPCCC). Methods: This was a retrospective chart review of patients at RPCCC who were diagnosed with breast cancer and prescribed oral chemotherapy between 8/1/21 - 7/31/22. The primary outcome evaluated was average out-of-pocket (OOP) cost of an oral chemotherapy prescription. Secondary outcomes studied included 1) the number of patients enrolled in manufacturer patient assistance programs (PAPs), copay cards, foundation grants, and/or New York State Elderly Pharmaceutical Insurance Coverage (EPIC) program, and 2) median days to treatment start date, approval of prior authorization (PA) and/or PAPs. For patients who filled at outside pharmacies, days to first insurance claim were collected and compared to days to first fill for patients who filled at Roswell Park Pharmacy. Results: A total of 116 patients with a median age of 64 and 122 oral chemotherapy prescriptions were included. Majority of the patients were white (n = 93; 80%) and enrolled in Medicare managed plans (n = 58; 50%). Palbociclib (n = 47; 39%) and capecitabine (n = 29; 24%) were most commonly prescribed. 49 patients filled at Roswell Park Pharmacy; average OOP cost was $48.00 (range: 0-2239.50) per prescription claim. Average OOP cost was $85.18 for patients with Medicare managed plans, $23.35 for patients with commercial insurance, and $3.66 for patients with government-funded insurance. Twenty patients (17%) enrolled in PAPs, foundation grants, copay cards, and/or EPIC program. OOP costs prior to any financial assistance was available for thirteen patients; median OOP cost was $2491.51 (403.62-18165.94). Median days to approval of PAPs and approval of PA was 10 (1-50) and 0 (0-14), respectively. When filling internally at Roswell Park Pharmacy, median days to treatment start date was 6 (0-61) compared to 9 (0-67) for those who filled at outside pharmacies. There was a significant difference (p = 0.0111) between the median days to first fill for patients who filled at Roswell Park Pharmacy (0 days [0-25]) and the median time to first insurance claim (2 days [0-20]) for patients filling at outside pharmacies. Conclusions: Despite utilization of financial assistance program, OOP costs remain high for cancer patients. Having a defined workflow to screen and identify patients at risk for financial toxicity and the ability to refer to appropriate resources to mitigate OOP costs promptly is vital to prevent delays in treatment. Utilizing an integrated health-system specialty pharmacy can be helpful to streamline patient access and avoid further treatment delays.

Implementing Electronic Patient-Reported Outcomes for Patients With New Oral Chemotherapy Prescriptions at an Academic Site and a Community Site.

Oral chemotherapy challenges providers' abilities to safely monitor patients' symptoms, adherence, and financial toxicity. COVID-19 has increased the urgency of caring for patients remotely. Collection of electronic patient-reported outcomes (ePROs) has demonstrated efficacy for patients on intravenous chemotherapy, but limited data support their use in oral chemotherapy. We undertook a pilot project to assess the feasibility of implementing an ePRO system for patients starting oral chemotherapy at our cancer center, which includes both an academic site and a community site. Patients initiating oral chemotherapy were asked to participate. A five-question tool was built in REDCap. Concerning responses triggered outreach within one business day. The primary outcome was time to first symptom assessment. For comparison, we used a historical cohort of patients who had been prescribed oral chemotherapies by providers in the same disease groups at the cancer center. Twenty-five of 62 (40%) patients completed ePRO assessments. Fifty historical charts were reviewed. Time to first symptom assessment was 7 days (IQR, 4-14 days) in the historical group compared with 3 days (IQR, 2-4 days) in the ePRO group. Time to clinical action was 14 days (7-35 days) in the historical group compared with 8 days (4-19 days) in the ePRO group. No statistically significant differences were detected in 30-day emergency department visit or hospitalization (12% for both groups) or 90-day emergency department visit or hospitalization rates (historical 28% and ePRO 20%). An ePRO tool monitoring patient concerns about adherence, cost, and toxicities for patients with new oral chemotherapy regimens is feasible and improves time to symptom assessment. Further investigation is needed to improve patient engagement with ePROs and evaluate the long-term impacts for patients on oral chemotherapy.

Implementation of an oral chemotherapy adherence tool at an NCCN comprehensive cancer center.

265 Background: Adherence to oral chemotherapy (OC) is a critical factor in achieving optimal oncologic outcomes. Correct dosing, education, and symptom management are essential to maximizing adherence. As part of the 2020 Quality Oncology Practice Initiative Certification Program Fox Chase Cancer Center (FCCC), a NCCN Comprehensive Cancer Center, learned that only 33% of patients on OC had a documented OC plan, 7% were assessed for adherence, and 0% had documentation reflecting efforts to address non-adherence. Methods: Our goal was to create and implement an electronic medical record (EMR) tool (Oral Chemo Smart Form) to address the variance and deficiencies in monitoring adherence to OC. The Smart Form (SF) was designed to include fields to document the OC plan (drug, indication, dose, schedule, duration of cycle, initial start/end date) as well as provide a standard for documentation of education, management of toxicity and non-adherence. We integrated the SF into nursing, pharmacy, and physician workflows to capitalize on shared EMR tools. A series of Plan-Do-Study-Act cycles were conducted over 8 weeks within pilot clinics. Weekly review of the SF and feedback forms generated real-time progress reports which were serially appraised and shared with stakeholders. Results: Two oncologists (piloted in Genitourinary and Breast Cancer clinics), two pharmacists, and several nurses used the SF March 15, 2021 to May 7, 2021. Over these 8 weeks, 223 patients on OC were seen in clinic. If the OC was dispensed from FCCC, pharmacists were to complete the SF at the time of initial OC prescription, 7 days after dispensing, and with each refill. Pharmacists also identified patients receiving OC through a specialty pharmacy and routed a message to clinic nurses via an EMR message pool. The message became the trigger for nurses to call patients within two weeks to troubleshoot dispensing issues and/or complete the SF. Oncologists were to complete the SF with each clinic visit for a patient on OC. Feedback from the clinical and pharmacy teams motivated changes in the content fields of the SF and workflow. Ultimately, 45% of patients on OC had the SF completed. An OC plan was documented in 41% of patients, compared to 33% at baseline; 87% had an administration schedule compared to 81%. There was an increase in the number of patients contacted following start of OC, 35% from 4%. Medication adherence was assessed in 35% of patients, up from 7%. Documented discussions addressing medication adherence increased to 78%, from 0%. Conclusions: Introduction of the Oral Chemo SF in pilot clinics improved documented OC plans and administration schedules. Its use introduced a standard process for monitoring safety, assessing and addressing non-adherence, while troubleshooting specialty pharmacy dispensing issues. The SF will be implemented throughout FCCC and further evaluated with efforts focused on adopting and streamlining this as standard work.

Évaluation de la pratique de prescription d’une chimiothérapie orale type « capécitabine ». Résultats de la première enquête auprès des oncologues médicaux marocains

Oral anticancer therapy is becoming increasingly developed; their prescription has become a common practice in oncology. However, there is a variability and diversity in prescription practice. Its magnitude has been very little studied in scientific literature. To our knowledge, this is the first study in Morocco and North Africa to evaluate the practice of prescribing oral chemotherapy. The authors conducted a national exhaustive cross-sectional survey, to evaluate the practice of the oral chemotherapy "Capecitabine" type prescription by Moroccan oncologists and to identify strategies to promote an adherence to oral anti-neoplasic therapy. Ninety-one medical oncologists answered out of 118, from public oncology centres (29.7%), Hospital University (58.2%), and private sector (12.1%). Thirty-four of the oncologists replied by email, 33 through phone conversation and 24 by filling paper questionnaires. In total, 32% of the cases were handwritten prescriptions, and 51.6% electronically generated. Forty-six percent of medical oncologists dedicated more time to the oral chemotherapy type Capecitabine prescription versus its intravenous equivalent 5FU. However, 33% medical oncologists take less time to this prescription, and 20.9% of them take the same time. Adherence to oral chemotherapy was evaluated by simply questioning of patients in most of the cases (94%) and 4% of medical oncologist declared that they did not evaluate this adherence. In total, 87.9% of Moroccan medical oncologists revealed that they have not received any specific training in the therapeutic education of the patient with oral anti-cancer treatment. In Morocco, there is a great variability in prescription and follow-up practice for patients receiving oral chemotherapy. There is a lack of a national standardization with regards to the procedures of prescribing and monitoring patients to ensure the quality and safety of the oral chemotherapy prescription.

P09.02 Impact of COVID-19 in Portuguese Lung Cancer Patients’ Treatment: Portuguese Lung Cancer Study Group Survey

The first patient with COVID-19 in Portugal was diagnosed on March 2. There was a lack of knowledge concerning the risks of COVID-19 infection in lung cancer patients, prognostic factors, the influence of cancer treatments and cure criteria. Treatments and consultations were readjusted in order to maintain the ones that increase patients’ survival, while reducing the risks of SARS-CoV-2 infection. International and national “guidelines” were followed, but each hospital had its own strategies to reduce COVID-19 risk. Purpose: The Portuguese Lung Cancer Study Group launched a survey in order to study the early impact of COVID-19 in lung cancer patients, changes in treatments and the way of implementation of COVID-free circuits. A survey was sent to lung cancer doctors of all the Portuguese hospitals. At the data cut-off, information from twenty one hospitals was collected, corresponding to about 66% (n=3.446) of each year new diagnoses of lung cancer in Portugal. In March and April there was a reduction in newly lung cancer diagnosed patients while comparing with 2019: in March, 86% had a reduction; in April, 90% of the hospitals reported a reduction and it was greater than 40% in eight hospitals (38%). About 62% of the doctors considered less referral from primary care as a cause, and 33% delayed biopsies or other imaging exams. The most difficult exams to obtain were CT guided biopsies and EBUS for 48%. The majority of the hospitals (57%) were also referral for COVID-19 patients’ treatment. In 48% of the lung cancer treating departments’ there were doctors reallocated to COVID-19 treatment areas. In 48% the assistance teams were divided into teams that weren’t previously working together. The majority of doctors (90%) reported having individual protection equipment available. Hospitals performed teleconsultation (100%), and, in seven hospitals (33%), more than half of the consultations were done using communication technology. All the hospitals were able to perform SARS-CoV-2 testing. It was done before every cycle of chemotherapy in 90% of the hospitals. In the majority (67%) it was only performed before day D1, in D1 and D8 chemotherapy protocols. About 19% reported changes in prescription of adjuvant chemotherapy and in maintenance chemotherapy, 33% increased the prescription of oral chemotherapy, 33% changed the periodicity, 29% reported reduction in inclusion in clinical trials. In 33% there was an earlier end of chemotherapy in ECOG2 and vulnerable patients. In 38% the prescription of G-CSF (Granulocity-colony stimulating factor) increased, being used for prophylaxis if the risk of febrile neutropenia was more than 10-15%. The periodicity of consultations was changed for patients under TKI treatment in 86%, and 67% hospitals reported changes in immune checkpoint inhibitor treatment schedule. In 29% oral drugs could be delivered at patients’ home. All the patients admitted for surgery were tested for SARS-CoV-2, and 86% performed SARS-COV-2 testing before radiotherapy. Portuguese hospitals responded to the sudden need of creation of COVID-free circuits, change protocols and even teleconsultation. With a larger follow up we will study the late consequences of COVID-19 pandemic in lung cancer diagnosis and treatment.

Sécurisation du parcours de soins du patient sous thérapie orale en oncologie : expérimentation autour d’un lien pharmaceutique hôpital–ville

Due to the increasing prescription of oral anticancer therapies, the inpatient care pathway has shifted to an outpatient care pathway. This transformation requires an interdisciplinary coordination to provide a continuum of care and ensure therapeutic monitoring, as well as patient safety. To better support patients on oral anticancer therapies, a task group named "hospital-to-community pharmacist coordination" has been set up to create tools aiming at standardising the information exchanged between ambulatory and hospital pharmacists. A retrospective study examined the utilisation of the tools over a period of one year. The task group identified the expectations of all parties regarding the care pathways of patients undergoing oral chemotherapy, which lead to the creation of computerised exchange tools (integrated into the computerised patient's medical file). Over the course of this study, the cancer centre's pharmaceutical team contacted 425 ambulatory pharmacists regarding the prescription of oral chemotherapy to patients. Forty-two follow-ups from ambulatory pharmacists, gathering information on 34 patients, were submitted to the cancer centre pharmacists (7,7%). These first follow-ups allowed pharmaceutical responses regarding patient compliance, drug interaction and toxicities.

Medically integrated pharmacies make patient care more efficient

Medically integrated pharmacies make patient care more efficient

Practice Patterns for Oral Chemotherapy at Different Cancer Centers in Riyadh, Saudi Arabia: A Multicenter Observational Study

The present study was aimed to explore the current practices related to oral chemotherapy prescription, dispensing, monitoring and patient education. The novelty of this study was based in utilizing most recent data for retrieving relevant outcomes. A cross-sectional design was employed to recruit 161 pharmacists, physicians, and nurses. A survey questionnaire was implemented to examine prescribing practices, coordinating and monitoring adherence, safety monitoring, and education of patients regarding oral chemotherapy. Descriptive statistics and Chi-square analysis were used to present data through Statistical Package of Social Sciences software. A majority of the healthcare providers (79 %) received training on the safe handling of oral chemotherapy, while 74 % were trained by their organization regarding patient education. While 68 % of hospitals used self-designed papers as resources to guide patient education, 51 % used drug pamphlets and 16 % used personalized treatment calendars. Almost 94 % of hospitals applied double checks for calculated doses as additional safety technique; while, other hospitals (34 %) used barcode scanning. The future planning and implementation of oral chemotherapy needs proper educational and training for the healthcare workers. In addition, health care workers should follow guidelines for quality assurance of their prescriptions.

Electronic monitoring of patient-reported adherence and symptoms on oral chemotherapy at an academic and a community site.

283 Background: Monitoring of toxicity and adherence is often lacking for patients recently started on oral chemotherapy. National guidelines recommend active outreach to patients within a week after treatment start. We developed an online tool to actively reach out to patients newly started on oral chemotherapy at one academic medical center and community practice. Methods: A multi-disciplinary team, including patients, developed an online oral chemotherapy adherence, symptom, and financial toxicity assessment tool within REDCap. We implemented this tool for new oral chemotherapy prescriptions in May 2018 in the gastrointestinal oncology group of an academic medical center and a general community practice. To quantify the impact of this tool on symptom management, we completed a retrospective analysis of patients receiving new oral chemotherapy prescriptions at these same sites, in the 13 months immediately preceding clinical implementation of the online tool, May 2017 to May 2018. Results: In the pre-intervention historical cohort (n = 58) the median time to first symptom assessment by a clinician was 7 days (range 1 – 41 days, SD 7 days), median time to identifying a new or worsening symptom was 10 days (range 1-55 days, SD 10 days), and median time to clinical action regarding a new or worsening symptom was 10 days (range 1-104, SD 20 days). Our first intervention patient used the online tool in May 2018 to report symptoms of “nausea and fatigue,” 4 days after starting oral chemotherapy. This resulted in an oncology clinical nurse calling the patient to review symptom management by phone. Conclusions: The median time to first symptom assessment in our historical control cohort is 7 days, with standard deviation of 7 days, suggesting potential room for improvement. Thus far, the online tool has been completed by one patient. Further data will be reported regarding the uptake of this tool, the tool’s impact on quality measures, and patient reported symptoms, adherence, and financial toxicity.

Oral chemotherapy education sessions at an academic and community cancer center.

254 Background: Oral chemotherapy is becoming more widely utilized within oncology. Concerns regarding poor adherence and toxicity may be addressed by providing patient education. Methods: We developed and implemented a pharmacist-led initial education session for patients newly prescribed oral chemotherapy in both an academic medical center gastrointestinal oncology clinic and an affiliated community oncology cancer center. We provided an education packet including drug-specific information, clinic contact telephone numbers, and a drug schedule calendar. Standardized teaching and documentation templates were used. Patients completed each education session with the MOATT teaching tool for patients receiving Oral Agents for Cancer V1.2. Assessment of compliance with the ASCO/ONS Chemotherapy Administration Safety Standards on Oral Chemotherapy Education was assessed through use of Quality Oncology Practice Initiative (QOPI) quality measures where applicable and compared to historical QOPI data from the academic medical center from 2015-2017. Results: Thirty-one patients were newly prescribed oral chemotherapy and received the initial education session from November 2017 through May 2018. Based on a monthly report generated of new oral chemotherapy prescriptions, after a seven-month run-in, the rate reached 100% of patients at both sites for the most recent month. When comparing the intervention cohort to the historical QOPI cohort using a one-sided P value of 0.017 with bonferroni correction, there was improvement in safe handling/storage (pre: 19%, post 100%, P = 0.0001), drug-drug and food interactions (pre: 31%, post 100%, P = 0.0001), and plan for missed doses (pre: 37%, post: 97%, P = 0.0001). A trend toward improvement was found for schedule/start date discussion (pre: 87%, post: 100% P = 0.018) and side effect/toxicities (pre: 87%, post: 100% P = 0.018). Conclusions: Implementation of an oral chemotherapy education session in both an academic and community setting was feasible and improved adherence to QOPI measures of oral chemotherapy education and ASCO/ONS standards for oral chemotherapy. Further data regarding time to clinical outcomes is forthcoming.

Enhancing safety and delivery of oral chemotherapy utilizing lean methodology.

266 Background: An oral chemotherapy safety event prompted analysis of related workflows utilizing lean quality improvement methodology. This analysis identified high variation in prescription processing, lack of standardized safety checks, inefficient use of pharmacy time, and inadequate data collection. Our goal was to create an oral chemotherapy protocol that could ensure patients have the right oral chemotherapy agent, at the right dose, at the right time, with independent and efficient safety checks by nursing, pharmacy, and providers. Methods: Multidisciplinary teams participated in two kaizen workshops. utilizing lean methodology. Primary workshop objectives were (1) develop safety standards for oral chemotherapy similar to those for intravenous chemotherapy; (2) make workflows more efficient; and (3) have workflows that enable data collection and process control. The first workshop standardized oral chemotherapy prescription processing though a single workflow in the EMR. This enabled robust data collection and established a platform for safety interventions. The second workshop developed standardized safety checks for and integrated those into the EMR workflow. Given the rarity of serious safety events, a validation measurement was not feasible to track in 30-day PDCA cycles. Consequently, surrogate measures of utilization of the EMR prescribing algorithm and reduction of non-clinical pharmacy interventions were used to assess progress. Safety data were collected and correlated to surrogate outcomes for long-term impact assessment. Results: Interventions resulted in the following outcomes: 100% reduction in oral chemotherapy order defects reaching pharmacy; 97% improvement processing oral chemotherapy though a single EMR workflow; 23% reduction in oral chemotherapy processing time; In spite of a 51% increase in oral chemotherapy volume, no serious safety events have occurred in the last year. Conclusions: Comprehensive quality improvement in our oral chemotherapy process increased safety and efficiency while developing data collection systems for continuous improvement. Multidisciplinary workshops with key stakeholders using established lean methodology were critical to success.

Financial impact from in-office dispensing of oral chemotherapy

Oral chemotherapy agents are being prescribed more frequently in many cancer types. In-office dispensing of oral chemotherapy agents has demonstrated clinical benefits and also shown financial benefit to third-party payers. A previous publication estimated over $200,000 in cost savings annually from in-office dispensing solely from medications returned to stock for credit. However, pharmacists in the in-office setting perform many other interventions that may affect financial outcomes. Assess financial impact of oral chemotherapy in-office dispensing by a clinic-based oral chemotherapy program serving five outpatient cancer centers in Southern Idaho. Outcomes include calculated monetary waste and cost avoidance of oral chemotherapy prescriptions from in-office dispensing and mail-order pharmacies. Prescriptions received by the clinic-based oral chemotherapy program for filling through in-office dispensing and mail-order pharmacies were monitored for monetary waste and cost avoidance events from December 2016 through May 2017. Information was collected on the number of returned medications, therapy discontinuations, and dose adjustments. Monetary outcomes were calculated using average wholesale price. During the six-month evaluation, prescriptions filled through in-office dispensing had a total cost avoidance of $1,020,193 (n = 154) and total waste of $154,985 (n = 36) resulting in an estimated net cost avoidance annually of $1,730,416. Prescriptions filled through mail-order had a total cost avoidance of $20,497 (n = 4) and a total waste of $80,394 (n = 15) resulting in an estimated $119,794 net annual waste. In-office dispensing of oral chemotherapy provided significant cost savings to third-party payers compared to mail-order pharmacy dispensing. Continued evaluation may help further justify the importance and value of in-office dispensing.

Improving oral chemotherapy documentation in a breast medical oncology outpatient practice.

71 Background: The safe administration of oral chemotherapy is a challenging yet important process to ensure patient safety. Comprehensive initial and subsequent documentation especially regarding dosage and toxicities in the plan of care for patients receiving oral chemotherapy can be instrumental in improving patient safety by ensuring comprehensive health information is available to all health team members. Methods: We are undertaking a rapid cycle improvement project to improve initial and subsequent documentation of new oral chemotherapy care plans by increasing our compliance with the number of components of an oral chemotherapy care plan (as outlined by QOPI’s 13 standards). We performed a baseline chart audit to confirm our current low level of compliance. We then created a process to use smart phrases that include necessary QOPI elements for progress notes upon new prescription of oral chemotherapy as well as smart phrases for subsequent patient initiated telephone encounters regarding oral chemotherapy, that feed into a universal “med note” location. Post implementation, we will perform a chart audit to determine our updated compliance. Staff satisfaction with the old vs the new process will be compared to verify that we have created a more efficient system to answer patient questions regarding oral chemotherapy. Results: Baseline chart audit revealed the number of components of an oral chemotherapy care plan (as per QOPI standards) documented in the EMR was 43% (i.e contained 5/13 components). A Pareto chart confirmed that underutilization of current EMR resources and lack of knowledge regarding QOPI standards were common reasons for poor oral chemotherapy documentation. Implementation of smart phrases for documentation for initial patient encounters and subsequent telephone encounters is currently in process to determine our new level of compliance with QOPI standards for a sustained and meaningful improvement. Conclusions: This quality improvement initiative was designed to improve patient safety by enhancing documentation of an oral chemotherapy care plan in the EMR and also to create a more efficient system to answer and document patient phone calls regarding oral chemotherapy.

Documentation of pharmacist-provided patient education for oral chemotherapy.

237 Background: Pharmacist-provided patient education for oral chemotherapy is poorly documented in patient electronic medical records (EMR) at UIC Oncology Pharmacy. At baseline, 41% of patients who started new therapy with selected oral chemotherapies had a patient education note documented by a pharmacist in their EMR. Our aim is to provide and document patient education for at least 90% of patients who start new oral chemotherapy and fill their prescriptions at UIC Oncology Pharmacy over three months. The importance of patient counseling and documentation is recognized by the Quality Oncology Practice Initiative (QOPI) group. Approximately 25% of patients undergoing chemotherapy are on oral chemotherapy. (Deutsch S, Koerner P, Miller RT, Craft Z, Fancher K. Utilization patterns for oral oncology medications in a specialty pharmacy cycle management program. J Oncol Pharm Pract. 2014;0:1-8.) Methods: A multi-disciplinary team performed an affinity sort and created a process map to identify areas of intervention. The first intervention was labelling prescription bags to identify them as oral chemotherapy prescriptions that require counseling by a pharmacist. Data was collected after two weeks. Results: At the completion of the first PDSA cycle, 40% of patients who started new oral chemotherapy had a documented patient education note written by a pharmacist in their EMR. Documentation of education was performed on the day of pick-up in 89% of cases. Table 1 shows the percentage of notes that included the elements recognized by QOPI standards: documentation of start date, adherence, and adverse effects. Conclusions: Documentation of patient education for oral chemotherapy should be a well-integrated component of ambulatory pharmacy practice. A second PDSA cycle is planned to increase rates of documentation by utilizing the pharmacy resident to perform patient counseling and documentation. Future interventions will be aimed at improving the quality of the data included in the documented notes. [Table: see text]

Bringing provincial improvements to oral chemotherapy prescribing through co-ordinated regional initiatives.

107 Background: Oral chemotherapy delivery is complex, making safe medication practices a high priority. Cancer Care Ontario, the provincial government agency responsible for continually improving cancer services in Ontario, undertook a jurisdiction-wide quality improvement initiative to ensure that all oral chemotherapy drugs are prescribed using Computerized Prescriber Order Entry (CPOE) or standardized Pre-printed Orders (PPO). The initiative was further enabled by changes to the provincial funding approach that flows facility funding for oral chemotherapy delivery. Methods: All 35 facilities prescribing chemotherapy in Ontario across 14 regions implemented strategies to work towards the common aim of reducing handwritten/verbal oral chemotherapy prescribing to zero by June 30th, 2015. Baseline audits were completed between Sept-Nov 2014; repeat audits were performed between Mar-May 2015. Each facility reported the number of patients that received an oral chemotherapy prescription, and the method of prescribing. Results: At baseline, 30% of audited prescriptions across the province were handwritten or verbal, which decreased to 9% by June 2015. Improvements were seen in thirteen of the 14 regions. Thirteen out of 35 facilities met the aim of 0 handwritten/verbal orders, with an additional 16 facilities seeing an improvement. Alignment with funding mechanisms, an early physician engagement strategy, and education of key stakeholders on CPOE systems were identified as key enablers to implementation. Conclusions: Though the goal of zero handwritten/verbal prescriptions was not met by all facilities, the initiative encouraged a change in implementing safe prescribing practices for oral chemotherapy. Further audits will assess that the gain was sustained and that the provincial goal is achieved. This initiative is part of a larger strategy to standardize care for systemic treatment patients and promote a culture of safety in hospitals. [Table: see text]

Integrating nursing into oral chemotherapy education.

81 Background:The shift of chemotherapy administration from the oncology infusion suite to the home has unwound systems and left patients vulnerable to errors. Many of the safeguards for parenteral chemotherapy, including education by an oncology nurse, are absent for oral chemotherapy. The 2013 American Society of Clinical Oncology/Oncology Nursing Society Standards served as the framework for improving the initiation of oral chemotherapy at Beth Israel Deaconess Medical Center. Methods: Clinicians caring for patients with melanoma and renal cell cancer were surveyed. A team of clinicians, nurses and pharmacist delineated a process map from writing an oral chemotherapy prescription to first follow-up appointment. A retrospective chart review of baseline data provided by a specialty pharmacy revealed 33 patients who initiated oral chemotherapy between July 2014 to July 2015, were not on a clinical trial and had at least two follow-up appointments. The team’s aim is by February 1, 2016 patients initiating oral chemotherapy receive nursing education by the first follow-up visit and at least 50% have documentation of a comprehensive education, including administration, safe handling and side effects. Results: The survey response rate was 9 of 9 (100%). The clinicians ranked patient education as the top priority. Second to time, lack of nursing involvement was identified as the most common contributing factor to patients not receiving a comprehensive education. At baseline, 1 of 33 (3%) patients initiated on oral chemotherapy received education from a nurse. Side effect education was documented in 21 of 33 (64%) clinicians’ notes, though education on safe handling only in 7 of 33 (15%), and education on administration was never documented. Plan-Do-Study-Act cycles are ongoing to implement varied approaches of nursing involvement, including telephone and in-person consultations. Conclusions: Lack of nursing involvement was identified as a missing element in oral chemotherapy care. Because clinicians were engaged, a survey to evaluate the current process succeeded with a high response rate. At baseline, there are significant gaps and variability in current practice, and interventions to provide patients with a comprehensive education are underway.

Building a new process: Nursing verification of pediatric oral chemotherapy.

199 Background: While team-based safety checks ensure safe prescribing of parenteral chemotherapy, oral chemotherapy is usually prescribed by a single clinician. With the growing use of oral chemotherapy, processes are needed to protect these vulnerable patients from prescription errors. Methods: A team of nurses, clinicians, pharmacists and administrators developed a new process and checklist for nursing verification of oral chemotherapy prescriptions at Dana-Farber’s pediatric neuro-oncology program. Prescriptions are verified against the treatment plan by two pediatric oncology nurses. The verification checklist includes drug, dose with any modifications, height and weight, laboratory values and patient instructions. When available, the prescription bottle is also verified. Data was collected over a three-month pilot period. Results: From 6/18/15-9/16/15, 56 prescription verifications occurred. Verification rate of on-site retail pharmacy filled prescriptions was 47% (32/68 prescriptions). Median time for verification was 20 minutes (IQR 15, 40) per nurse. Nurses identified problems outside of prescription verification, including missing prior authorizations and unclear treatment plans. Medication bottles were not routinely available for verification. One identified near miss would have resulted in an 80% under-dose of everolimus. Conclusions: Prescription verification by nursing in a pediatric oncology clinic was feasible. While it was successful in identification of one medication error before it reached the patient, only 47% of prescriptions were verified. Since prescription bottles are usually obtained after a visit, verification of the actual bottles will require new workflows, such as additional clinic visits or uploading a picture via the patient portal. Involving the nurse in the review of oral chemotherapy not only identified a prescription error, but also highlighted issues within other aspects of patients’ care, including inconsistent documentation of the treatment plan. The inclusion of nursing in the review and management of oral chemotherapy has the potential to improve safety and outcomes for these patients.

Improving the Safety of Oral Chemotherapy at an Academic Medical Center.

Over the last decade, the use of oral chemotherapy (OC) for the treatment of cancer has dramatically increased. Despite their route of administration, OCs pose many of the same risks as intravenous agents. In this quality improvement project, we sought to examine our current process for the prescription of OC at the Abramson Cancer Center of the University of Pennsylvania and to improve on its safety. A multidisciplinary team that included oncologists, advanced-practice providers, and pharmacists was formed to analyze the current state of our OC practice. Using Lean Six Sigma quality improvement tools, we identified a lack of pharmacist review of the OC prescription as an area for improvement. To address these deficiencies, we used our electronic medical system to route OC orders placed by treating providers to an oncology-specific outpatient pharmacist at the Abramson Cancer Center for review. Over 7 months, 63 orders for OC were placed for 45 individual patients. Of the 63 orders, all were reviewed by pharmacists, and, as a result, 22 interventions were made (35%). Types of interventions included dosage adjustment (one of 22), identification of an interacting drug (nine of 22), and recommendations for additional drug monitoring (12 of 22). OC poses many of the same risks as intravenous chemotherapy and should be prescribed and reviewed with the same oversight. At our institution, involvement of an oncology-trained pharmacist in the review of OC led to meaningful interventions in one third of the orders.

Systemic Treatment Safety Symposium 2014: Oral Chemotherapy

The second Systemic Treatment Safety Symposium, which took place February 21, 2014, in Toronto, aimed to identify opportunities for improving the delivery of systemic cancer treatment in Ontario based on regional needs, while providing a venue for collaboration and knowledgesharing. The agenda included a series of panel sessions followed by discussions, presentations of regional improvement projects and results, and breakout sessions. Based on the discussion that took place at the symposium, a provincial goal of zero handwritten or verbal oral chemotherapy orders by June 30, 2015, has now been established, and regions will be provided with funding for safe prescribing initiatives to support achievement of that aim. Building on the lessons learned from the 2014 System Treatment Safety Symposium, a common measurement strategy will be identified, and Cancer Care Ontario (cco) will also support the work by identifying the recommended key elements of a safe oral chemotherapy prescription. Additionally, cco will identify areas for improving systemic treatment computerized prescriber order entry systems to better enable prescribing of oral agents within such systems. Among the most prominent of the lessons learned during the symposium was the importance of having a focused topic (such as oral chemotherapy) while maintaining a province-wide scope. Another significant takeaway was that attendees appreciate the opportunity to hear from colleagues across the province about the work underway in various regions. Future safety symposia will also explore opportunities for enhanced engagement with participants through greater use of technology.