Improving Adherence to Oral Therapies
Ellen Rice Tichich, MFA, MSN, RN-BC
A process-based approach pulls together the components of care, ensuring a smoother journey for patients.
Advances in oral chemotherapies provide patients with more convenient treatment options, but these improvements also create challenges for clinicians, particularly in medication adherence.
Current data reveal nonadherence rates as high as 46%, a definite cause for concern and an urgent call to action. The problem is multifaceted, manifested by a variety of factors, including individual patient characteristics, disease type, treatment specifics, and provider and system components. Although some of these elements exist beyond the scope of influence, improvement in adherence is nonetheless attainable through application of a process-based approach consisting of strategic interdisciplinary planning, collaborative implementation, and dedicated follow-through.
WHAT’S NEW, WHAT’S NOT
The approval and availability of oral chemotherapy agents over the past 20 years has changed how cancer treatment is delivered, providing many patients the convenience of at-home administration while reducing the frequency of clinic visits for intravenous therapy. What hasn’t changed: the need for accurate monitoring, ongoing communication, education, evaluation, and reassessment of patient response to ensure best outcomes.
In an interview with Oncology Nursing News®, Jody Pelusi, PhD, FNP, AOCNP, the first nonphysician member of the FDA's Oncologic Drugs Advisory Committee and a highly regarded expert in oral adherence, recalls her concerns about the way patients would be educated, monitored, and managed when capecitabine first received approval for use in 1998. She realized the importance of having a process for community practices and the institutional management of patients taking oral agents and, in response, developed a 13-step drug management program. Her process remains as relevant now as it was then.
ESTABLISHING THE FLOW
A process, defined as a series of actions and steps taken to achieve a particular end, to improve adherence begins by evaluating current flow patterns to determine if:
• The practice environment ensures staff competency, satisfaction, and support
• The emotional, physical, educational, safety, and financial needs of patients and caregivers are met
• The intent of guidelines and recommendations is achieved
• Outcomes are consistently documented and easily evaluated
In addition, providers and care team members should revisit their commitment to patients, including their responsibility to reduce or eliminate misinformation, misunderstanding, and other aspects of disconnect that might, and do, occur.
With flow patterns identified and commitment to patients and communication renewed, the work of pulling together a comprehensive and proven process can begin.
PUTTING PROCESS TO GOOD WORK
Oral adherence toolkits provide easyto- use information directed at patient assessment and education, ordering standards and pharmacy concerns, reimbursement and assistance programs, and other factors affecting adherence. However, it is process that provides the mechanism for putting these tools to good work. “If we have all our steps in place—if we stick to the process—then people don’t get left out,” says Pelusi, who works at Honor Health Research Institute in Scottsdale, Arizona.
Process allows clinicians to use adherence tools properly and consistently when aligned to each practice’s unique services and needs, beginning with the fulcrum of quality patient care: staff education.
For education to be most effective, it must be complete, inclusive, and consistent. Patients are best served when all staff members understand the process for managing oral chemotherapy adherence and when education is ongoing, evaluated, and part of required competency training. “Educating the entire staff on oral drugs that are utilized becomes very important, so anyone who picks up the phone knows what to ask and when to ask, and what to look for,” says Pelusi. “All of those things are part of the process.”
Pelusi’s process-based approach also includes evaluating patient candidacy for oral therapy from a variety of perspectives, including complexity of care, personal and medical history, and other factors that may influence adherence success, as well as the pros and cons of specific treatment options. Patient selection lends itself to following steps, each of which builds upon the former, further propelling the process:
• Treatment discussion and selection
• Pretreatment evaluation • Medication authorization and acquisition
• Obtaining informed consent
• Development and dissemination of the treatment plan (including its goal) With the treatment plan in progress, the process for monitoring and follow-up begins.
Providers and care team members must determine how to monitor and how often, as well as the most appropriate follow-up strategies to employ. Adherence tools aid in determining the what, why, and how of decision making.
Patient and caregiver education is a main component as the process advances and presents many challenges for all member of the health-care team. Working out the details and taking care to identify which information the patient must know, should know, and like to know helps clinicians prioritize and plan education.
“Adherence is more than just taking the pill,” Pelusi says. “It’s taking it the right way.” Patients need to understand why and how a drug is taken. To prevent incompatibilities with other prescriptions, primary physicians need to know what other drugs patients are taking, such as antibiotics, heart medications, or diabetes management agents. Tying together all the pieces of the patient care management includes developing processes for accurate and complete documentation, communication, and evaluation, all of which should be done consistently and with care.
Lastly, it is important to create and maintain policies, procedures, and variance reporting mechanisms geared toward medication adherence, including management approval and buy-in to ensure adequate support and continuance.
ADHERENCE, OUTCOMES, AND FUTURE
Achieving optimal patient outcomes depends on adherence. “It’s the clinician’s responsibility to make sure patients understand how taking their medications as ordered will help them reach their goal, whether it be for cure, to slow tumor progression, prevention, or palliation,” Pelusi says.
Forming partnerships with patients and seeking ways to help them manage their oral therapy are crucial for treatment to work as intended.
Pelusi recognizes the nurse as pivotal in the patient partnership. “Oral therapy is not going away. This is our future,” she says. “Nurses need to embrace this. This is nursing. You have to assess the patient. You have to educate the patient. You have to monitor the patient.”
“Everything the nurse does is basically what we need for oral adherence,” Pelusi continues. “Don’t give away the nursing component, because that is what is going to get the patient adherent. It’s the nurse who has the ability and the knowledge to manage symptoms so patients can stay on the drug. Don’t give that away.”
As more oral chemotherapy agents are developed and approved, physicians, nurses, pharmacists, and other members of cancer care teams must have a system in place that promotes the same high level of management for patients receiving oral treatment at home as those receiving intravenous therapy in clinic.
Pelusi strongly feels that the key to meeting patient and provider goals for treatment is having a workable process in place that weaves all the components of care together: “Believe it or not, once you have the process, oral therapy can run like clockwork.”