Stacey McCullough, PharmD
With the increase of oral medications in oncology, adherence has become a significant issue since patients take the drugs home with them, and whether or not they stick to a regimen is hidden from the provider’s view.
Therefore, patients on their oral oncology medications should involve a combination of active management, record keeping, and coordination among healthcare workers, according to pharmacy professionals during a panel discussion on the final day of the 2017 Community Oncology Alliance annual conference in National Harbor, Maryland.
Panelists said that one of the most successful tactics to maintaining adherence is engaging directly with patients to make sure they understand their treatment, know how to incorporate drug ingestion with their daily routines, and have a sufficient supply of drugs on hand, the panelists said. That engagement should include regular phone calls directly to patients, they added. “Refill rates were significantly higher when we reached out to patients,” noted Stacey McCullough, PharmD, senior vice president of pharmacy, Tennessee Oncology.
Also on the podium was Ray Bailey, RPh, director of pharmacy, Florida Cancer Specialists (FCS), which is the nation’s largest independent oncology practice, with multiple locations, and operates a central call center that facilitates therapy maintenance. Joining McCullough and Bailey was Todd Murphree, PharmD, ambulatory pharmacy manager, Clearview Cancer Institute.
Bailey described a multi-stage oral adherence IT platform used at FCS that allows for thorough tracking of all elements of the orals-issuance process. This helps with scheduling calls with patients, knowing patient profiles, and tracking pharmacist counseling and lab results. Bailey called that proprietary system ORCA, short for Oncology Resource Compliance Application.
In earlier years, the pharmacy department at FCS waited for patients to call in with requests for prescription fills and other assistance. “I knew that was very inefficient. I just didn’t know how inefficient it was,” Bailey said. What changed was that as FCS merged with more and more independent practices, they added IT automation that was capable of tracking the volumes of medication dispensed. They noticed that volumes went up around the times that they called patients at home, which led to the realization that there were probably gaps in therapy adherence when patient communication lapsed. They began checking with patients more regularly and their measures of adherence shot up, Bailey explained. “Just because we filled the prescription doesn’t mean they’re taking it.”
He said he concluded that a superior measure of adherence is “persistency,” which is whether a patient takes a drug for as long as it is prescribed. Adherence is a measure of whether a patient takes the medication as prescribed, without missing doses or exceeding dose quantities or taking doses at incorrect intervals. Based on that notion, FCS has been working harder the past 2 years to pay attention to persistency rates by drug. This is what led to the development of ORCA.
ORCA also enabled FCS to develop patient care plans rapidly, which was important for getting patients onto drugs and into clinical trial programs quickly, Bailey said.
“One of the things we found out when we started this program is that there are some patients who don’t need a lot of intervention. Their drugs don’t have a bad side effect profile,” Bailey said. However, some drugs have a higher risk, and FCS made a list of them, knowing that patients on these drugs would need a lot of supportive care, and they get more frequent phone follow-up and monitoring as a result.
Other features of ORCA enable pharmacists at FCS to ensure that lab work is done correctly, track pharmacist interventions to prevent unnecessary hospitalizations, and avoid drug wastage by responding quickly to changes in prescribed dosage.
McCullough agreed that patient documentation is vital to keeping patients on their regimens. At Tennessee Oncology, phone calls to patients occur not just with treatment initiation but for refills, too. Efforts are also made to contact patients about adverse effects they may be experiencing, so that they know what to do, “and sometimes just reassuring them so that they know it’s normal,” McCullough said.
She described calls that might involve multiple parties—however many are needed to communicate all necessary information and ensure adherence. Talks may also be in depth, lasting up to 30 minutes, based on the realization that each patient has a different lifestyle and may not know how to coordinate a drug regimen with that. McCullough added that Tennessee Oncology pharmacy staff have endeavored to simplify their speech so that patients can understand them. “A lot of times we use jargon when we ourselves don’t even know what we’re saying,” she said.
These talks often reveal that patients aren’t as secure with their drug regimen as they may initially indicate. For example, if a patient says at the outset that she has ample medication, by the end of the talk the patient may admit that the quantity is down to just a few pills, McCullough said. “It takes time to figure out how these patients are doing. You have to be their advocate and push them to get the best outcomes,” she said.
Efforts are also made to confirm that what pharmacists are doing and have recorded are in sync with what is in the electronic health record, a process that also helps to coordinate clinical and pharmacy operations, McCullough said.
Murphree described an adherence program at Clearview Cancer Institute that also includes calls to patients and efforts to coordinate activities with the clinical side of treatment, such as response to adverse effects. He said challenges to the success of that program come in the form of software programs that don’t communicate well with one another or with the electronic health record. For example, he said, at any given time he may have several programs open on his computer screen so that he can do the necessary cross checking required. This, he said, leads to a fragmented workflow, increased burden on pharmaceutical staff, and decreased efficiency.
Another problem is reduced access to patients. Pharmacy Benefit Managers (PBM) are succeeding in getting patients to fill their prescriptions at PBM-owned pharmacies, which makes it difficult to know whether a patient has filled a prescription and is following through by taking it, Murphree said.
He added that there are issues with patients themselves deliberately not taking drugs, and becoming discouraged from taking them because of adverse effects. There is also involuntary nonadherence, he said. This encompasses patients forgetting to take drugs, not being able to afford them, or being prevented from accurate adherence due to complex oral/intravenous or multidrug regimens.