Quality Improvement in Managing Oral Chemotherapy During Hospital Admission

1. Quality Improvement in Managing Oral Chemotherapy During Hospital Admission Gretchen Marcelino, PharmD PGY1 Pharmacy Practice Resident NYU Winthrop Hospital

2. Background Khandelwal N, PhD, BPharm, Duncan I, FSA, FIA, FCIA, MAAA, Ahmed T, PhD, MBA, Rubinstein E, MPH, PharmD, Pegus C, MPH, MD. Impact of Clinical Oral Chemotherapy Program on Wastage and Hospitalizations. Journal of Oncology Practice. Vol. 7, Issue 3S. May 2011.; Weingart SN, Flug J, Brouillard D, Morway L, Partridge A, Bartel S, Shulman LN, Connor M. Oral chemotherapy safety practices at US cancer centres: questionnaire survey. BMJ. 12 Jan 2007. • With oral chemotherapy, patients can • Conveniently take their medications at home (obtained by specialty pharmacies) • Save time from going to infusion centers • Lose continuity of care upon hospital admission

3. Recently Approved Oral Chemotherapy (2017) 2017 FDA Approved Drugs. CenterWatch. Available at: https://www.centerwatch.com/drug-information/fda-approved-drugs/year/2017. Accessed 27 April 2018.

4. Good Medical Practice Ann M. Birner, PharmD, BCOP, Marilyn K. Bedell, MS, RN, OCN, Jean T. Avery, MBA, BSN, RN, Marc S. Ernstoff, MD. Program to Support Safe Administration of Oral Chemotherapy. Journal of Oncology Practice. Vol. 2, Issue 1. January 2006.; Khandelwal N, PhD, BPharm, Duncan I, FSA, FIA, FCIA, MAAA, Ahmed T, PhD, MBA, Rubinstein E, MPH, PharmD, Pegus C, MPH, MD. Impact of Clinical Oral Chemotherapy Program on Wastage and Hospitalizations. Journal of Oncology Practice. Vol. 7, Issue 3S. May 2011.; Weingart SN, Flug J, Brouillard D, Morway L, Partridge A, Bartel S, Shulman LN, Connor M. Oral chemotherapy safety practices at US cancer centres: questionnaire survey. BMJ. 12 Jan 2007. Keep patients on schedule with their chemotherapy cycle Reduce medication cost/waste by allowing patients to take their own supply of medication Optimize patient care with a collaborative team effort

5. Study Objectives

6. Definition

7. The Process of Prescribing Oral Chemotherapy

9. Pharmacist Role Ann M. Birner, PharmD, BCOP, Marilyn K. Bedell, MS, RN, OCN, Jean T. Avery, MBA, BSN, RN, Marc S. Ernstoff, MD. Program to Support Safe Administration of Oral Chemotherapy. Journal of Oncology Practice. Vol. 2, Issue 1. January 2006.; Khandelwal N, PhD, BPharm, Duncan I, FSA, FIA, FCIA, MAAA, Ahmed T, PhD, MBA, Rubinstein E, MPH, PharmD, Pegus C, MPH, MD. Impact of Clinical Oral Chemotherapy Program on Wastage and Hospitalizations. Journal of Oncology Practice. Vol. 7, Issue 3S. May 2011.; Weingart SN, Flug J, Brouillard D, Morway L, Partridge A, Bartel S, Shulman LN, Connor M. Oral chemotherapy safety practices at US cancer centres: questionnaire survey. BMJ. 12 Jan 2007. • Assess patient profiles and medication orders • Indication • Dosing strategy • Enter orders into CPOE and dispense medications • Educate the healthcare teams

10. Study Design Single-centerstudy Retrospective chart review of written oral chemotherapy orders Includes pediatric and adult patients Hospital admission from January 2017 to January 2018 Approved by the institutional review board

11. Methods

12. Results: Baseline Characteristics Number of oral chemotherapy orders prescribed for specific disease indications

13. Classes of Oral Chemotherapy Oral chemotherapy agents prescribed (N=160) Note: Hormonal agents exclude tamoxifen, raloxifene (Per institutions exclusions for a chemo order form)

14. Service Prescribing Oral Chemotherapy

15. Primary Outcome: Delayed Orders The number of orders delayed by heme/oncvs non-heme/onc providers (n=83)

16. Primary Outcome: Days Delayed The number of days oral chemotherapy orders were delayed from day 1 of admission (N=160)

17. Definitions

18. Secondary Outcome: Appropriateness of Delay Delayed oral chemotherapy orders that were appropriate vs inappropriate

19. Secondary Outcome: Appropriateness Based on Formulary Status The number of orders delayed that were appropriate(n=41) The number of orders delayed that were inappropriate(n=42)

20. Secondary Outcome: Reasons for Delay

21. Secondary Outcome: Formulary Status of Delayed Oral Chemotherapy Classification of delayed oral chemotherapy agents based on hospital supply (n=30) The number of ordersdelayed based on hospital supply (n=83)

22. Education to Prescribers

23. Have You Ordered Oral Chemotherapy?

24. Do You Know Where to Access the Chemotherapy Forms?

25. Do You Know Where to Access the Anti-Neoplastic List?

26. Have You Used Lexicomp?

27. Do You Know How to Access Lexicomp?

28. Did You Know that You Can Get Lexicomp Mobile Access?

29. Conclusion • 52% (n = 83) orders (N = 160) were delayed by at least one day • 49% provided appropriate reasons • 27% were waiting for order forms to be signed • Antimetabolites were most frequently prescribed (54%), followed by enzyme inhibitors (33%) • 64% of orders were prescribed by hematology-oncology providers • Missed doses were not related to formulary status • Survey shows that not all prescribers were aware of where to access the order forms and the anti-neoplastic list of medications

30. Future Implications • Proper documentation on written and electronic medical records by providers • Enhanced communication with the multidisciplinary healthcare teams • Education about oral chemotherapy agents and the medication use process

31. Study Limitations Single-center, retrospective study Failure to preserve resolution of paper orders when faxed/scanned Illegible handwriting on order forms Orders may have been missed/not filed appropriately

32. Learning Assessment Question How can pharmacists play a role in managing oral chemotherapy during hospital admission? A) By keeping patients on schedule with their chemotherapy cycle B) Reducing medication cost/waste by allowing patients to take their own supply of medication C) Optimizing patient care with a collaborative team effort D) All of the above

33. Learning Assessment Question How can pharmacists play a role in managing oral chemotherapy during hospital admission? A) By keeping patients on schedule with their chemotherapy cycle B) Reducing medication cost/waste by allowing patients to take their own supply of medication C) Optimizing patient care with a collaborative team effort D) All of the above

34. Acknowledgements

35. References Ann M. Birner, PharmD, BCOP, Marilyn K. Bedell, MS, RN, OCN, Jean T. Avery, MBA, BSN, RN, Marc S. Ernstoff, MD. Program to Support Safe Administration of Oral Chemotherapy. Journal of Oncology Practice. Vol. 2, Issue 1. January 2006. KhandelwalN, PhD, BPharm, Duncan I, FSA, FIA, FCIA, MAAA, Ahmed T, PhD, MBA, Rubinstein E, MPH, PharmD, Pegus C, MPH, MD. Impact of Clinical Oral Chemotherapy Program on Wastage and Hospitalizations. Journal of Oncology Practice. Vol. 7, Issue 3S. May 2011. Lexicomp. Wolters Kluwer Clinical Drug Information. Available at: online.lexi.com. Accessed 18 April 2018. WeingartSN, Flug J, Brouillard D, Morway L, Partridge A, Bartel S, Shulman LN, Connor M. Oral chemotherapy safety practices at US cancer centres: questionnaire survey. BMJ. 12 Jan 2007.

36. Quality Improvement in Managing Oral Chemotherapy During Hospital Admission Gretchen Marcelino, PharmD PGY1 Pharmacy Practice Resident NYU Winthrop Hospital

37. Results Table 1: Oral chemotherapy agents on formulary

38. Results Table 2: Oral chemotherapy agents classified as non-formulary

39. Results Table 3: Oral chemotherapy agents not-stocked

40. Results: Safety Outcomes