Pharmacist Contributions to Quality Improvement in Oncology Care Presented at the ASCO Quality Care Symposium 2020

Ann Schwemm, PharmD, MPH, BCOP
Senior Pharmacist
Flatiron Health, Inc.
New York, NY

Shahrier Hossain, PharmD
PGY-2 Oncology Pharmacy Resident
Dana-Farber Cancer Institute
Boston, MA

Gena Hoefs
PharmD Candidate-Class of 2021
University of Minnesota College of Pharmacy
Minneapolis, MN

The virtual fall 2020 American Society of Clinical Oncology (ASCO) Quality Care Symposium showcased methods for measuring and improving the quality and safety of cancer care, including the work of many oncology pharmacists. Quality healthcare domains, as defined by the Institute of Medicine (IOM) include safe, effective, efficient, equitable, timely, and patient-centered care.¹ Measurement of quality care should be practical, meaningful, inexpensive, and user-friendly. Four abstracts demonstrating pharmacy leaders measuring and im­proving quality care for patients with cancer are highlighted.

Organizational Partnership to Expand the ASCO Quality Training Program (QTP) to Oncology Pharmacists²
Pharmacists are critical in optimizing medication management and quality care in oncology patients. The HOPA Quality Oversight Committee (QOC) sought to improve educational opportunities in the area of oncology value and quality-based patient care for phar­macists. This led to discussion and a partnership with the Ameri­can Society of Clinical Oncology (ASCO) Quality Training Program (QTP) to develop a one-day workshop tailored to oncology pharma­cists, aimed to strengthen their knowledge in quality improvement (QI) measures and strategies for practice improvement.

A pre- and post-workshop comparative assessment of attend­ees demonstrated the following on a 10-point scale: A 3-point improvement in knowledge and skills, and a 2.8-point increase in competence with 93% of attendees reported as very or extremely likely to use the new skills learned. The authors concluded that the workshop resulted in meaningful training in quality improvement measures for oncology pharmacists. Future partnership plans include additional one-day workshops and a modified ASCO QTP six-month course specifically for HOPA members.

State-wide Quality Improvement Addressing Overutilization of Neurokinin-1 Receptor Antagonists³
ASCO’s Quality Oncology Practice Initiative (QOPI) Symptom and Toxicity Module (SMT) metric 28a focuses on the overuse of anti­emetics, specifically of neurokinin-1 receptor antagonists (NK1-RA) for low or moderate emetogenic regimens. A team including oncol­ogy pharmacists created a quality improvement project to support a reduction in use of NK1-RA when not indicated. Baseline mea­surements of performance, prescriber knowledge and beliefs, and pre-populated antiemetic order sets were assessed.

A quality improvement intervention was initiated and included practice and state-level performance reporting to the Michigan Oncology Quality Collaborative (MOQC); chemotherapy-induced nausea and vomiting education, and a value-based reimbursement related to measure performance. Initial responses assessing pre-populated antiemetic order sets showed that 23% had NK1-RA or olanzapine in moderate emetic regimens. Post-education, 48% of respondents had plans to, or had already, rectified their order sets. This ultimately improved performance from 27% to 19% (p<0.05) and below the 2020 QOPI mean performance measure of 31%.

Development and Implementation of an Evidence-based Malignant Hematology Clinical Pathway Program⁴
Clinical pathways often include a systemic approach to clinical deci­sion support aimed at providing quality care while decreasing cost. Brahim and colleagues describe their institution’s implementation of a clinical pathways program to standardize practice and increase quality of care as measured by pathway adherence. A team of phy­sicians, pharmacists, nurses, a quality manager, and information technology staff worked together to create pathway algorithms and review treatment plans for acute myeloid leukemia. This included treatments, laboratory testing, and supportive care (antiemetics, antimicrobials, and tumor lysis prophylaxis). The primary objective was to achieve a pathway adherence rate of 80% or higher.

A retrospective chart review one year after implementation was completed to assess adherence. Forty-four pre-pathway implemen­tation patient charts utilizing best clinical evidence as a standard were compared to 44 post-implementation patient charts. There were 16 deviations pre-pathway. This included omitted medica­tions, medications added, dose variations, different regimens, and supportive care. There were five deviations in the post-pathway group. Deviations included omitted medications, added medica­tions, and different regimens. Pre- and post-pathway implemen­tation adherence was 64% and 89%, respectively (p=0.006). The investigators plan to expand their program to other disease states, such as multiple myeloma and acute lymphoblastic leukemia (ALL) while continuing to monitor adherence and program objectives.

Providing Uninterrupted Oral Oncolytic Therapies During the COVID-19 Pandemic⁵
The COVID-19 pandemic has created significant financial and lo­gistic hardships for patients and pharmacies to provide continued oral oncolytic therapy. A team investigated whether the pandem­ic impaired access to oral chemotherapy at Tennessee Oncology’s medically-integrated specialty pharmacy. In a retrospective analy­sis, investigators compared medication possession ratios (MPRs) of the 5 most common medications prior to and during the pandemic (January–May), as well as copayments and use of financial assis­tance resources.

Consistent MPRs were demonstrated for the five most common therapies analyzed in 2019 versus 2020 (95.13% vs 94.86%). They also found similar aggregated copay amounts between the study pe­riods and an increase in the use of copay cards (22%) and foundation assistance (12%) from 2019 to 2020. They concluded uninterrupted access to oral oncolytics and financial support services was provided throughout the beginning of the pandemic and attributed main­tained MPRs to proactive and strategically-timed patient outreach.

Conclusion
Oncology pharmacists contribute significantly to improving quality and value metrics in the care of patients with cancer. Assessment of quality metrics and engagement in value-based contracts contin­ues to grow and has become applicable to broader populations of patients with cancer in health-systems and oncology clinics. The impact of these on payment models continues to add pressure to meet these goals by the healthcare team including pharmacists. Re­gional and national publications and presentations aimed at quality improvement and research efforts will continue to show the value of the oncology pharmacist within patient-centered care.

REFERENCES

1. Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington (DC): National Academies Press (US); 2001.
2. Mackler ER, Morris A., Carro GW, et al. Organizational partnership to expand the ASCO Quality Training Program to oncology pharmacists. J Clin Oncol. 2020: 38 (suppl 29); abstr 198.
3. Mackler ER, Procailo KM, Bedard L, et al. State-wide quality improvement addressing overutilization of neurokinin-1 receptor antagonists. J Clin Oncol. 2020:38 (suppl 29); abstr 8.
4. Brahim A, Vargas F, Wilkinson R, et al. Development and implementation of an evidence-based malignant hematology clinical pathway program. J Clin Oncol. 2020:38 (suppl 29); abstr 304.
5. Arrowsmith E, Mitchell RL, Taylor JL, et al. Providing uninterrupted oral oncolytic therapies during the COVID-19 pandemic. J Clin Oncol. 2020:38 (suppl 29); abstr 226.