Addressing the Risk of Financial Toxicity in an Ambulatory Oncology Practice: Results from an ASCO Quality Training Program

Gee Youn (Geeny) Kim, PharmD
PGY-2 Hematology/Oncology Resident
Hospital of University of Pennsylvania
Philadelphia, PA

Novel cancer therapies have undoubtedly exploded in the past few years. It has been an exciting journey for clinicians to witness the development and positive effects of oral antineoplastic agents and immunotherapy in patients’ cancer treatments. Although these chemotherapeutics work through different and unique mechanisms to kill cancerous cells, unfortunately, the one toxicity profile common to all these new agents is financial toxicity. Concerns that their high price tags can cause disparities in cancer care and adversely affect patients’ quality of life, symptom burden, adherence, and survival appear to be well-founded. As a result, a few ambitious members of the NorthShore University Health System initiated a project to reduce the risk of financial toxicity by improving patient education at the time of informed consent through the Quality Training Program (QTP) of the American Society of Clinical Oncology (ASCO).¹ Thomas A. Hensing, MD, the project leader, formed a multidisciplinary panel that included George Carro, RPh MS BCOP, director of oncology pharmacy services at NorthShore, and Anna Palafox, PharmD BCOP, a clinical pharmacy specialist at NorthShore.

The aim of their project was to increase the proportion of oncology patients receiving information about financial risks and support resources available for high-cost treatments at the time of informed consent. The first phase of the pilot project specifically targeted immune checkpoint inhibitors because of their frequent use and high cost. Disappointingly, at the beginning of the project it was determined that none of the patients receiving these medications routinely received information on the financial risks of high-cost cancer treatments or the financial support services that were available to them. This omission compromised their ability to make informed decisions and caused them financial distress. A cause-and-effect diagram revealed that the main reasons that clinicians did not address financial risk during the informed-consent process were the lack of educational tools and a poorly understood prior-authorization process. To address these problems, the first rapid-cycle plan-do-study-act (PDSA) initiative involved developing an educational tool to use with patients during the informed-consent process, which was approved by the institution’s patient advisory board. The second PDSA initiative involved revising and optimizing the prior-authorization process. The third and final PDSA initiative focused on monitoring patient distress and financial toxicity through the National Comprehensive Cancer Network’s distress and patient-reported-outcome tools, respectively.

The results of the initiatives were dramatic. The proportion of patients receiving information about the risk of financial toxicity during the informed-consent process increased from 0% (0/20) in the preintervention group to 53% (9/17) in the postintervention group. The percentage of patients who successfully secured prior authorization before starting therapy jumped from approximately 50% (10/20) to 94% (16/17) after the interventions. Furthermore, with the optimization of workflows and staff education on financial toxicity and the early involvement of the patients’ financial advocates, the time required for successful prior authorization decreased significantly. Because of the success seen with these rapid-cycle PDSA initiatives, plans are now under way to expand the project to include all therapies, including oral chemotherapeutics. In addition, NorthShore University Health System was able to expand the number of financial advocates because this project’s findings supported the need for additional assistance. This change will advance the project and, more important, help achieve improvements in patients’ cancer care.

Overall, this project demonstrated that the involvement and empowerment of patients and providers in discussing the financial impact of high-cost chemotherapy is feasible at the time of informed consent. Optimization in the prior-authorization workflow led to immediate decreases in time to successful prior authorization and increases in the number of patients reached with educational tools. However, the long-term effects of this project, such as ability to gauge patient distress and financial toxicity, will need to be continually monitored.

In an interview with ASCO featuring pharmacy professionals and their multidisciplinary involvement in the QTP, George Carro emphasized his positive experiences in working with staff in other disciplines. All the stakeholders were supportive and encouraging during this collaboration, working toward the shared goal of improving patients’ cancer care. The interdisciplinary work of George Carro and Anna Palafox exemplifies the importance of teamwork and collaboration in optimizing the efficacy and safety of patients’ cancer care while minimizing financial toxicity.

Reference

1. Hensing T, Bauer T, Palafox A, Whalen M, Carro G. Addressing risk of financial toxicity in an ambulatory oncology practice: our institutional experience with the ASCO Quality Training Program. Poster presentation, ASCO Quality Care Symposium, Orlando, FL, March 3–4, 2017.