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

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

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

Gena Hoefs
University of Minnesota College of Pharmacy
PharmD Candidate-Class of 2021
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 that demonstrate pharmacy leaders measuring and improving quality care for patients with cancer are highlighted.

Quality Training Program (QTP) to Oncology Pharmacists²
Pharmacists are critical in optimizing medication management and quality care in oncology patients. The Hematology Oncology Pharmacy Association (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 ASCO 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 comparative assessment of attendees pre- versus post-workshop demonstrated a three-point (on a 10-point scale) improvement in knowledge and skills and a 2.8 point increase in competence. A vast majority (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) SMT28a metric 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 provide support to reduce the 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.

Additionally, 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 have 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 consisting of physicians, pharmacists, nurses, a quality manager, and information technology staff worked together to create pathway algorithms and reviewed treatment plans for the treatment of acute myeloid leukemia. This was inclusive of treatments, laboratory testing, supportive care (antiemetics, antimicrobials, and tumor lysis prophylaxis). A retrospective chart review was completed one-year after implementation to assess adherence. The primary objective was to achieve a pathways adherence rate of 80% or higher. Forty-four patient charts pre-pathway implementation utilizing best clinical evidence as a standard were compared to 44 patient charts post-implementation. 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 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 hardship 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 five most common medications prior to and during the pandemic

(Jan – May), as well as copayments and use of financial assistance resources. Consistent MPRs were demonstrated for the five most common therapies analyzed in 2019 vs 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 to payment models continues to add pressure to meet these goals by the health care team including pharmacists.

Publication and presentations regionally and nationally of quality improvement and research aimed at 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 21^st 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