Pharmacist Contributions to Quality Improvement in Oncology Care Presented in the ASCO Quality Care Symposium 2021

Rachel L. McDevitt, PharmD, BCOP
Clinical Pharmacist Specialist, Ambulatory Oncology
University of Michigan Rogel Cancer Center
Ann Arbor, MI

Gena Hoefs, PharmD
PGY1 Pharmacy Resident
M Health Fairview-University of Minnesota Medical Center
Minneapolis, MN

Elizabeth Graver
PharmD Candidate - Class of 2022
University of Texas at Austin, College of Pharmacy
Austin, TX

Introduction
The fall 2021 American Society of Clinical Oncology (ASCO) Quality Care Symposium showcased many projects and research endeavors aimed at improving the quality and safety of cancer care, including the work of many oncology pharmacists. Three pharmacist-led abstracts aimed at measuring and improving quality care for patients with malignancies are highlighted here.

Improvement in Time to Oral Anticancer Agent Follow-up₁
Johengen and colleagues evaluated the time to first follow-up visit for patients initiated on oral anticancer agents before and after implementation of a dedicated oncology pharmacist. Prior to oncology pharmacist implementation, care managers were responsible for follow up in patients prescribed new oral anticancer agents. This group compared the time to first follow-up for 79 patients started on oral anticancer therapies in the pre-pharmacist time period (11/1/20 - 2/28/21) to the follow-up times for 40 patients started on oral anticancer therapies in the post-pharmacist implementation time period (3/1/21 - 4/30/21).

The authors found the median time to first follow-up after oral anticancer therapy initiation was 8 days for patients in the pre-pharmacist group compared to 7 days in the pharmacist group. Additionally, time to first follow-up was within 10 days of initiating an oral anticancer therapy for 67.1% of patients in the pre-pharmacist group compared to 95% of patients in the pharmacist group (p<0.001).

The authors concluded time to first follow-up for patients started on oral anticancer therapy was shorter for patients cared for by a pharmacist. Future directions include characterizing the interventions made by the pharmacist at time of follow-up, evaluating patients’ duration of oral anticancer therapy, and rate unplanned admissions in these patients.

Implementation of an EHR-embedded Decision Support Tool in Community Oncology Practices.²
Flatiron Health, Inc, is a healthcare information technology company that specializes in creating and refining clinical decision support (CDS) tools based on real-world data derived from electronic health records and guideline-recommended treatment regimens.³ In effort to evaluate the prevalence of use of the EHR-embedded CDS tool, Flatiron Assist, investigators tracked how often providers were using the CDS tool to guide treatment decisions for patients diagnosed with non-small cell lung cancer (NSCLC) at 2 months, 6 months, and 1 year after adoption. The rationale for implementing the CDS tool is to document and report various quality metrics in hopes of improving the delivery of value-based cancer care.

Their study found over the 1-year observation period, frequency of use of Flatiron Assist increased from 30% at 2 months to 80% at 1-year. Additionally, the study investigated concordance of NSCLC orders with National Comprehensive Cancer Network (NCCN) Guidelines and NCCN Preferred Treatment regimens, and found that over the observed time period, concordance decreased from 94% at 2 months to 85% at 1 year.

The most common reasons providers reported for ordering non-concordant regimens were physician’s choice, patient status, and newly published evidence. The investigators postulated that the decrease in NCCN-concordant orders was attributed to increased usage or greater comfort with the CDS tool over time.

Based on this data, the investigators concluded that Flatiron Assist was quickly adopted by most prescribers and used for the majority of NSCLC orders over the 1-year observation period, most of which were in concordance with NCCN recommendations. Further research is required to further define workflow time, predictors of non-use and non-concordance orders, and correlation of Flatiron Assist with improved clinical outcomes.

Real-world EGFR Testing Patterns Among U.S. Patients with Advanced NSCLC4
Multiple targetable mutations, including mutations in the epidermal growth factor receptor (EGFR), have been identified in patients with NSCLC and help guide therapy selection. NCCN Guidelines recommend molecular testing for these mutations prior to initiating therapy and after disease progression. However, molecular testing presents its own set of challenges including wait times, access to testing, and cost.⁵ To better characterize real-world use of EGFR testing, Vanderpoel and colleagues performed a retrospective observational study in a cohort of patients with advanced NSCLC from the Flatiron Health database. The study examined a total of 22,726 patients from 2015 to 2020. Overall, 75% of the patients received at least one EGFR test and 15% of those patients tested positive for an EGFR mutation. Of patients who tested positive for an EGFR mutation prior to first line therapy, 36% received a second EGFR test prior to initiating second line therapy.

Notably, the team found the rate of EGFR mutation testing improved over the study period with an 11% increase from 2015 to 2020. Time from sample collection to test results also decreased from 26 days to 16 days for next generation sequencing, and from 17.5 days to 12 days for polymerase chain reaction tests. Identified areas of improvement included increasing the proportion of patients who receive EGFR testing prior to first line therapy and prior to initiating therapies after disease progression.

Conclusion
These projects and many others illustrate the impact of oncology pharmacists in continuing to provide and optimize safe and effective care for patients with cancer. Regional and national presentations and publications by pharmacists in the quality space will continue to show the value of oncology pharmacists.

REFERENCES

1. Johengen E, Davidson A, Beekman KW, et al. Improvement in time to oral anticancer agent follow-up. Journal of Clinical Oncology, 2021; 39 (28): suppl 28, abstr 235. 10.1200/JCO.2020.39.28_suppl.235
2. Maniago R, Richey SS, DeVincenzo S, et al. Implementation of an EHR-embedded decision support tool in community oncology practices. Journal of Clinical Oncology, 2021; 39 (28): suppl. 28, abstr 274. 10.1200/ JCO.2020.39.28_suppl.274
3. About Us. Flatiron Health, Inc. https://flatiron.com/about-us/
4. Vanderpoel J, Pericone C, He J, et al. Real-world EGFR testing patterns among U.S. patients with advanced NSCLC. Journal of Clinical Oncology, 2021; 39 (28): suppl 28, abstr 298. 10.1200/JCO.2020.39.28_suppl.298
5. Cuppens K, Lodewyckx L, Demedts I, et al. Real-World Treatment Patterns, Epidermal Growth Factor Receptor (EGFR) Testing and Outcomes in EGFR-Mutated Advanced Non-small Cell Lung Cancer Patients in Belgium: Results from the REVEAL Study. Drugs Real World Outcomes. 2021;8(2):141-152. doi:10.1007/s40801-021-00243-w