Pharmacists-in-Training Implementing Quality Initiatives in Oncology Care
Alyssa B. Bradshaw, PharmD
PGY-2 Oncology Pharmacy Resident
Wake Forest Baptist Health
Michelle K. Azar
PharmD Candidate (2021)
University of Michigan College of Pharmacy
Ann Arbor, MI
Demonstrating the ability to provide high-quality and cost-efficient care by using process, outcome, and patient-reported metrics is now an essential part of health care and is linked to reimbursement and star ratings. The Centers for Medicare and Medicaid Services (CMS) created the Merit-Based Incentive Payment System and alternative-payment Oncology Care Model with the goal of promoting high-quality patient-centered care. CMS has approved the American Society of Clinical Oncology (ASCO) Quality Oncology Practice Initiative (QOPI) as a quality assessment program that can increase the potential for reimbursement by focusing on patient care and measuring quality in areas such as symptom management, evidence-based medicine, and cost mitigation. Oncology pharmacists are in an ideal position to influence the quality of care through financial stewardship by developing policies, improving patient outcomes through therapeutic management, and enhancing patient perceptions through direct education and enhanced supportive care.1 Pharmacists-in-training make it possible to expand the services offered by a pharmacist. The impact of pharmacy residency training programs on quality improvement initiatives has been documented since at least 1996.2 Although many projects remain unpublished and are being used solely for internal quality improvement, various publications demonstrate the involvement of pharmacy residents and students in efforts to improve quality metrics such as medication reconciliation, discharge follow-up, patient education, and patient engagement.
Leveraging Layered Learning to Expand Patient Care and Meet Quality Metrics for Oncology Patients
A study by Bates and colleagues published in 2016 evaluated the impact of leveraging pharmacists-in-training to expand care by conducting discharge medication reconciliation and counseling for malignant hematology and medical oncology patients.3 The advanced pharmacy practice experience (APPE) student was focused on obtaining admission medication histories and counseling, while the resident was responsible for discharge medication reconciliation, patient education, documentation, order verification, and providing support for obtaining medications. The clinical pharmacist assisted and coordinated team activities. During the 60-day study period, 61 patients (51%) received discharge medication reconciliation and counseling. The number of medication-related problems (MRPs) identified at discharge (mean of 1.26 for malignant hematology patients; mean of 2.1 for medical oncology patients) was captured and showed that the majority of problems involved coordination of specialty medications for the malignant hematology group and the need for an additional drug in the medical oncology group. The pharmacy team made recommendations to resolve all MRPs; the acceptance rates were 89.7% and 78% for the malignant hematology and medical oncology teams, respectively. This study demonstrated that pharmacists-in-training can be integrated into efforts to expand pharmacist care and improve patient outcomes.
Student Pharmacist–Driven Medication Reconciliation
A number of studies have evaluated the impact of pharmacy student–led medication reconciliation in the ambulatory care setting, such as in the infusion center of a comprehensive cancer center. A study by Ashjian and colleagues involved students in their introductory pharmacy practice experiences who completed medication histories for 510 hematology/oncology patients and found that 88% had at least one discrepancy.4 In a separate study, Phan and colleagues utilized APPE students to complete medication histories for 60 patients and found a similar rate of at least one discrepancy (83%), with 21% of those discrepancies involving a high-risk medication.5 Pharmacists-in-training can add significant value to patient care by correcting discrepancies and reducing the likelihood of medication errors.
Pharmacy Resident and Clinical Pharmacist Postdischarge Follow-Up Telephone Program
Discharge planning and follow-up are essential components of patient care and the prevention of avoidable hospital readmissions and complications. Patients with cancer are at an increased risk of transitions-of-care errors because of the complexity of their medication regimens. Pharmacists at the University of Texas MD Anderson Cancer Center teamed up with a PGY-1 resident and an educational specialist to develop a pilot program for postdischarge telephone calls to assess medication adherence, provide education, and address medication-related concerns with patients.6 Two hundred and six calls were made within 72 hours following discharge, and 150 (73%) of patients were successfully reached; 20 of the 206 patients who were contacted (9%) declined the call. Of the patients reached, 87 (58%) were found to have one or more discrepancies with their medications. Although it is known that scheduled follow-up with patients after hospitalization is beneficial, time and resources are a limiting factor. Pharmacists are well positioned to improve continuity of care and have a positive impact on medication-related issues, both of which are measures endorsed by the National Quality Forum and are National Patient Safety Goals, according to the Joint Commission.
Increased Patient Engagement Following Chemotherapy Consultation by a Pharmacist and Trainees
The literature is replete with evidence suggesting that patients who are engaged in their care have better outcomes and a lower cost of care. Patient engagement, or patient activation, refers to a patient’s knowledge, skills, and confidence to manage their own health and can be measured using the patient activation measure (PAM)-10 tool, with a higher score indicating improved outcomes. One study demonstrated this through a first-cycle chemotherapy consultation service, which was completed by a pharmacist or pharmacist-in-training.7 This service included patient education, medication therapy management, and the addressing of MRPs. After administering a baseline PAM-10 survey, pharmacists or trainees called the patient within 2 days of discharge for a second PAM-10 survey. Of the 36 patients analyzed in this study, the PAM-10 scores were significantly improved following the intervention (68.5 vs. 75, pre- and postintervention, respectively; p = .001). This study highlights the effectiveness of using pharmacy residents and students to positively affect patient care and encourage patient involvement in the care process.
Oncology pharmacists have demonstrated their abilities to influence patient care and positively affect quality metrics endorsed by ASCO QOPI as part of their current scope of practice. Pharmacy residents and students are able to assist in this process and can be called upon to supplement quality care given by the team. They can help implement and expand on established pharmacy services. Although pharmacists and pharmacy trainees have made significant contributions to enhancing the quality of oncology care, additional opportunities for pharmacy involvement remain. Areas of well-established pharmacist-led impact on quality include patient education, symptom management, medication reconciliation, discharge follow-up, transitions of care, and increasing patient engagement and activation. Focusing on developing new services and activities to address quality metrics and using pharmacy trainees in the process is an essential responsibility and next step for oncology pharmacists to further improve patient care while also ensuring that reimbursement is optimized.
Acknowledgment: The authors acknowledge and thank Gayle Blouin, PharmD BCOP, for her guidance and her review of the article.
- Vulaj V, Hough S, Bedard L, et al. Oncology pharmacist opportunities: closing the gap in quality care. J Oncol Pract. 2018;14:e403-e411.
- LeRoy ML, Pruemer J. Impact of an oncology pharmacy residency training program on quality improvement initiatives in an oncology center. Pharm Pract Manag Q. 1996;16:59-65.
- Bates JS, Buie LW, Amerine LB, et al. Expanding care through a layered learning practice model. Am J Health Syst Pharm. 2016;73:1869-1875.
- Ashjian E, Salamin LB, Eschenburg K, et al. Evaluation of outpatient medication reconciliation involving student pharmacists at a comprehensive cancer center. J Am Pharm Assoc. 2015;55:540-545.
- Phan H, Williams M, McElroy K, et al. Implementation of a student pharmacist-driven medication history service for ambulatory oncology patients in a large academic medical center. J Oncol Pharm Pract. 2019;25:1419-1424.
- Patel SD, Nguyen PAA, Bachler M, Atkinson B. Implementation of post-discharge follow-up telephone calls at a comprehensive cancer center. Am J Health Syst Pharm. 2017;74:S42-S46.
- Bates JS, Auten J, Sketch MR, et al. Patient engagement in first cycle comprehensive chemotherapy consultation pharmacist services and impact on patient activation. J Oncol Pharm Pract. 2019;25:896-902.