Positive Quality Interventions: An Innovative Platform for Oncology Practice Collaboration

Care for patients in the oncology setting is extremely diverse and complex. Management of the many distinct oral oncolytic regimens through pharmacy dispensing platforms in clinical practice can leave gaps within the healthcare system that should be addressed. These gaps are not caused by knowledge gaps; they result from a lack of contact with consistent and updated education material that succinctly describes and explains the primary details of treatment with specific medications, including but not limited to compliance obstacles and solutions, instructions on managing side effects and major adverse effects, and expectations of therapeutic onset and duration.

To this effect, the National Community Oncology Dispensing Association, Inc (NCODA), has developed education material dedicated to the promotion of better patient care in the oncology setting. Called Positive Quality Intervention (PQI), the material is developed by NCODA members across oncology practices throughout the United States who share their best practices. With numerous therapies to cover, a healthcare team must efficiently manage and allocate resources, a task that can potentially lead to competing priorities. A patient’s attention must also be directed toward other facets of dispensing, such as financial assistance and healthcare navigation. Sharing information across the organization can help clinicians stay current and help drive positive patient care interactions. An eye on the overall health of a patient and the ability to provide affordable healthcare and patient satisfaction can push the practice of oncology pharmacy forward.¹

Background

In the 2000s, approximately 20% of the cancer medications in use were oral therapies. That number has nearly doubled, with oral medications making up 40% of treatments now used in oncology, in tandem with diagnostic and surgical procedures as well as various pharmacy-driven regimens that continue to expand every day.² Barriers to effective use of oral anticancer agents include low adherence and patient literacy. Patients are often confused with the vast amount of information they receive, right from diagnosis and initiation of treatment, and some may also be intimidated by the regimen itself. Miscommunication of therapy regimens can lead to lower adherence and reduced treatment efficacy, increased hospitalization, disease progression, and increased health costs for both the patient and the provider network.

Trying to stay up-to-date on targeted oral medications that are indicated for only certain types of rare cancer can be challenging. Each new oral agent has its own specific barriers that could lead to patients’ not being able to successfully stay on therapy long enough or not being able to benefit fully.

Education Efforts by NCODA

NCODA’s PQI is designed with both the pharmacist and patient in mind. The treatment and management of oncology patients on oral drug therapy is constantly evolving. The professionals at in-office dispensing practices are uniquely positioned to ensure appropriate treatment, increase compliance, and maximize patient health outcomes. As NCODA quality standards, PQIs are designed to operationalize and standardize those practices to achieve these positive clinical outcomes. NCODA’s quality standards, publicly available on the organization’s website,³ are built into 4 domains that work cohesively with one another to create a more standardized and effective form of oncology practice³:

1) Patient centered

2) Positive quality interventions

3) Foundational elements

4) Health information technology (IT)

The 4 quality standards of NCODA help drive the basis of PQI while simultaneously being influenced by the PQIs themselves. The primary components of these standards can yield improved management of oral oncolytics in patient care:

1. Patient centered

With the objective of providing exceptional patient care, in-office dispensing practices should focus on maximizing patient convenience, providing timely access to treatment, ensuring financial support, and delivering individualized patient education. Developing a strong relationship with the patient is extremely important for sustaining and growing a practice toward better patient care. This involves, but is not limited to, direct access to patients and reviewing patient therapy regimens through direct patient interaction, developing standards of practice for dispensing the medication to the patient, and monitoring overall patient safety. Consistent patient vigilance with ever-changing regimens and therapy transitions is necessary to avoid medication waste and extraneous expenses. Cost avoidance is key to any clinical practice, and by adequate resource management, practices can obtain more effective value from treatment regimens. A strong patient-centered focus can increase patient compliance and adherence to medication and result in a more persistent regimen that can have a stronger overall therapeutic response.³

2. PQIs

PQIs were developed to ensure that a patient-centric model exists at all times within the in-office dispensing setting and to improve the overall management of patients who receive oral cancer medications. Interventions made by NCODA members and professionals were created, reviewed, and implemented to increase the speed to therapy, reduce costs and hospitalizations, improve persistence and compliance, and provide a higher level of patient care.

By identifying and recommending appropriate therapy, practices face inherent challenges in keeping current with new drug approvals, new indications, and compendia/guideline updates:

• Helping to minimize and manage the toxicities associated with treatment, with the goal of keeping patients on consistent therapy as long as efficaciously possible
• Providing an efficient operation of a demanding dispensing process
• Designing medication management tools that focus on specific issues associated with managing oral drug therapies for cancer

Using the practice of evidence-based medicine, the PQIs are developed for specific medications and/or diseases and continuously guide in-office dispensing professionals in managing a patient’s drug therapy. Through PQIs, practices are able to mitigate toxicities and assist providers by highlighting appropriate drug therapy and dose based on individual patient characteristics.³

PQIs involve clinical reference tools to establish an up-to-date library of education for all practices involved in oral medications for oncology. The education materials themselves, which are reviewed by NCODA professionals and archived, can be accessed and used by practices for patients at an acceptable literacy level for effective communication during the counseling phase of dispensing. These materials will be made available online as well as through monthly meetings for healthcare professionals through NCODA, providing both literary and audio support. The material also includes standards of practice for inventory maintenance for timely initiation as well as assistance in pharmacist verification and validation.

3. Foundational elements

Foundational elements are established to facilitate the ongoing nature of pharmacy operational elements, which include:

• Work flow and process ow diagrams, including both single- and multisite practices and dispensing areas
• Central business office alignment, which refers to the integration of billing services and billing reconciliation
• Contracting and payer implementation
• Prior authorization processing
• Group purchasing organization affiliations
• Liability insurance
• Claims accounting, which involves editing, adjudication, and reconciliation
• Audit preparation and readiness
• Credit card processing companies
• Cost-avoidance documentation
• Financial counseling and patient advocacy

This quality standard interfaces with creating a proper dispensing space; a thorough communication plan involving healthcare providers, patients, and auxiliary staff; continuous quality improvement; and corrective/preventive action assessments for standards of procedure to fulfill an all-encompassing healthcare process.³

4. Health IT

Having data integrated into oncology dispensing pharmacy platforms is critical to closing the gaps in educational material and improving on the patient-centered model. The ability to closely link to prescriber-level data provides a distinct advantage in helping to manage patients and track multiple data points such as adverse drug reactions, dose changes, cost avoidance, medication waste, and therapy discontinuation. Being able to provide additional care beyond the first medication fill is crucial to creating a stronger connection to the patient and data points such as financial support and adherence rate. One of the most underused aspects of community oncology care is the vast amount of contact time with the patient involving both subjective and objective data. Tapping consistent data provides the ability to predict future trends in therapy education and management, for which NCODA can create proactive education to manage an ever-changing oncology landscape. Broadening those trends over the large network of NCODA member practices across the country can exponentially increase the speed and brevity at which best practices can be developed to suit the needs of the healthcare provider community.³

Future Data Collection

NCODA is collaborating with promising health IT initiatives that will better interface with pharmacy dispensing systems to help evaluate the impact of the PQIs. Areas of interest include evaluating how long patients stayed on therapy and whether emergency department visits and hospitalizations were reduced when information written in a PQI was followed. This type of analysis will be vital in the new quality-driven positive-outcomes world. The data would be gathered across large and small NCODA practices as well as those that have or have not participated in the Oncology Care Model (OCM). Documenting a positive impact with PQIs will confirm the quality care that patients receive at oncology centers and also lend support to the in-office dispensing model.

The prospective outlook on the oral oncology space will be evaluated with future PQIs. Quantitative measurement of these early initiatives, however, may require a different outlook. We can possibly evaluate NCODA members, in both OCM and non- OCM practices, who perform best practice surveys before implementation of PQIs at a predetermined time range—for example 6 months prior to and then 2 months after PQI implementation. A comparison of practice changes can provide preliminary evidence about the impact of PQIs as well as the depth of oncology practice overall.

Current PQIs

The PQI pipeline developed by NCODA is dictated by the reported needs of NCODA members and includes broad topics such as medication-related adverse event management. With the addition of practices in various degrees of size and scope, the network of information developed will help create standardized resources for a growing range of healthcare systems. The sharing of best practices facilitates the evolution and improvement of oncology care across the healthcare setting.³

NCODA’s constantly growing list of PQIs has been addressing the following topics:

• Hand-foot syndrome
• Stomatitis
• Chemotherapy-induced diarrhea
• Metastatic colorectal cancer (mCRC)
• Epidermal growth factor receptor medications
• Polycythemia vera
• Myelofibrosis
• mCRC (tri uridine and tipiracil)
• Dose reduction practices
• Specific drug-based follow-up call schedule
• Olanzapine use for nausea prevention
• Hepatocellular carcinoma
• Cyclin-dependent kinase 4 inhibitors

Conclusion

Advancing the value of dispensing practices for oncology physicians constitutes a significant part of the NCODA mission. The need for best dispensing practices in the oncology setting is increasingly becoming apparent, and PQIs play an integral role in helping achieve this. With the PQI initiative, NCODA members across cancer centers can use their collaborative power to develop best practices that can lead to the best possible patient care.

Pharmacists, nurses, pharmacy technicians, and physicians make up the diverse group of NCODA’s membership. Each professional contributes and helps make the organization and its mission possible and successful. By creating a new type of progressive practice network focused on standardizing the oncology field, NCODA is able to prepare for the incoming wave of oral oncology medications that cover more tailored therapy regimens across a wide pool of varying patient demographics. Positive quality interventions are designed to fulfill the triple aim of improving patient satisfaction and care quality, improving the health of the overall population, and reducing the per capita cost of healthcare.¹ With future data-collection methods and a pipeline of PQI creation in place, these standardized practices will help extend patient therapy and prevent loss of efficacy which will lead to better care throughout the comprehensive oncology space.

AUTHOR INFORMATION

Joshua Nubla, PharmD, is assistant manager of stakeholder engagement, National Community Oncology Dispensing Association, Inc.

Neal Dave, PharmD, is area pharmacy manager, Texas Oncology.

Michael Reff, MBA, is executive director and founder, National Community Oncology Dispensing Association, Inc; and pharmacy manager, The Patient Rx Center, Hematology and Oncology Associates of Central New York.

ADDRESS FOR CORRESPONDENCE

Joshua Nubla PharmD

9 Albany St, Ste 2E

Cazenovia, New York 13035

E-MAIL

joshua.nubla@ncoda.org

REFERENCES

1. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759-769. doi: 10.1377/ hlthaff.27.3.759.

2. Tipton J. Oral therapies: strategies to ensure adherence. Oncology Nurse Advisor website. oncologynurseadvisor.com/navigation-summit-2017/ strengthening-oral-adherence-to-oncology-medications/article/669366/. Published June 17, 2017. Accessed August 14, 2017.

3. Quality standards. NCODA website. ncoda.org/quality-standards. Published 2017. Accessed August 1, 2017.