2012 Finalist: St. Luke's Mountain States Tumor Institute

A Pharmacist-Managed Oral Chemotherapy Program

Over the last 15 years, the number of FDA-approved oral chemotherapy agents has more than doubled. A 2007 study by Weingart and colleagues showed that most cancer centers and cancer treatment hospitals have strict policies and procedures for safely processing intravenous chemotherapy, but not for oral chemotherapy. In 2009, national guidelines were published on the safe administration of chemotherapy, including standardized ordering, preparation, education, monitoring and follow-up. These guidelines also emphasized intravenous chemotherapeutic medications. When oral chemotherapy agents are prescribed, patient education, monitoring and follow-up is often limited. 

In 2009 a pharmacy resident at St. Luke’s Mountain States Tumor Institute reviewed patients’ oral chemotherapy usage and then developed a 6-week pilot project that involved a multidisciplinary group of health care professionals, including nurses, pharmacists, physicians, social workers, pharmacy technicians and patient financial advocates. New patients who were prescribed oral chemotherapy agents were referred to the program by the physician’s primary nurse. The pharmacist would evaluate patients’ prescriptions for correct indication, correct dose, drug interactions and plans for appropriate laboratory monitoring. An oncology-trained pharmacist educated patients about the medications, and pharmacy technicians reviewed the patients’ health care insurance to determine if coverage issues would affect patient access. Patients with coverage issues were referred to a social worker or patient financial advocate for co-pay assistance or enrollment in medication assistance programs. This pilot yielded 20 patient referrals; high patient, physician, and nursing satisfaction; and an economic analysis that justified a full-time pharmacist.

From 2009 through 2011, the oral chemotherapy project provided care to more than 700 patients. While up to 20-percent non-fulfillment rates for oral chemotherapy medications are reported in the literature, this program has been able to reduce prescription non-fulfillment to 9 percent, with less than 2 percent due to insurance or access issues. The involvement of social workers and financial advocates has led to procurement of more than $1 million in free medications and nearly $200,000 in co-pay assistance for these patients. The process has also increased health-system revenue by increasing the outpatient pharmacy’s dispensing of oral chemotherapy prescriptions, written within the organization, from less than 20 percent to 85 percent and by reducing medication write-offs to less than 1 percent. This increase in revenue has strengthened support of the expanded pharmacist role.

Through this program, pharmacists identified 82 drug interactions; 25 patients that required dose adjustments for renal or hepatic dysfunction; and 34 patients who had other pharmacist interventions, including addition of anti-emetics and prescription corrections. The oncologists accepted 88 percent of all pharmacist interventions. These pharmacist interventions have reduced the rate of potential medication errors to 2 percent, as compared to a 20-percent rate reported in the literature, and no errors have reached a patient or caused harm since program inception. Interventions described are optimized by the pharmacists’ presence within the system and full access to the patients’ entire medication lists, labs and prescribing oncologists. This allows for rapid intervention; prevention of delays in start of treatment; and improvement in outcomes, including economic and safety as well as patient, physician and nursing satisfaction.

Multidisciplinary Team
Robert S. Mancini, Pharm.D., Team Chair
Jill Collins, B.S.N.
Catherine Gundlach, Pharm.D.
Thea Hutchinson, B.A.
Clementine Mehrens
Colleen Powell, C.Ph.T.
Delissa Rapp, M.S.W./LCSW
David B. Wilson, B.S.Pharm.
Dan Zuckerman, M.D.