Clinical and economic impact of clinical oncology pharmacy in cancer patients receiving injectable anticancer treatments: a systematic review

PURPOSE

Clinical pharmacy can reduce drug-related iatrogenesis by improving the management of adverse effects of drugs, limiting drug-drug interactions, and improving patient adherence. Given the vulnerability of cancer patients and the toxicity of injectable anticancer drugs, clinical pharmacy service (CPS) could provide a significant clinical benefit in cancer care. This review aims to synthesize existing evidence on clinical pharmacy's impact on patients treated with intravenous anticancer drugs.

METHODS

A comprehensive search was performed in the PubMed/Medline database from January 2000 to December 2021, associating the keywords: clinical pharmacy, pharmaceutical care, pharmacist, oncology, and chemotherapy. To be eligible for inclusion, studies have to report clinical pharmaceutical services for patients treated with intravenous chemotherapy with a clinical and/or economic impact.

RESULTS

Forty-one studies met the selection criteria. Various CPS were reported: medication reconciliation, medication review, and pharmaceutical interview with patient. There was a lack of randomized study (n = 3; 7.3%). In one randomized controlled trial, pharmaceutical intervention significantly improved quality of life of patients receiving pharmaceutical care during injectable anticancer drugs courses. Economical results appear to show positive impact of clinical pharmacy with cost savings reported from 3112.87$ to 249 844€. Although most studies were non-comparative, they highlighted that clinical pharmacy tend to limit chemotherapy side effects and drug-related problems, improve quality of life and satisfaction of patients and healthcare professional, and a positive economic impact.

CONCLUSION

Clinical pharmacy can reduce adverse drug events in cancer patients. More robust and economic evaluations are still required to support its development in everyday practice.

Practicing and evaluating clinical pharmacy in oncology: Where are we now? A scoping review

BACKGROUND

Clinical pharmacy is a discipline structured around multiple activities whose objective is to secure patient care. Among all the specialties where it can be applied, oncology is a field of choice. More and more studies are being conducted on the impact of this activity, but their methodology and results seem at first sight very heterogeneous.

OBJECTIVE(S)

The objective of this literature review was to describe the clinical oncology pharmacy activities found in the literature, and analyze the methodology used and the outcomes measured by the authors for their evaluation.

METHODS

This literature review was based on the PRISMA-ScR criteria. The Embase, CINAHL, Google Scholar, and PsycINFO databases were searched. All studies reporting the evaluation of hospital-based clinical pharmacy activity in cancer patients were included based on a previously validated search equation. The search was conducted until the end of 2020. The quality of all studies was assessed using the MMAT.

RESULTS

Of the 2521 results of the initial query, 93 were selected for complete review. The main interventions implemented were pharmaceutical analysis as well as pharmaceutical interviews. The indicators assessed most often were the number of pharmaceutical interventions as well as treatment-related problems. The overall quality assessment score was 55%.

CONCLUSION

Clinical pharmacy activity in oncology still lacks robust studies, whether methodologically or of the measured indicator. Patient-centered impact indicators are still too rare. This area of research should focus on the homogenization of indicators and their relevance.

Impact of clinical pharmacy in oncology and hematology centers: A systematic review

BACKGROUND

Oncology and hematology is a complex and specific area that requires monitoring by a multidisciplinary team capable of personalizing the treatment of each patient. Clinical pharmacy services have the potential to contribute significantly to the effective and economical care of cancer patients.

OBJECTIVE

To evaluate, synthesize and critically present the available evidence on the impact of the Clinical Pharmacy in the treatment of patients with hematological cancer.

METHOD

A review was carried out on the bases PubMed/MEDLINE, LILACS and Google Scholar. The included studies were: studies that evaluated the effects of pharmaceutical interventions in clinical in oncology and hematology services and having as a population patient with hematological cancer.

RESULTS

17 studies were selected among 745 identified. 4.771 patients were included, with an average follow-up time of 15.3 months. Patients affected by some type of hematological cancer, undergoing chemotherapy treatment, showed better adherence and continuity when accompanied by a clinical pharmacist, added to this professional in carrying out interventions, provides control of symptoms such as cancer pain, nausea and constipation and, thus, contributes to decrease the length of hospital stay.

CONCLUSION

The implementation of a Clinical Pharmacy service in oncology and hematology centers contributes significantly to the effectiveness of pharmacotherapeutic treatment, treatment costs reduction, safety increase in the use of medications and the patient's quality of life.

Impact of clinical pharmacy services in a hematology/oncology ward in Morocco

BACKGROUND

Clinical pharmacists are contributing to safe medication use by providing comprehensive management to patients and medical staff. The aim of this study is to document and evaluate the role of clinical pharmacy services in oncology department.

PATIENTS AND METHODS

A prospective, descriptive, observational study was carried out from July 2018 through June 2019 at the Department of Medical Oncology at the National Institute of Oncology, Morocco. Medication reviews concerning hospitalized adult cancer patients were performed every day by the clinical pharmacist assigned to the department.

RESULTS

A total of 3542 prescriptions of 526 adult cancer patients were analyzed. The pharmacist identified 450 drug-related problems (12.7% of the prescriptions) primarily related to the analgesics (31.5%). Medication problems included mostly untreated indications (31.3%), overdosing (17.1%), drug-drug interactions (12.4%), underdosing (11.1%), administration omissions (6.7%), drug not indicated (6.0%), and contraindication (5.3%). Interventions (n = 450) led to drug additions (30.7%), drug dosing adjustments (27.1%), treatment discontinuations (20.0%), recall of the treatment (6.2%), replacement of a drug with another one (5.1%), administration optimization (4.0%), therapeutic drug monitoring (3.1%), alternate routes of administration (2.5%), and extension of treatment duration (1.3%). Most (98%) of the interventions were accepted and implemented by the medical staff-172 (38.2%) having a significant clinical impact on the patient, 88 (19.6%) as having a very significant clinical impact, and 71(15.8%) as having a potential vital impact.

CONCLUSION

This work highlights the positive clinical relevance of pharmacists' interventions in oncology and the importance of medicopharmaceutical collaboration to prevent medication error.

Demonstrating the value of the oncology pharmacist within the healthcare team

INTRODUCTION

Although many oncology pharmacists are embedded members within the healthcare team, data documenting their contributions to optimal patient outcomes are growing. The purpose of this paper is to demonstrate the value of the oncology pharmacist within the healthcare team and describe the knowledge, skills, and functions of the oncology pharmacist.

METHODS

A systematic literature review of articles that were published on PubMed between January 1951 and October 2018 was completed. Identified abstracts were reviewed and included if they focused on measuring the value or impact of the oncology pharmacist on provider/patient satisfaction, improvement of medication safety, improvement of quality/clinical care outcomes, economics, and intervention acceptance. Review articles, meta-analysis, and studies not evaluating oncology pharmacist activities were excluded. Studies were thematically coded into four themes (clinical care, patient education, informatics, and cost savings) by 10 oncology pharmacists.

RESULTS

Four-hundred twenty-two articles were identified, in which 66 articles met inclusion criteria for this review. The selected literature included 27 interventional and 38 descriptive studies. The value of the oncology pharmacist was demonstrated by published articles in four key themes: clinical care, patient education, informatics, and cost savings.

CONCLUSION

With an expected shortage of oncology physicians and the ongoing development of complex oncology therapies, the board-certified oncology pharmacist is well suited to serve as a physician extender alongside nurse practitioners and/or physician assistants as the medication expert on the oncology care team. The demonstrated value of the oncology pharmacist supports their role as frontline providers of patient care.

Clinical oncology pharmacist: Effective contribution to patient safety

Management and prevention of problems related to oncology drugs are particularly important due to the excessive cost, high toxicity, and narrow therapeutic index of the antineoplastic drugs, in addition to the patients' state of health. Therefore, the presence of the pharmacist as a member of the multidisciplinary team is essential to contribute to patient safety. In this work, the interventions performed were identified, quantified, and classified to characterize the work of the clinical oncology pharmacist. This is a prospective and quantitative study, conducted over a period of six months in the outpatient oncology and chemotherapy clinic of the University Hospital of the University of Campinas, Brazil. A total of 3526 medical prescriptions were evaluated for the 780 patients seen and, among these prescriptions, 220 (6.24%) contained errors, representing 6.24% of the total number. The most common error was dose-related with 79 (22.83%) cases of overdosing. Wrong-patient medication error was the least reported (0.29%). Thirty drugs were involved in the pharmaceutical interventions, Carboplatin and Ondansetron being the most frequent. Thirteen types of potential errors were evaluated according to the method proposed by Cardinal and Fernandes. Two (15.38%) included interventions of indication, contraindication, and therapeutic efficacy of a drug. Five of them (38.46%) are related to the treatment regimen, and two (15.38%) were related to prevention of potential adverse events. Four interventions (30.77%) concerned technical interventions in injectable drugs such as dilution, compatibility, and administration time. Of the 346 interventions performed, 1 (0.29%) was classified as potentially lethal, 114 as serious (32.95%), 140 as significant (40.46%), and 91 as minor (26.30%).

Implementation of additional prescribing authorization among oncology pharmacists in Alberta

Purpose

To describe the practice settings and prescribing practices of oncology pharmacists with additional prescribing authorization.

Methods

A descriptive, cross-sectional survey of all oncology pharmacists in Alberta was conducted using a web-based questionnaire over four weeks between March and April 2016. Pharmacists were identified from the Cancer Services Pharmacy Directory and leadership staff in Alberta Health Services. Descriptive statistics were used to describe the practice setting, prescribing practices, motivators to apply for additional prescribing authorization, and the facilitators and barriers of prescribing. Logistic regression was used to explore factors associated with having additional prescribing authorization.

Results

The overall response rate was 41% (71 of 175 pharmacists). Oncology pharmacists with additional prescribing authorization made up 38% of respondents. They primarily worked in urban, tertiary cancer centers, and practiced in ambulatory care. The top 3 clinical activities they participated in were medication reconciliation, medication counseling/education, and ambulatory patient assessment. Respondents thought additional prescribing authorization was most useful for ambulatory patient assessment and follow-up. Antiemetics were prescribed the most often. The median number of prescriptions written in an average week of clinical work was 5. Competence, self-confidence, and the potential impact on patient care/perceived impact on work environment were the strongest facilitators of prescribing. The strongest motivators to apply for additional prescribing authorization were relevancy to practice, the potential for increased efficiency, and advancing the profession.

Conclusion

The current majority of oncology pharmacist prescribing in Alberta occurs in ambulatory care with a large focus on antiemetic prescribing. Pharmacists found additional prescribing authorization most useful for ambulatory patient assessment and follow-up.

Prescribing errors intercepted by pharmacist intervention in care of patients hospitalised with breast and gynaecological cancer at a Brazilian teaching hospital

Oncologic inpatients often require multiple drug therapy. They may be at higher risk of experiencing prescribing errors, which pharmacist interventions may help to avoid. This study aimed to evaluate the types of prescribing errors, pharmaceutical interventions and differences in clinical significance, in prescriptions for hospitalised patients with breast and gynaecological cancer. A cross-sectional, prospective study was conducted at the oncology ward of a clinic specialised in breast and gynaecology cancer. A clinical pharmacist analysed prescriptions, identified errors, performed interventions and classified clinical significance. A total of 1,874 prescriptions of 248 patients were evaluated; 11.5% prescriptions were involved at least in one prescribing error, totalising 283 errors. The most common error was unsafe medication due to drug interaction (89[31.4%]). Drugs for the alimentary tract and metabolism, and nervous system were the most involved in errors with statistical association (p = .0246 and p = .0002 respectively). Of the 294 interventions, 73.5% were accepted. The clinical significance of prescribing errors and interventions were classified as significant and very significant respectively. The pharmacist interventions obtained a good acceptance rate and impact significantly, avoiding prescribing errors classified as significant.

Pharmacists' roles in oncology pharmacy services: Results of a global survey

Background

Oncology pharmacists are capable of providing medication therapy management (MTM) because of their level of training, practice experiences, and responsibilities. Very little data exist about their current practice, including changing roles in the multidisciplinary team, overall impact, and effects in the education of patients and healthcare professionals.

Methods

A 70-item survey about oncology pharmacists' activities in oral chemotherapy programs, MTM, and collaborative practice agreements (CPAs) was deployed using a web survey tool (Qualtrics, Provo, UT, USA), targeting pharmacist members of American College of Clinical Pharmacy (ACCP) Hematology/Oncology Practice and Research Network (PRN). The objective of this study was to determine oncology pharmacists' activities in areas of oral chemotherapy programs, MTM, and CPAs. A cross-sectional survey was distributed to the ACCP Hematology/Oncology PRN membership. Investigational Review Board approval was obtained.

Results

Of the 795 members who were sent the survey, 81 members (10%) responded; 33 respondents (47%) are involved with an oral chemotherapy program; with 42% measuring outcomes of programs. Only six pharmacists (19%) have published or presented their data. A total of 28 (35%) respondents provide MTM services, with almost half (43%) of these MTM services being dictated by CPAs. A small fraction of these pharmacists (21.4%) reported conducting quality assurance evaluations of their MTM services and three pharmacists (10.7%) reported publishing their results. Those pharmacists practicing under CPAs ( n = 28) were surveyed as to activities included in their CPA. The most common activities included adjusting medication, ordering, interpreting, and monitoring lab tests, developing therapeutic plans and educating patients. Reimbursement for providing these services was uncommon: MTM (4%), oral chemotherapy program (6%), and CPA services (11%). Reported obstacles to reimbursement included lack of understanding, administrative assistance, or time with setting up reimbursement models within the institution.

Conclusion

Many oncology pharmacists are participating in oral chemotherapy programs, MTM, and/or CPAs and perceived barriers were identified. Increased efforts should be directed toward prospectively reporting and assessing the impact these services have on patient care.

Impact of outpatient interventions made at an ambulatory cancer centre oncology pharmacy in Singapore

Objectives

To evaluate the clinical significance of interventions made by pharmacists in an oncology pharmacy in Singapore and their acceptance rate and to identify common drug-related problems and workflow-related interventions.

Methods

A two-month prospective intervention study was conducted at National Cancer Centre Singapore. During the study, pharmacists documented the reason for intervening and its related drug(s). Each intervention was evaluated for its clinical significance by an expert panel: two oncologists and a pharmacist using a five-point scale. The Kendall’s test of concordance and Cohen’s weighted kappa were employed for analysis of agreement among the respondents. Other variables were analysed using descriptive statistics.

Results

A total of 331 interventions were recorded: 147 cases were due to missing chemotherapy orders while 184 cases had potential drug-related problems. Among the 184 cases, 60 cases were related to clarification of orders, while the others had drug-related problems. The Kendall’s concordance coefficient was calculated to be 0.612 ( p < 0.001) while weighted kappa test results showed fair agreement across the evaluators. Acceptance rate of interventions was 93%. Most commonly documented drugs requiring interventions were carboplatin, trastuzumab and capecitabine.

Conclusions

About half of the documented interventions by pharmacists were evaluated as clinically ‘significant’ or ‘very significant’.