Board-certified pharmacy specialties: Growth from 2008 to 2020 and projections to 2025.

PURPOSE: To track and analyze the growth of 12 Board of Pharmacy Specialties (BPS) specialties from 2008 to 2020 and, subject to criteria, to project specialty numbers through 2025. The analysis considered residency data and Bureau of Labor Statistics projections. METHODS: BPS data were used to determine numeric growth, growth rates, and trends for 12 BPS specialties from 2008 to 2020. Specialties begun after 2008 were analyzed from their start date. For specialties with more than 2 data points and coefficients of determination greater than 0.80, we calculated projections through 2025. We also estimated the percentage of BPS-certified pharmacists with postgraduate year 1 training. RESULTS: BPS-certified pharmacists grew in number from 3,004 (2008) to 41,802 (2020), an over 13-fold increase. Currently, 4 of the 5 largest specialties (pharmacotherapy, ambulatory care, oncology, and critical care) continue to grow at a fast rate. Pharmacotherapy experienced the largest numeric growth (20,624) despite the ongoing introduction of new specialties. Critical care and infectious diseases had the highest growth rates (both 32%). We were able to make projections for 10 of 12 specialties, with greater than 62,000 certifications projected by 2025. Growth to these projected levels will require more residencies and more certification preparation opportunities. Residency-trained BPS specialists currently constitute slightly less than 50% of the BPS-certified population. CONCLUSION: Specialization in the pharmacy profession is growing at a rapid pace. As more clinical privileges are approved, the demand for more specialized pharmacists will likely continue to increase. Data from this study document the growth of the pharmacy specialty workforce. The data and analysis can be used to estimate potential pharmacist contributions across the healthcare spectrum in clinical areas where BPS-certified pharmacists practice.

Trends in the delivery of care to oncology patients in the United States: Emphasis on the role pharmacists on the healthcare team.

OBJECTIVE: The purpose of this study was to identify trends in oncology care that allow one to forecast workforce supply and demand, the training and skills needed by the oncology pharmacist for the likely future of oncology care. METHODS: Interviews were conducted with experienced oncology pharmacists in leadership roles at 20 organizations balanced by geographic region and type of practice site (academic or community/ambulatory). Results were analyzed using descriptive statistics and theme identification. RESULTS: Practice sites differed widely in numbers of patient visits, practitioner/patient ratios, residency program presence, and other structural features. Despite this, the majority reported an expectation of growth in cancer patients, oncology physicians, oncology pharmacists, pharmacy technicians, oncology nurses, and advanced practice practitioners in the next two to five years. Fifty percent of sites currently support Post Graduate Year 2 (PGY2) oncology residencies. At least 50% reported routine pharmacist involvement in 12 clinical functions. More future involvement was predicted for immunotherapy (80%) and oral oncolytic therapy (90%). Interprofessional involvement was reported for a broad variety of practice-related committees and patient education teams. Limited pharmacist involvement in credentialing, quality measurement, and value-based reimbursement systems was found. CONCLUSION: Anticipated increases in demand for oncology pharmacists strongly suggest the need for more PGY2 oncology residency programs and on-the-job oncology training programs. Oncology pharmacists are currently involved in many clinical and administrative functions including multidisciplinary management. While a core set of clinical functions has been identified, oncology pharmacists must prepare for the increased use of oral oncology agents and immunotherapy. Pharmacist involvement in value-based reimbursement and other data-based quality outcome measurements should be increased to optimize involvement in team-based patient care.

Oncology Pharmacists Can Reduce the Projected Shortfall in Cancer Patient Visits: Projections for Years 2020 to 2025.

Based on the projected need for a larger oncology care workforce, we estimated the patient care visits and care activities that Board Certified oncology pharmacists (BCOPs) could contribute to oncology care from 2020-2025. Using projected counts for BCOPs through 2025, we estimated that 2.9-4.1 million 30-min BCOP patient visits were possible at 50% workforce capacity. BCOPs' clinical activities overlapped strongly with those of nurse practitioners (NPs) and physician assistants (PAs) in patient education and treatment management. BCOPs could help reduce provider stress and burnout concerns by spreading these activities across a broader set of providers. BCOPs were more active than NPs and PAs in clinical trials research. Recent advances in immunotherapy, pharmacogenetics, pharmacogenomics, and oral oncolytic agents make the medication-focused training of OPs particularly useful to care teams. Comparison also showed that BCOPs were less active in providing follow-up visits and prescribing. Fulfilling the projected BCOP numbers through 2025 will require continued growth in Postgraduate Year 2 (PGY2) oncology pharmacy resident programs and on-the-job training programs. Our review of the trends in cancer incidence, mortality, and survivorship suggest a sustained need for the activities of BCOPs and other oncology care providers.

Efficient and effective precepting of pharmacy students in acute and ambulatory care rotations: A Delphi expert panel study.

PURPOSE: Using the Delphi process, a panel of experienced preceptors achieved consensus on best practices to increase preceptor efficiency and effectiveness. METHODS: The Delphi panelists completed 3 survey rounds and a face-to-face meeting. Survey questions covered several topics, including preparation of students for rotations, preceptor efficiency and effectiveness, potential resident contributions to precepting, methods of developing critical-thinking skills and providing assessment and feedback, precepting time metrics, and barriers to preceptor effectiveness. Panel consensus was defined as agreement of ≥80%. RESULTS: Fifteen of 36 invited preceptors (42%) completed all 3 survey rounds. The expert panel reached consensus on 6 essentials for effective rotations, 8 precepting contributions that could be made by appropriately trained residents, precepting barriers, 4 strategies for teaching critical thinking, and 5 valuable characteristics of the One Minute Preceptor model. Panelists reported on time spent with students presenting new patient cases (median, 10 minutes per case), time devoted to assessment of students' clinical performance (median, 22 minutes per student weekly), and time dedicated to student professional development (median, 20 minutes per student weekly). CONCLUSION: Important strategies for preceptors identified by the panel included (1) a thorough orientation to logistics, expectations, and scheduling of activities, (2) using appropriately trained residents in student training, (3) providing opportunities for critical thinking and therapeutic decision-making, (4) giving frequent, quality feedback on clinical activities, and (5) giving feedback to learners on a regular basis.

Value Frameworks for the Patient-Provider Interaction: A Comparison of the ASCO Value Framework Versus NCCN Evidence Blocks in Determining Value in Oncology.

BACKGROUND: To address the rising concern about oncology drug costs, the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN) recently developed unique tools to help providers and patients make informed decisions about the value of an anticancer regimen. The ASCO Value Framework (AVF) allows users to generate a net health benefit (NHB) score along with drug acquisition costs for oncology regimens that have been compared in a prospective randomized clinical trial. In contrast, the NCCN Evidence Blocks (NEB) derives ratings from an expert panel assessment in the categories of efficacy, safety, quality and consistency of evidence, and affordability. OBJECTIVE: To compare the results of the AVF and NEB by applying each tool to the same clinical scenarios. METHODS: We evaluated 2 regimens using the AVF and NEB scores: (1) enzalutamide for treatment of metastatic castration-resistant prostate cancer and (2) nivolumab versus docetaxel in treatment of advanced squamous and nonsquamous non-small cell lung cancer (NSCLC). RESULTS: Enzalutamide generated a total NHB score of 44.8 (range 0-180) for use before chemotherapy and 70.8 for use after chemotherapy with a monthly cost of $8,495 in the AVF. The NEB scored enzalutamide 4 (very effective) for efficacy, 4 (occasionally toxic) for safety, and 2 (expensive) for affordability in the no visceral metastases block. It scored 3 (moderately effective) for efficacy, 4 for safety, and 2 for affordability in the visceral metastases block. Nivolumab in advanced nonsquamous NSCLC scored 36.0 and 73.2 in advanced squamous NSCLC, with a monthly cost of $7,010 in the AVF. The NEB gave nivolumab a score of 4 for efficacy and safety and 1 (very expensive) for affordability in the NEB in advanced nonsquamous and advanced squamous NSCLC. CONCLUSIONS: The AVF and NEB are novel tools that take different approaches in assessing the value of an oncology treatment regimen. From this study, it is clear that the findings generated by these tools are distinct. The AVF provides a summary score for treatments across all clinical benefit and toxicity categories, whereas the NEB provides component scores for treatment efficacy, safety, quality and consistency of evidence, and affordability. Both tools are novel and come with their own challenges. DISCLOSURES: No outside funding supported this study. Shah-Manek is also employed by Ipsos Healthcare, a consulting firm. The authors have no conflicting interests to report. Study concept and design were contributed by Shah-Manek and Ignoffo. Galanto and Nguyen collected the data, and data interpretation was performed by all the authors. All the authors contributed to writing the manuscript, which was revised primarily by Shah-Manek, along with Galanto, Nguyen, and Ignoffo. This research was previously presented as a poster and podium presentation at the Academy of Managed Care Pharmacy Nexus 2016 held October 3-6 in National Harbor, Maryland.

Board-Certified Oncology Pharmacists: Their Potential Contribution to Reducing a Shortfall in Oncology Patient Visits.

PURPOSE: With an aging US population, the number of patients who need cancer treatment will increase significantly by 2020. On the basis of a predicted shortage of oncology physicians, nonphysician health care practitioners will need to fill the shortfall in oncology patient visits, and nurse practitioners and physician assistants have already been identified for this purpose. This study proposes that appropriately trained oncology pharmacists can also contribute. The purpose of this study is to estimate the supply of Board of Pharmacy Specialties-certified oncology pharmacists (BCOPs) and their potential contribution to the care of patients with cancer through 2020. METHODS: Data regarding accredited oncology pharmacy residencies, new BCOPs, and total BCOPs were used to estimate oncology residencies, new BCOPs, and total BCOPs through 2020. A Delphi panel process was used to estimate patient visits, identify patient care services that BCOPs could provide, and study limitations. RESULTS: By 2020, there will be an estimated 3,639 BCOPs, and approximately 62% of BCOPs will have completed accredited oncology pharmacy residencies. Delphi panelists came to consensus (at least 80% agreement) on eight patient care services that BCOPs could provide. Although the estimates given by our model indicate that BCOPs could provide 5 to 7 million 30-minute patient visits annually, sensitivity analysis, based on factors that could reduce potential visit availability resulted in 2.5 to 3.5 million visits by 2020 with the addition of BCOPs to the health care team. CONCLUSION: BCOPs can contribute to a projected shortfall in needed patient visits for cancer treatment. BCOPs, along with nurse practitioners and physician assistants could substantially reduce, but likely not eliminate, the shortfall of providers needed for oncology patient visits.

Current research on PONV/PDNV: Practical implications for today's pharmacist.

PURPOSE: Guidelines have been constructed to optimize the management of patients at risk of developing postoperative nausea and vomiting or postdischarge nausea and vomiting (PONV/PDNV), including the 2002 American Society of Anesthesiologists (ASA) recommendations, the 2006 guidelines assembled by an American Society of PeriAnesthesia Nurses task force (ASPAN), and another set published in 2007 with the support of the Society for Ambulatory Anesthesia (SAMBA). The recommendations set forth are reviewed. SUMMARY: Patient risk factors have been identified that are associated with higher incidences of PONV. For prophylaxis of PONV in high-risk patients, combinational and multimodal therapies with as many as three interventions, including a 5-HT(3)-based therapy and other antiemetic agents with different mechanisms of action, were advocated by guidelines and systematic reviews; specific pharmacotherapies and other interventions were recommended, as well as a treatment algorithm. The number of antiemetic agents prescribed should be appropriate for the individual's risk level, once again emphasizing the importance of patient risk stratification. Prophylaxis for PONV should be maintained throughout the period of risk. CONCLUSION: Evidence from the Prospective Observational Study of Treatments, Outcomes, and Patterns of Care study indicates that the use of guideline recommended PONV and PDNV prophylactic treatments leads to improved outcomes.

Survey of topical oral solutions for the treatment of chemo-induced oral mucositis.

PURPOSE: The objectives of this study were (1) to describe the usage of topical oral solutions in patients experiencing chemotherapy-induced oral mucositis (CIOM); and (2) to survey the care of oral mucositis provided to patients by clinical oncology pharmacists in institutional settings. METHODS: Surveys were distributed to institutional pharmacists in the US, who were asked to provide the components of their 'magic mouthwash'. Other questions included whether an institutional mucositis management guideline is available and what is the involvement of clinical pharmacy in mucositis care. RESULTS: Forty institutions returned surveys during the study period. The top five ingredients used to compound the magic mouthwash are diphenhydramine, viscous lidocaine, magnesium hydroxide/aluminum hydroxide, nystatin and corticosteroids. Most institutions administer the mouthwash every 4 hours (36%) or every 6 hours (36%). Of the surveyed institutions, 33% currently possess guidelines for the management of CIOM. CONCLUSIONS: Most institutions in the country formulate their topical solution, or magic mouthwash, with a variety of ingredients. There is a need to standardize the ingredients used to compound the magic mouthwash, in order to fully evaluate the efficacy of the solution to manage CIOM.

Overview of bevacizumab: a new cancer therapeutic strategy targeting vascular endothelial growth factor.

PURPOSE: The pharmacology, pharmacokinetics, preclinical and clinical experience to date, and clinical concerns in monitoring patients receiving bevacizumab, recombinant humanized monoclonal antibody to vascular endothelial growth factor (VEGF), are described. SUMMARY: Preclinical research revealed that bevacizumab specifically inhibits VEGF, has activity in multiple cancer cell lines, and is synergistic with several cancer chemotherapeutic agents. In humans, bevacizumab has a long half-life, allowing intravenous administration once every two to three weeks. Dose-limiting toxicities, the formation of antibodies to bevacizumab, and problems with wound healing after surgery have not been observed in clinical trials. A phase II study of bevacizumab in combination with 5-fluorouracil and leucovorin in patients with metastatic colorectal cancer showed promising results (i.e., therapeutic response rate and disease-free progression of survival), although a clear dose-response relationship was not demonstrated and concerns were raised about the potential for thromboembolic events, bleeding, hypertension, and proteinuria. In a phase III study in patients with refractory metastatic breast cancer, bevacizumab doubled the response rate from capecitabine but it did not affect survival. First-line use of bevacizumab with irinotecan, orouracil, and leucovorin produced significant improvements in response rate, duration of response, and survival in a phase III study of patients with metastatic colorectal cancer. Bevacizumab was associated with hypertension, which was readily managed with mild antihypertensive agents, and possibly with gastrointestinal (GI) perforation, but not with serious bleeding, thromboembolism, or proteinuria. Nevertheless, patients receiving bevacizumab should be monitored for GI perforation, bleeding, thromboembolism, hypertension, and proteinuria, especially if they have a condition that predisposes them to these problems (e.g., a history of unusual bleeding or clotting, hypertension, or proteinuria; use of anticoagulants or other medications that affect clotting or coagulation). CONCLUSION: In clinical trials, bevacizumab has shown promise in promoting synergism with other chemotherapeutic agents in the treatment of various cancers.

Rituximab therapy for CNS lymphomas: targeting the leptomeningeal compartment.

Most lymphomas that involve the central nervous system are B-cell neoplasms that express the cell surface molecule CD20. After intravenous administration, rituximab can be reproducibly measured in the cerebrospinal fluid (CSF) in patients with primary central nervous system lymphoma; however, the CSF levels of rituximab are approximately 0.1% of serum levels associated with therapeutic activity in patients with systemic non-Hodgkin lymphoma. Because lymphomatous meningitis is a frequent complication of non-Hodgkin lymphoma, we have conducted an analysis of the safety and pharmacokinetics of direct intrathecal administration of rituximab using cynomolgus monkeys. No significant acute or delayed toxicity, neurologic or otherwise, was detected. Pharmacokinetic analysis suggests that drug clearance from the CSF is biphasic, with a terminal half-life of 4.96 hours. A phase 1 study to investigate the safety and pharmacokinetics of intrathecal rituximab in patients with recurrent lymphomatous meningitis will be implemented based on these findings.

Effect of telephone follow-up on the physical well-being dimension of quality of life in patients with cancer.

OBJECTIVE: To evaluate the effect of telephone follow-up on the physical well-being dimension of health-related quality of life in patients with cancer. DESIGN: Randomized, controlled trial. SETTING: Public teaching hospital. PATIENTS: One hundred fifty patients with cancer who were discharged to home from the hospital. INTERVENTION: Patients received a telephone follow-up call 48-72 hours after discharge. Information was solicited regarding drug-related (and other) problems. Problems were addressed, and advice and support were given. MEASUREMENTS AND MAIN RESULTS: Analysis of variance revealed no differences in the physical well-being dimension of health-related quality of life between patients who received telephone follow-up and a control group who did not. Sixty-eight percent of the follow-up group and 40% of the control group (p = 0.007) reported having had at least one contact with a health professional. CONCLUSION: One possible explanation for the lack of effect of the intervention is that high-risk patients in the control group received a similar intervention from other health care professionals. We suggest that telephone follow-up be coordinated among health professionals.