Evaluation and optimization of a clinical pharmacist driven transitions of care model for malignant hematology.

PURPOSE: To implement and optimize a pilot transitions of care model for scheduled chemotherapy admissions in patients with hematologic malignancies at our institution.Methodology: We utilized the plan-do-study-act (PDSA) quality improvement technique to prospectively measure success of interventions related to improving transitions of care processes that occurred in multiple stages including development of standardized operating procedures, electronic medical record documentation, and education to the malignant hematology multidisciplinary group. Chart review was performed retrospectively for at least nine patients per PDSA cycle. Areas of intervention addressed and measured regarding communication between the ambulatory care and acute care settings included: admission purpose, processes related to insurance benefits investigations for specialty medications required in the post-discharge setting, and plan for growth factors, prophylactic antimicrobials, and follow-up.Results and conclusions: We included 28 patients and performed a total of three PDSA cycles demonstrating specific improvements in: communication regarding status of benefits investigations performed for specialty medications prior to admission, resolution of these benefits investigations at various time points, improvement in efficient use of the electronic medical record for chemotherapy orders, and patient instructions for appropriate use of prophylactic antimicrobials. Although improvement was noted initially with prescribing of discharge antiemetics and antimicrobials, regression to baseline was noted with the third PDSA cycle.

An Evaluation of the Effect of Pharmacist-Led Comprehensive Chemotherapy Consultation Services on Outpatient Appointment Adherence.

BACKGROUND: The North Carolina Cancer Hospital at the University of North Carolina Medical Center serves patients with a variety of malignant conditions and discharges more than 130 patients each month. Processes to improve transitions of care prompted implementation of a first-cycle, pharmacist-led chemotherapy consultation service on the inpatient oncology units. This process provides education to improve patient engagement and activation. High patient activation has been associated with better patient outcomes; poor patient activation has been associated with increased health care costs. OBJECTIVE: To determine the effect of pharmacist-led comprehensive chemotherapy consultation services on adherence to outpatient follow-up appointments within 30 days of discharge. METHODS: This was a single-center, retrospective chart review. This study consisted of 2 groups: adult patients who received comprehensive consultation services between April 2017 and September 2017 and a 2:1 historical group of adult control patients randomly selected from a list of patients who received their first cycle of chemotherapy during a hospital admission between April 2014 and April 2017. The primary endpoint was the effect of comprehensive consultation services on adherence to outpatient follow-up appointments within 1 month after discharge. RESULTS: Ninety-six patients were included in this study. The percentage of appointments attended was 98.0% for the intervention group and 92.3% for the control group (P = 0.0018). CONCLUSIONS: This study demonstrates that pharmacy consultation in the inpatient oncology setting is associated with improved adherence to outpatient appointments within 30 days of discharge. This represents the first published data on pharmacist interventions resulting in improved outpatient appointment adherence. DISCLOSURES: Funding for this study was contributed by the Hematology/Oncology Pharmacy Association (HOPA). This publication was also supported by Grant Number UL1TR002489 from the National Center for Advancing Translational Sciences at the National Institutes of Health. Auten reports fees from PTCE and ASHP/ACCP, unrelated to this study. Clark reports consulting fees from Ellion Benson Research, unrelated to this study. The other authors do not have any conflicts of interest to report. This study was presented as a trainee poster on April 5, 2019, at the HOPA Ahead 15th Annual Conference in Fort Worth, TX.

Pharmacists' Role in Managing Patients with Chronic Lymphocytic Leukemia.

Chronic lymphocytic leukemia (CLL) is a hematologic malignancy that has seen significant advances in care over the last 5 years with the approval of oral agents such as ibrutinib and venetoclax for the treatment of this disease. As such, there has been a substantial shift away from the traditional chemotherapy infusions which have allowed patients greater autonomy with oral cancer therapies. This paradigm shift poses new challenges for the medical team, including drug-drug interactions, adherence counseling, and financial toxicity. Pharmacists are uniquely trained and equipped to help to manage the changing landscape of CLL care. From identifying common medications which may impair ibrutinib clearance to ensuring patients are on the appropriate anti-infective prophylaxis while receiving obinutuzumab, pharmacists can play a vital role in ensuring the highest quality of patient care. Furthermore, additional credentialing of clinical pharmacists in select states allows for independent visits with the pharmacists, allowing for greater involvement, particularly for initiation of venetoclax and management of ibrutinib-induced toxicities. Pharmacists are essential to both expanding and enhancing the care of patients with CLL and should be leveraged to improve patient outcomes whenever possible.

Dose-related mucositis with hydroxyurea for cytoreduction in acute myeloid leukemia.

Hyperleukocytosis occurs in 15-20% of all newly diagnosed acute myeloid leukemia patients and requires emergent treatment with leukapheresis or hydroxyurea when accompanied by signs or symptoms of leukostasis. Currently, there is no standardized hydroxyurea dosing strategy, although usual dosing ranges from 50 to 150 mg/kg/day, and prescribing patterns vary significantly among oncologists and institutions. In addition to other hematologic and dermatologic toxicities, the use of hydroxyurea may be associated with significant mucositis and mucositis-related pain. The purpose of this study was to compare mucositis-related pain between two different hydroxyurea dosing strategies in patients who received hydroxyurea for cytoreduction during induction. A retrospective chart review of adult patients with acute myeloid leukemia treated with chemotherapy at UNC Medical Center from April 2014 to April 2016 who received at least one dose of hydroxyurea for cytoreduction was conducted. This study compared the safety and toxicity profiles of hydroxyurea in patients who received high-dose hydroxyurea (≥75 mg/kg/day) versus low-dose hydroxyurea (<75 mg/kg/day). Safety and toxicity were evaluated based on indicators of mucositis and cumulative intravenous narcotic requirements following induction chemotherapy. Data collection included baseline demographics, mucositis risk factors, baseline laboratory values, hydroxyurea dosing, mucositis indicators, and pain indicators. A total of 55 patients were included in the study, 21 patients (38.2%) received the high-dose hydroxyurea dosing strategy. The high-dose hydroxyurea dosing strategy had a significantly higher white blood cell count at diagnosis, increased duration of hydroxyurea, and received a higher cumulative dose of hydroxyurea. Additionally, the high-dose hydroxyurea dosing strategy patients were associated with significantly more grade 3 or 4 mucositis requiring a formulation change (0% versus 28.6%, p = 0.002) and significantly higher cumulative intravenous narcotic requirements during induction (p = 0.019). No significant differences in baseline demographics or mucositis risk factors between dosing strategies were identified. The high-dose hydroxyurea dosing strategy patients had a significant increase in cumulative intravenous narcotic requirements and formulation changes, both common interventions made for the treatment of mucositis. Additional studies are needed to further elucidate the safety and toxicity profiles of hydroxyurea dosing strategies and to explore the correlation between total cumulative hydroxyurea dose and total cumulative narcotic requirements.

Comparison of Weight-Based Dosing Strategies for Intravenous Immunoglobulin in Patients with Hematologic Malignancies.

STUDY OBJECTIVE: Intravenous immunoglobulin (IVIG) is a weight-based therapy used to treat and prevent infections in patients with hematologic malignancies. IVIG doses were calculated traditionally using actual body weight (ABW). However, limited pharmacokinetic data suggest dosing strategies using ideal body weight (IBW) or adjusted body weight (adjBW) may be appropriate given the small volume of distribution of IVIG. Our objective was to compare the effectiveness of using a precision-dosing strategy (IBW or adjBW) with a traditional-dosing strategy (ABW) for IVIG in patients with hematologic malignancies or those undergoing hematopoietic stem cell transplant, as well as to perform an IVIG drug use analysis. DESIGN: Retrospective cohort study. SETTING: Academic medical center. PATIENTS: Between April 2014 and September 2016, 209 IVIG encounters met inclusion criteria for the primary outcome. Of those encounters, 125 were dosed using the traditional-dosing strategy, and 84 used the precision-dosing strategy. MEASUREMENTS AND MAIN RESULTS: The primary outcome was infection rate within 30 days of IVIG administration. Secondary outcomes included 60-day infection rate, immunoglobulin G (IgG)-level response (IgG higher than 400 mg/dl), and realized and potential IVIG savings. No difference in 30-day infection rate between precision- and traditional-dosing strategies was identified (15.5% vs 16%, respectively, p=0.823). Similarly, no difference was identified in the 60-day infection rate between groups (23.2% vs 19.8%, respectively, p=0.568). Levels of IgG obtained after IVIG repletion showed a treatment response rate of 86% in both groups. Use of a precision-dosing strategy achieved $2600/month in institutional savings with the opportunity for an additional $4600/month in savings with complete adherence to this dosing strategy. CONCLUSION: No differences in infection rate and IgG-level response were identified when a precision-dosing strategy was used. Implementation of an IVIG precision-dosing strategy provided institutional cost savings.