Oral Meds: How to Encourage Compliance

by Don Jewler, Director of Communications, ACCC

REPORT FROM ACCC’S ONCOLOGY PHARMACY EDUCATION NETWORK PRECONFERENCE

A panel of experts at ACCC’s Oncology Pharmacy Education Network Pre-conference in Seattle looked at the issue of adherence to oral anti-cancer drug regimens.

The statistics are striking: 50 to 80 percent of patients taking oral medications at home do not take their medications as prescribed. Patients may take the wrong drug or dose at the wrong time; or they may miss a dose.

In general, adherence reduces the risk for null or poor treatment outcomes by 26 percent, and adherent patients are three times as probable to have a good treatment outcome, according to J. Andrew Shirvin, PharmD, BCOP, associate clinical professor at Northeastern University and oncology/hematology pharmacist at Dana Farber Institute, Brigham & Women’s Hospital. Education about oral drugs for non-oncologic diseases reveals improved patient outcomes in 10 of 13 studies and improved adherence in 3 of 6 studies.

Major predictors of poor adherence are inadequate follow-up or poor discharge planning as well as presence of psychological problems, particularly cognitive impairment or depression, Use of antidepressant agents in the year preceding tamoxifen initiation, for example, is a predictor of poor adherence.

Factors such as age, duration of therapy, and pill burden affect adherence rates. Extremes of age, those under age 45 and those older than 85, are less likely to be compliant. Patients on multiple or more complicated regimens are also less likely to be compliant.

“Most of our patients are on multiple medications…some on 14-, 21-, 28-day cycles with food interactions that can’t be taken with other medications,” said Faye Flemming, RN, BSN, OCN, from Southside Regional Medical Center in Petersburg, Va. “How can nurses find time to manage home medications in addition to everything else they do?”

Flemming explored the answer in her analysis of exemplary oral programs identified through ACCC’s educational project on small-population cancers. A multidisciplinary team with defined roles and home assessment to determine who is helping the patient are both critical to manage compliance. So are the following best practices:

A look-and-see policy. Count pills. The patient must bring every medication to every visit. Sounds simple, but many practices do not ask patients to follow this policy, said Flemming. Tell the patient to bring all their medications to every visit.

Pharmacist consult. The pharmacist is a key player and should be educating the patient. That goes for the physician, nurse, nutritionist, and social worker as well—the whole team.

Written processes for order completion, support, education, and how to monitor the patient. The entire team should be in agreement.

Financial counseling. Patients need assistance with paperwork and co-pays. Programs need someone who specializes in financial counseling, someone who can help patients find help with their co-payments.

Prescription of oral drugs only one month at a time. Not 90 days! Once a month is easier to monitor, especially if doses need to be modified.

Extensive patient education and counseling. The physician, nursing staff, pharmacist, nutritionist, and social worker must work together.

Timely lab monitoring. Need a good process that the patient gets the right labs, you get the results, and there is follow-up.

Programs and practice must decide if dispensing oral oncology drugs is economically sound, said John E. Hennessy, executive director, University of Kansas Cancer Center, who joined Flemming in the discussion. The margin is not great, said Hennessy, and patients’ high out-of-pocket costs carry risk. “For those cancer programs or practices that decide to dispense oral oncology drugs, reimbursement is a big issue and patient out-of-pocket costs are a massive issue. . . If you want to be in the oral drug distribution business, you must be in the collection business, too.”

Economics aside, “the number one issue is how you handle adherence.” Like Flemming, Hennessy advised face-to-face counseling—brown bag sessions, where patients bring all their medications with them.

If programs or practices decide to manage oral oncolytics in-house, physician and nurse time spent in educating patients is hard to get reimbursed. On the opportunity side, reimbursement for the time spent by nurse practitioners and physicians is available.

If programs or practices use a third-party specialty pharmacy, adherence is still a huge issue. “Adherence remains a joint responsibility, but your partner is out there doing the heavy lifting,” said Hennssy. “The direct financial risk is passed, but the patient out-of-pocket stress may still surface in your office.”