Orlando, FL—Establishing a multidisciplinary oral chemotherapy clinic (MOCC) in a community hospital can reduce emergency department visits, increase patient and provider satisfaction, and lead to earlier recognition of adverse events, according to Patricia Disperati, MD, Malignant Hematology Physician Lead, Michael Garron Hospital, Toronto, Canada.
According to Dr Disperati, whereas Michael Garron Hospital has a well-defined process for intravenous chemotherapy administration, for oral chemotherapy—taking into account the myriad of drugs available for hematologic malignancies—the process is currently not well-defined. At the American Society of Clinical Oncology 2017 Quality Care Symposium, Dr Disperati discussed her center’s experience with instituting an MOCC.
Dr Disperati and her colleagues designed an MOCC around a nurse and a pharmacist operating with physician oversight. They standardized teaching and monitoring of all chemotherapeutic agents for malignant hematology, with the primary outcome of decreasing emergency department visits by 20% after 12 months of implementation. Process measures included documenting oral chemotherapy in 100% of nursing assessments, determining patient and staff satisfaction via qualitative interviews, and effecting a 20% increase in nursing “interventions,” defined as unscheduled physician visits, documentation of grade 3 or 4 adverse events caused by oral chemotherapy, dose modifications, and/or drug reconciliations.
A total of 30 patients (17 men, 13 women) receiving oral chemotherapy for hematologic malignancies were included in the study, and these patients were compared with a baseline cohort of patients before the MOCC. Median age of the study population was 69 years, and the majority of patients were taking lenalidomide alone or in combination, followed by tyrosine kinase inhibitors, ibrutinib, and idelalisib. Of the 30 patients, 11 were starting chemotherapy for the first time, and 4 discontinued oral chemotherapy during the study period. Median follow-up was 7 months.
Positive Results, High Satisfaction
Before the MOCC, patients averaged 10 months receiving oral chemotherapy, compared with 7 months after it was established. After implementation of the clinic, Dr Disperati and colleagues noticed a 47% increase in interventions brought up by nurses. Unscheduled physician visits went from 3% to 20%, and dose modifications and grade 3 and grade 4 adverse events were more frequently noticed; at baseline, 0% dose modifications and 0% grade 3 and grade 4 adverse events were documented, compared with 8% and 5%, respectively, after establishment of the MOCC.
“Initially the number of issues being brought up by nursing staff was very low, but afterwards it increased, and that change was sustained. Nurses were identifying a lot more issues and bringing them to the attention of the physicians or dealing with them themselves,” Dr Disperati said.
There was a 33% reduction in emergency department visits compared with baseline (from 9 to 6 during the first 12 months of therapy), but this finding did not reach significance.
“At first we saw a high incidence of DVT [deep vein thrombosis] in patients on lenalidomide, but after institution of the clinic we had interventions to prevent that. So I think at baseline we had more preventable admissions, whereas afterwards they were more idiosyncratic,” she noted.
Further follow-up is needed to confirm the reasons for emergency department admissions, Dr Disperati added.
The median number of assessments increased, from 0.8 to 1.4 per month.
“Patients started coming to the clinic a lot more frequently after the MOCC was established,” she said. Standardized documentation of oral chemotherapy also increased, from 33% at baseline to 100% post-MOCC. Treatment compliance was unknown before the MOCC, but reached 92% after its implementation.
Satisfaction with the program was high.
“The staff really liked the project because handover was exceptional. The plans were very clear, and they were excited even though they were seeing more patients,” Dr Disperati said. Patients reported feeling comfortable discussing issues with nurses that they typically did not have time to discuss with physicians, and felt that this positively impacted their care.
“Due to these positive outcomes, we will continue with this change. We will add more patients, involve other stakeholders, and review the results after 2 years,” Dr Disperati added.