A Collaborative Pharmacist-Physician Multi-Professional Pre-Chemotherapy Assessment in Hematology Cancer Patients Is an Efficient & Cost-Effective Model for Service Delivery of Outpatient Systemic Anti-Cancer Therapy (SACT)

Introduction

Increasing complexity of cancer care has resulted in a paradigm shift from individual clinician-based to a larger multidisciplinary team approach. Expectantly the chemotherapy specialist pharmacist role in delivering such complex therapies will fall short of demand in current care delivery models & has expanded beyond dispensing medications & medication counseling. The UK National Cancer Vanguards have proposed models of care in order to enhance clinical chemotherapy services' performance thereby improving cancer patient outcomes & experience. These incorporate 2 principal themes; Medicines Optimization & development of an integrated team approach. We applied these 2 concepts by devising a joint Pharmacist-Physician Multiprofessional Team (MPT) clinic to achieve such objectives.

Methods

We prospectively piloted a newly designed Pharmacist-Physician MPT clinic. The aim is to determine the impact of adjunct pharmacist input as a model of care for outpatient pre-SACT assessment in lymphoma & myeloma patients (pts). An age- & sex-matched patient cohort receiving corresponding SACT assessed by single-handed clinicians in outpatient clinics during the same time-frame was used as the control cohort. The following data were collected: (1) prevalence of adverse events (AE) as per Common Terminology Criteria for AE version 4.03 & their outcomes upon intervention, (2) prevalence of unnecessary/potentially inappropriate prescriptions (U/PIP) & polypharmacy (PP) & (3) clinic & chemotherapy administration waiting times. Patient experience surveys based on the National Health Service (NHS) England Chemotherapy Patient Experience Survey (CPES) with added purpose-specific questionnaires were included to measure pts' perspectives, expectations & satisfaction. Descriptive statistics were calculated by using Fisher's exact test, Chi2 test for categorical variables & rank-sum analysis for continuous variables. Financial metrics were collected in retrospect to track downstream revenue with the following benchmarks: (1) Any delay beyond 60 minutes in any of the waiting times incurs £2.4/hour surcharge on the patient & an average £30/hour on the Hospital Trust per patient, (2) MPT attendance is priced higher than single professional counterpart (£171 versus (vs) 109) as per 2017/18 NHS National Tariff Payment System.

Results

A total of 82 pts (127 visits; median 1, range 1-5) were reviewed in the MPT clinic between 01-31-17 & 07-11-17; mean age 62 (25-82) years, 52% were women & 88% had lymphoma. The control cohort included 81 pts; median age 63 (26-79) years, 55% were women & 91% had lymphoma. 27 pts in the MPT group reported grade ≥2 AE vs 37 control pts; AE grades 2, 3 & 4 were recorded in 17, 9 & 1 pts vs 26, 11, 0 pts, respectively; p=.038. All pts evaluated in the MPT clinic experienced an improvement in AE by at least 1 grade & 15 pts achieved complete recovery with intervention. In the control group, 8 pts had no improvement in AE grade with 7 pts achieving complete recovery with intervention; p=.03. Prevalence of U/PIP, PP (≥5 & <10 medications) & excessive PP (≥10 medications) use were 11% (n=9), 6.1% (n=5) & 1.2% (n=1) in the MPT clinic & 20.7% (n=17), 12.2% (n=10) & 2.4% (n=2) in the controls; p<.001. Clinic waiting times were significantly shorter in the MPT clinic; median <30 min vs 1-2 hours, p<.001. Chemotherapy administration waiting time was also shorter in the MPT clinic; median 20 min (-20-150) vs 54 min (0-188), p=.008, with 82% of those reviewed at MPT being <60min vs 45% in the control; p=.001. With 1027 pre-SACT reviews recorded during the study period, MPT clinic would offer a minimum cost-saving of £16,945 & £63,674 profit. Eighty pts (40 from each group) completed the CPES. Key patient satisfaction metrics were significantly superior with MPT reviews, namely shorter clinic waiting times (p<.001), better understanding of progress (p=.0135), enhanced AE evaluation (p=.0325) & provision of advice/support in dealing with them which translated into subjective improvement in toxicity profile (p=.04).

Conclusion

A collaborative pharmacist-physician MPT approach has demonstrated significant improvement in chemotherapy-related AE, reduced waiting times, enhanced patient experience & translated to cost-savings to pts & the hospital. It has provided a proof of concept for a more robust, efficient & cost-effective model for cancer care delivery but also a platform for revenue generation.