Nursing Interventions for Improved Oral Chemotherapy Adherence

Alicia VautourSusan D. Flynn Oncology Fellow

August 27, 2015

Objectives

• Background on Oral Chemotherapy• Describe the Problem• Present Nursing Interventions for

Standardizing Oral Chemotherapy: Research• Describe Oral Chemo Resources at DFCI• Provide Recommendations for Improvement

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Background

• Chemotherapy– Infusion vs Pills

• What is Oral Chemotherapy?– Cancer-fighting drug– PO tablet, capsule, liquid form

• Why Oral Chemotherapy?– Taken at home

• Can Improve Quality of Life– Less frequent visits to hospital/clinic

Dana-Farber.org

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Safety of Oral Chemo

• Education– How to take the drug– Storage– Disposal– Safe Handling of body waste – Laundry– Side Effects– When to call/come in to Hospital

Dana-Farber.org

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Why This Topic

• Witnessed Pt in clinic with multiple bottles of chemo pills that were full

• Preliminary Research– Non-Adherence: Pt Barriers– National problem with pt adherence

• ASCO initiated project to develop standards for safe chemo administration

– Many trials underway to standardize the education – prescribing of oral chemo and production of new oral

chemo

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Barriers to Adherence

• Socioeconomic• Healthcare System• Disease• Treatment Regimen• Patient Related

University of Pennsylvania Medicine, 2015

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Barriers: Managing Side Effects

• Common Side Effects of Oral Chemotherapy– Varies from drug to drug– Targeted Therapies

• Skin– Acne-Like Rash (face, neck, chest, back)– Dry Skin– Itching

• Hair – Alopecia/thinning– Growing (i.e. face)

• Nail– Painful swelling & redness – Infected nailbeds (require antibiotics)

• Follow up with pts to manage and treat side effectsMASCC

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MASCC Education

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Research- National Survey

• Objective: – Describe current nursing practice in US regarding care and safety of pts taking

oral chemo– Study

• National Online Survey– Emailed to 5000 members of Oncology Nursing Society

• 577 oncology nurses in outpatient settings• Variables: pt care practices, nursing resources, and barriers to medication adherence

• Results:– 51% worked in practices that had developed specific policies, procedures and

resources for pts on oral chemo– Barriers: Cost (81%) and Side Effects (72%)

Roop & Wu 2014

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Research-Loma Linda University

• Objective:– Improved outcomes in adherence by an oral chemotherapy management clinic– Study

• Loma Linda University Cancer Center• Retrospective Cohort Study: 30 pts evaluated• Oncology pharmacists developed a comprehensive oral chemotherapy management

clinic (face-to-face initial and 3 month visits w/ RN, MD, & Pharmacists, telephone follow-ups at 3-5 days and 7-10 days, and unscheduled visits prn)

• Results:– Prevented moderate to severe drug interaction– Improved symptom management– Decreased cost of patient care– No missed doses for 21 of the 30 pts

Wong, Bounthavong, Nguyen, Bechtoldt, & Hernandez, 2014

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Research-Literature Review

• Objective:– Describe the development of an oral chemotherapy nursing position – Improve medication safety and adherence– Article

• 112 pts at one time• Initial teaching to 163 pts• Nursing assessments and interventions provided for 1,710 pts before their

next cycle of chemo• Telephone Triage to 2,410 pt calls

• Results:– In the 2 yrs following the program, 3 of 1710 pts were known to have varied from

their prescribed regimens– Oral chemotherapy nurse obtained excellent adherence outcomes

Moody & Jackowski, 2014

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Donna Berry, Phd, RN

• https://www.youtube.com/watch?v=OSUp6xTksLg

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DFCI Study

• Objective:– Evaluate a nurse-led intervention to enhance medication knowledge & adherence using

MOATT– Study

• 30 adult pts with lung cancer receiving oral Erlotinib at DFCI• Nurse-led education sessions using MOATT, 72- hour follow-up telephone contact, pts completed

KRS and MMAS-8 • Variables: knowledge & adherence; feasibility

• Results:– 27 pts completed study reporting high knowledge levels and MMAS-8 scores– Pts also initiated contact for assistance with prescription procurement & symptom

management– Feasible – Adherence & knowledge outcomes were encouraging

Boucher, Lucca, Hooper, Pedulla, & Berry, 2015

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MOATT

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MOATT

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Drug Diary

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Oral Chemo Videos

• https://www.youtube.com/watch?v=vzVDafn3iHA

– 4-part, web based oral chemo animated video series

– Available in English, Spanish, Portuguese, Mandarin, Russian, and Arabic

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Conversation with Kitty Hooper

• What is going on at DFCI now?– Initial phone call

• MOATT• Pharmacy directed• Calls documented in EPIC

– 72 hour adherence phone call• Program nurse• Go over side effects• Avg call 10-15 mins

– 2 week follow-up visit with provider• 2 week peak drug toxicity• Review drug diaries

– Every 2 months• May 2015: 80% of oral chemo pts had teaching

Kitty Hooper, personal communication, August 11, 2015

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Ongoing Issues at DFCI

• Phone call based– No in person teaching

• Initial education no longer done by nursing• Difficult to see if a patient is on oral

chemotherapy• Lack of nursing knowledge• Inconsistencies in Research Nursing

Kitty Hooper, August 2015

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Suggestions for Improvement

• Bring the education back to the nurses– Program nurse in each disease center– Oral Chemo Nurse position

• Continue standardized documentation forms for telephone calls that include administration instructions, precautions, monitoring and managing SE, etc– Standardize Research oral chemo as well

• Scheduling pt for 2 education appts w/RN prior to prescribing oral chemo• RN maintaining weekly call list for each patient on oral chemo• Routine follow-up phone calls or one week follow-up office visits• Improve view of oral chemo within EPIC• Providing classes for nurses & adding oral chemo as an annual competency

(? Healthstream)

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Questions?

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References

Boucher, J., Lucca, J., Hooper, D., Pedulla, L., & Berry, D. (2015). A structured nursing intervention to address oral chemotherapy adherence in patients with non-small cell lung cancer. Oncology Nursing Forum, 42(4), 383-389. doi: 10.1188/15.ONF.383-389

Dana Farber Cancer Institute. (2015). Chemotherapy. Retrieved from http://www.dana-farber.org/Adult-Care/Treatment-and-Support/Treatment-Centers-and-Clinical-Services/Chemotherapy.aspxMoody, M., & Jackowski, J. (2014). Are patients on oral chemotherapy in your practice setting safe? Clinical Journal of

Oncology Nursing, 14, 339–346. doi:10.1188/10.CJON.339-346 Nuess, M., Polovich, M., McNiff, K., Esper, P., Gilmore, T., LeFebvre, K., Schulmeister, L., & Jacobson, J. (2013). 2013

updated american society of clinical oncology/oncology nursing society chemotherapy administration safety standards including standards for the safe administration and management of oral chemotherapy. Oncology Nursing Forum, 40(3), 225-233. doi:10.1188/13.ONF.40-03AP2

Penn Medicine. (2013). Patient adherence to oral cancer therapies: A nursing resource guide. OncoLink, 1-8. Retrieved from www.oncolink.org

Rittenberg, C., Johnson, J., Kav, S., Barber, L., & Lemonde, M. (2010). MASCC oral agent teaching tool (MOATT). MASCC, 1-28.

Roop, Janna & Wi, Horng-Shiuann. (2014). Current practice patterns for oral chemotherapy: Results of a national survey. Oncology Nursing Forum, 41(2), 185-194. doi:10.1188/14.ONF.41-02AP

Wong, S., Bounthavong, M., Nguyen, C., Bechtoldt, K., & Hernandez, E. (2014). Implementation and preliminary outcomes of a comprehensive oral chemotherapy management clinic. American Journal of Health-System Pharmacy, 71(11) 960-965. doi: 10.2146/ajhp130278

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DFCI, BWH, & Fred Flynn