A Multi-disciplinary Collaboration to Promote Adherence in Cancer Patients Taking Oral Agent MedicationsOncology Nursing Society (2013)
Problem and State of the Science: Over 50 oral agents in pill form are currently on the market, with projections that in three years, 25% of cancer treatment will be delivered in pill form with patients assuming responsibility for self-management at home. For oral agents to achieve a therapeutically effective level for cancer treatment, patients must strictly adhere to the regimen. Adherence to oral cancer agents is often less than 80%, which may be inadequate for treating the cancer. Many barriers exist to promoting medication adherence for cancer patients in fast-paced office settings. This include time demands, focusing on physical care, not assessing adherence, not knowing what to do about lack of adherence, or not understanding the home environment. To date, standardization of care for this form of treatment has been lacking; and to complicate it even further, sporadic follow-up is occurring. Further, there is poor agreement on how to measure adherence other than patient self-report. There is also minimal to no payment for patient education or phone monitoring for patients receiving treatment in pill form.
Significance: Prior studies indicate adherence rates in cancer patients treated in pill form is less than 80%; and over 10% of those newly prescribed this form of treatment do not refill their first prescription. Thus, adherence is a significant clinical problem. This team targets a challenging clinical problem among patients with a life-threatening disease, assisting them in adhering to and completing their cancer treatment, impacting symptoms, quality of life, and longevity.
Team Members: Michigan Society of Hematology and Oncology called together a group of high performing research scientists (Dr. Spoelstra), advanced practice nurses (Candise Love, MSN, RN), practice managers (Seija Olivier, BSN, RN), as well as oncology pharmacists, and pharmaceutical company representatives.
Process: First, the group reviewed the State of the Science on oral agents to include: factors influencing adherence and successful interventions. Consensus has been reached on a concept map of the steps in the patient care process, tracking each step in the process to promote adherence to an oral agent. This starts with the decision to move to oral agent treatment, an evaluation of readiness for oral agent treatment (i.e., can they swallow and afford the pills), review of need for assistance with coverage, all culminating with the documentation of the prescription in the EMR. A pharmacist review of the full medication list would occur for polypharmacy, to prevent and drug-to-drug interactions. An oral agent training course would occur encompassing both adherence and symptoms management for the oral agent. This course would include both self-study modules and training face-to-face with an advanced practice registered nurse (APRN) and be documented in the EMR within a week of the script being written. Once the patient obtains the oral agent, the start date would be documented in the EMR. The patient would begin the oral agent, and ongoing weekly to monthly follow-up on the phone would occur by the APRN, assessing adherence and symptom severity as well as prescription refills. Office visits would be planned based on the type of treatment regimen and individualized to patient needs. The group intends to use the Information, Motivation, and Behavior Skills Model (IMB), used in HIV ART treatment, to guide its work. IMB asserts even a well informed or highly motivated individual will have difficulty achieving and sustaining optimal adherence if they lack objective skills required to acquire or self-administer medications or feels incapable of performing such behaviors.
Objectives: Future work includes: 1) development of patient and/or caregiver self-training manual in electronic format; 2) development of an electronic training manual for oncologists and advanced practice nurses; 3) agreement on a medication adherence and symptom management toolkit; 4) standardization of APRN scripts for face-to-face and phone interactions to include readiness for oral agent use; 5) development of a patient self-assessment of adherence and symptom; and 5) testing the effectiveness of this approach at assisting patients to manage their adherence and symptoms.
Expected Outcomes: 100% adherence to oral agents and use of symptom management strategies so that symptoms do not become so severe that patients reduce or stop their oral agent.
Evaluation: Formative and evaluative monitoring of the plan to develop a standard of practice for those administered cancer treatment in pill form will be ongoing over the next year at each phase of the development of this project.
Publication DateSummer 2013
Citation InformationSandra Spoelstra. "A Multi-disciplinary Collaboration to Promote Adherence in Cancer Patients Taking Oral Agent Medications" Oncology Nursing Society (2013)
Available at: http://works.bepress.com/sandra-spoelstra/24/