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Specialty Pharmacy Continuum • March/April 2021
OPERATIONS & MANAGEMENT
Collaborative Ca Agreements Cut Time, Costs A collaborative practice agreement (CPA) for oral oncolytics implemented at St. Luke’s Cancer Institute, in Boise, Idaho, slashed turnaround times for oral oncolytic drug processing and saved thousands in drug costs. The CPA expanded the scope of pharmacy practice while helping patients and providers, according to Amanda Wright, PharmD, an oncology pharmacist at St. Luke’s. “Implementing a CPA for oral oncolytics has helped our providers devote more time to aspects of patient care they are uniquely skilled to do,” said Wright, “while pharmacists have been able to make sure that treatments are dosed appropriately and that patients initiate and continue their therapy safely and in a timely manner.” St. Luke’s already had a CPA in place allowing five clinical pharmacists at their oral oncolytic office to help providers individualize antiemetic regimens for patients at the institute’s ambulatory care clinics, she said. These pharmacists also helped optimize oral oncolytic regimens by ensuring new prescriptions were indication appropriate, reviewing laboratory tests and concurrent medications, providing patient medication counseling, performing follow-ups to complete refills, and assessing adverse effects, adherence issues and new medications. However, “any changes pharmacists made to a prescription required provider approval, which took between a few hours to a few days to receive,” Wright said. This interrupted pharmacists’ workflow and, “since we needed to check the patient’s electronic medical record to see if the prescriptions had been signed,” she said, “it
also resulted in occasional delays in treatment initiation or continuation.” Wright and her team decided a CPA could overcome these inefficiencies. They identified a list of clinical activities that pharmacists could perform as part of an oral oncolytic CPA. These activities ranged from dose adjustments based on patient indications, renal and hepatic function, and toxicities; dose rounding to help cut drug costs; signing off on medication renewals; and ordering laboratory tests and examinations. “We presented these ideas as well as some metrics we would be looking at to our P&T [pharmacy and therapeutics] committee and to the providers and pharmacists that would be involved in a pilot project, and we incorporated their feedback and received approval,” Wright said.
The CPA proved its value in a pilot project conducted between November 2018 and February 2019, said Wright, presenting data on the project during the Association of Community Cancer Centers 2020 Virtual National Oncology Conference. Comparing
‘Not only were we able to improve the pharmacy workflow, we also reduced the time to initiation or continuation of patient treatment.’ —Amanda Wright, PharmD
6 Strategies for Implementing a Successful CPA Amanda Wright, PharmD, an oncology pharmacist at St. Luke’s Cancer Institute, in Boise, Idaho, shared some tips for pharmacists trying to set up collaborative practice agreements (CPAs) at their institutions to help oncology providers and improve patient care.
Develop rapport with the interdisciplinary team. “This is one of the most important steps, because establishing a relationship of trust with nurse practitioners and providers will allow pharmacists to complete their interventions without interruption.”
Identify areas where pharmacy can help providers with oral oncolytics. “Find areas where providers’ medication management workflows are challenging. The goal is for both pharmacists and providers to complete their tasks in a timely manner.”
Discuss and determine the best approach with the provider team. “Make sure the goals of pharmacists and providers are aligned, with the best interest of patients at heart, and identify provider
champions to review the pharmacist clinical activities and offer feedback on their expectations in the initial stages of creating the CPA.”
Create and present the CPA to the administrative team. “Provide a comprehensive look at the agreement you’ve created, including what goals you have for implementing the CPA. This will help get the buy-in and support you need before going ahead with this.”
Evaluate the CPA to share its impact on the clinic workflow. “A great aspect of how we set up our agreement was that we created data collection goals as part of the CPA. We found ways to evaluate the CPA and its impact within the clinic.”
Request feedback from all members of the team. “Make sure necessary adjustments are made so that patients receive the best care. The great thing about CPAs is that they’re really easy to tailor to the needs of your clinic” to allow you “to provide the best patient care.”
the intervention group of 54 patients treated by four providers with a group to 87 patients managed during the same period by 11 providers not operating under the CPA, they found prescription turnaround times averaged seven minutes in the CPA group and 55 hours in the control group. Dose-rounding interventions for two patients in the pilot group also led to significant cost savings, with one capecitabine prescription rounded to the nearest tablet size resulting in $547 in savings per treatment cycle ($9,858 annually), and a rounded temozolomide prescription saving $252 per cycle ($3,281 annually). Most providers were very satisfied with the new oral oncolytic CPA and believed it had a positive impact, saying they would recommend its use across other clinics at St. Luke’s, Wright noted. Indeed, the CPA was subsequently rolled out across St. Luke’s. Data collected over a three-month period from all 15 providers found the average prescription processing turnaround time was six minutes. “Not only were we able to improve the pharmacy workflow, we also reduced the time to initiation or continuation of patient treatment,” said Wright, noting that they have not yet found cost savings associated with the CPA since the systemwide rollout. Jane Rogers, PharmD, a clinical pharmacy specialist at The University of Texas MD Anderson Cancer Center, in Houston, who was not involved with the initiative, said the reductions in prescription turnaround time and cost savings that Wright and her team reported are “striking” and demonstrate the value of pharmacists in cancer care. “Oncology is an area with a tremendous need for services such as the ones highlighted in this study,” Rogers commented. Management of complex polypharmaceutical cancer regimens and their adverse effects and counseling on use of herbal and vitamin supplements are other important areas where clinical pharmacists can improve patient care, she said, predicting that “more publications like Wright and her team’s will help pave the way to make these services a normal part of everyday practice.” —David Wild
—D.W. The sources reported no relevant financial disclosures.
