Improving Oral Anticancer Medication Adherence/Adverse Event Assessment Documentation

Presenting Author: Lisa Holle, PharmD, BCOP, FHOPA, FISOPP, University of Connecticut, Storrs, CT

Co-Authors: Grace Morrison, BS, University of Connecticut, Storrs, CT; Andrea Moran, APRN-BC, DNP, and Margaret Savage, BSN, RN, UConn Health Carole & Ray Neag Comprehensive Cancer Center; Michael K. Keng, MD, University of Virginia

BACKGROUND: To improve patient safety, most oral anticancer medication (OAM) programs monitor adverse events (AEs) and adherence within 7 to 14 days following OAM initiation. At our institution, we identified key tasks associated with documenting OAM adherence and AEs during cycle 1. However, only 50% of these tasks were appropriately documented.

OBJECTIVE: As part of the 2022-2023 Hematology/Oncology Pharmacy Association/American Society of Clinical Oncology quality training program, we conducted a quality improvement project aimed at improving our task documentation rate to >75%.

METHODS: We engaged a multidisciplinary team to assist in gathering and interpreting data. A process map was created and barriers were identified. A cause-and-effect diagram, Pareto chart, and action prioritization matrix were used to narrow the focus of improvement changes initially and after each cycle. Three plan-do-study-act (PDSA) cycles were conducted (January 2023 to January 2024). Outcome measure was documentation of AEs/adherence by day 10 of cycle. Our study included all patients with cancer initiating OAM and excluded those on intravenous/oral regimens and gynecology/oncology patients. Process measure was percentage of 9 crucial tasks identified as necessary to appropriately document AEs/adherence. Balance measures included provider visits, emergency department visits, and telephone/electronic medical record OAM-related messages.

RESULTS: PDSA cycle 1 (education on documenting patient education) was implemented in January 2023. PDSA cycle 2 (retraining nurses on OAM AEs/adherence documentation process) was implemented in March 2023. PDSA cycle 3 (standardized cycle 1 OAM process and created a tool to facilitate communication of OAM start date) was implemented in September 2023. Improvement in our outcome measure (percentage of 9 essential tasks for documenting OAM adherence/AEs in cycle 1) was improved following PDSA cycles 1, 2, and 3 (50%-67%; P<.001). This rate was sustainable in the 2 months following project completion. OAM-related patient provider visits, emergency department visits, and OAM-related telephone messages (ie, balance measures) were decreased (P<.001). An improvement in documentation of OAM treatment start date was observed with each additional cycle (10%, 23%, and 83%, respectively) and improvement in AE documentation was similarly observed (10%, 12%, and 83%, respectively).

CONCLUSION: Our results were likely affected by significant nursing turnover, lack of formal OAM process training, and institutional buy-in for OAM program/training. Our standardizing process initiative improved the percentage of AEs/adherence documentation tasks necessary to ensure completion of appropriate OAM monitoring by day 10 of cycle 1 following prescription. This also resulted in fewer OAM-related telephone messages, which not only decreased provider time but signified that fewer potential problems occurred with appropriate AEs/adherence checks.

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