Pharmacist Interventions on Outpatient Leukemia Patients Improve Safety

Background: Transitions between inpatient and outpatient settings, which occur frequently with leukemia patients, (pts) are critical junctures at which patient care can become fractured, particularly with respect to medication reconciliation. Attention to adverse drug events, drug interactions, and dose adjustments for organ function can also minimize medical errors and improve patient care, particularly with chemotherapy regimens, antimicrobial agents, and anticoagulation. We evaluated the prevalence of medication discrepancies and the impact of a dedicated oncology pharmacist in an outpatient leukemia clinic on medication interventions.

Methods: All pts discharged from the inpatient leukemia service were seen by an oncology-trained pharmacist within 5 business days of discharge as part of routine transitions of care follow up. The pharmacist provided medication reconciliation to assess for medication list discrepancies and identify opportunities for medication-related interventions, including drug interactions, dose adjustments, and therapeutic drug monitoring. All pts were assessed for drug-related adverse events, correct regimen and dose, adherence and medication access concerns. If an intervention was necessary, the pharmacist made recommendations for management to the licensed medical provider. Pharmacist interventions were characterized as "serious" or "not serious" based on established methods (Overhage, J. Am J Health Systm Pharm. 1999). Serious interventions included: drug interactions likely to reduce efficacy or worsen toxicity of chemotherapy, management of anticoagulation in the setting of thrombocytopenia, and management of antimicrobials in pts with neutropenia. Interventions considered "not serious" included: therapeutic drug monitoring for antifungals, recommendations for the management of chemotherapy-induced nausea and vomiting, discontinuation of herbal products and other non-essential agents, and application for grants to minimize pt out-of-pocket costs for critical medications. All medication lists were updated within the electronic medical record following initial interventions.

We evaluated associations between endpoints and the following patient and clinical attributes: age, marital status, diagnosis, treatment type (induction, consolidation, salvage, or chronic such as long-term hydroxyurea, tyrosine kinase inhibitors, or ruxolitinib), and disease status (primary, relapsed/refractory, chronic) using Pearson chi-squared or Wilcoxon rank-sum tests. Analyses were stratified by gender, and significance conferred at the 0.1 level.

Results: Between November 2017 and March 2018,106 pharmacist-patient visits occurred with 76 distinct pts. Baseline demographics are described in Table 1. Twenty-five pts (33%) were seen more than once. For 26 visits (24%), the encounter was the first outpatient visit following initial induction chemotherapy for leukemia; for 25 (24%) it was the first outpatient visit for subsequent chemotherapy cycles; and for 55 visits (52%) it was the first outpatient visit following an admission for a complication or infection. Medication education and adherence counseling was provided during 93 visits (87%). A total of 173 medication discrepancies were identified and corrected. Sixty-three (36%) discrepancies required additional intervention, of which 22 (35%) were considered serious. In addition, 33 drug interactions were identified, of which 5 were considered serious. Male pts were more likely to have discrepancies if they were newly diagnosed, compared to those that were relapsed/refractory (P=.013). Female pts were significantly more likely to require intervention if they were single (P=.013) or younger (P=.08). No other factors predicted discrepancies or a need for interventions.

Conclusion: Leukemia pts discharged from the hospital had extremely high rates of medication discrepancies, particularly during an initial encounter. One third were considered serious. Presence of an oncology pharmacist led to meaningful clinical interventions with the potential to improve patient outcomes and safety.

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