Development and evaluation of the pharmacist service for
mandatory review of oral anti-cancer medicines
Wee Hui Ling1, Chung Yee Vun1, Sia Beng Yi1, Dr Chia Yee Hong2, Dr Mary-Carmel Kearney3
1Department of Pharmacy, Tan Tock Seng Hospital
2Department of Medical Oncology, Tan Tock Seng Hospital
3School of Pharmacy, Queen’s University Belfast
INTRODUCTION
Ø One third of the marketed anti-cancer drugs in United States are in the oral
formulation and it has been used increasingly to treat cancer patients. [1-2]
Ø Often any errors with oral anti-cancer drugs can potentially cause more harm
than other medicines, and in the worst-case scenario, can lead to fatal
consequences. [3]
Ø The high incidences and seriousness of medication errors with oral anti-
cancer drugs has been highlighted in a review article where chemotherapy
errors occur at a rate of about one to four per 1000 orders and affects at least
1–3% of adult and paediatric oncology patients. [4]
Ø Pharmacists play a critical role in reviewing these medicines to prevent
potentially fatal drug related problems and to bring about cost avoidance
and/or cost benefits.
Ø In Tan Tock Seng Hospital, oral anti-cancer drugs are dispensed from a general
dispensary, and these medicines are not screened by an oncology-trained
pharmacist prior to dispensing. Thus, there is a need for review of the oral
anti-cancer drugs by oncology-trained pharmacists prior to dispensing.
Routine pharmacists’ review of anti-cancer agents aims to improve patient
safety in this area of high-risk medicines. [5]
Ø With the gap identified in the pharmacy services provided, a small-scale
improvement project was planned to allow oncology-trained pharmacists to
provide mandatory review prior to dispensing of the oral anti-cancer drugs
and supportive medicines.
OBJECTIVE
Ø The service improvement project was for dispensing pharmacists or
pharmacy technicians to call oncology-trained pharmacists for clinical review
of oral anti-cancer drugs and supportive medicines prior to dispensing.
Ø Primary objective was to measure the clinical and financial impact of the
service provided, where oncology-trained pharmacists provide mandatory
review prior to dispensing of the oral anti-cancer drugs and supportive
medicines.
Ø Secondary objective was to determine correlation between medicines with
interventions and number of co-morbidities present, type of co-morbidities,
number of chronic medicines, type of medicine screened, medical discipline
of the prescribing doctor.
METHODS
Ø A prospective study was conducted and outpatient patients whose oral anti-
cancer drugs and supportive medicines reviewed by pharmacists during the
month of December, 2018 was included in this study.
Ø Descriptive data and correlation tests were analysed using SPSS software
(IBM, Armonk, United States) and p<0.05 was considered statistically
significant.
RESULTS AND DISCUSSION
Ø During the one-month study period, a total of 417 anti-cancer medicines
were screened and 12 cases of interventions were performed in 367 patients.
Ø The pharmacist’s intervention rate was 2.8 % and this was comparable with
other studies conducted in Korea, France and United States where
intervention rates ranged from 0.1 to 5.2%. [4,6-7]
REFERENCES
1. Geynisman DM, Wickersham KE. Adherence to targeted oral anticancer
medications. Discov Med. 2013 Apr;15(83): 231-41.
2. Hershman DL. Sticking to it: Improving outcomes by increasing adherence. J.
Clin. Oncol. 2016 Jun;34(21): 2440–2442.
3. Phillips J, Beam S, Brinker A, Holquist C, Honig P, Lee LY, et al. Retrospective
analysis of mortalities associated with medication errors. Am J Health Syst
Pharm. 2001 Nov;58(19):1835–41
4. Weingart SN, Zhang L, Sweeney M, Hassett M. Chemotherapy medication
errors. Lancet Oncol. 2018 Apr;19(4):191-199
5. Maleki S, Alexander M, Fua T, Liu C, Rischin D, Lingaratnam S. A systematic
review of the impact of outpatient clinical pharmacy services on medication-
related outcomes in patients receiving anticancer therapies. J Oncol Pharm
Practice. 2019 Jan;25(1):130–139
6. Han JM, Ah YM, Suh SY, Jun SH Hahn HJ, ImSA, et al Clinical and economic
impact of pharmacists’ intervention in a large volume chemotherapy
preparation unit. Int J Clin Pharm 2016 Oct;38(5):1124–1132
7. Ranchon F, Salles G, Spath HM, Schwiertz V, Vantard Nparat S, et al.,
Chemotherapeutic errors in hospitalised cancer patients: attributable
damage and extra costs. BMC Cancer. 2011 Nov;11:478
8. Chew C, Chiang J, Yeoh TT. Impact of outpatient interventions made at an
ambulatory cancer centre oncology pharmacy in Singapore. J Oncol Pharm
Practice. 2015 Apr;21(2):93–101
RESULTS AND DISCUSSION
Table 1: Type of interventions
Type of interventions (N=12) N (%)
Transcribing error 2 (16.7)
Incomplete/unintended dosage regimen 2 (16.7)
Drug incompatible with patient's condition 1 (8.3)
Monitoring of laboratory tests 2 (16.7)
Clarification or order 5 (41.7)
Ø The most common intervention type was clarification of orders of 41.7%,
which was comparative to the study conducted by Chew E. et al. where
clarification of orders comprised of 33% of interventions made in an oncology
pharmacy in Singapore.
Ø The clinical significance rated in study by Chew C. et al. has a higher
percentage of interventions being classified as ‘Significant’ or ‘Very
significant’ of 47%. According to the study by Han JM et al., 50.4 % of
intervention cases were higher than clinically ‘‘significant’’.
Ø In comparison, in our study 36.1% of the interventions were considered
significant. The different scoring levels of significance and a different panel of
raters did not allow us to make a direct comparison, but the overall number
of significant pharmacist interventions of this study was in line with that
observed from previous studies.
Table 2: Estimated cost avoidance level
Estimated cost avoidance level (N=24) N (%)
Level 1: Improved quality of care 19 (79.2)
Level 2: Reduced drug product cost 2 (8.3)
Level 3: Avoidance of physician visit 1 (4.2)
Level 4: Avoidance of additional prescription order 2 (8.3)
Level 5: Avoidance of emergency room visit 0 (0)
Level 6: Avoidance of hospital admission 0 (0)
Level 7: Life-threatening 0 (0)
Ø In the Korean study, a net cost-benefit of $116,493.4 and the cost avoidance
was $85,896.5. [6] However, the total estimated cost avoidance in this study
was $119.85.
Ø This cost-avoidance is much lower than the cost-avoidance for the study in
Korea because the their study focused on the interventions made in an
oncology pharmacy for those systemic anti-cancer agents that requires
compounding.
Ø This is because it is a sophisticated process ordering these anti-cancer drugs.
Factors such as type of diluent, diluent volume and infusion time could be
areas where there is higher chance of pharmacist’s interventions.
Ø The overall cost for pharmacist to verify the medicines was estimated to be
$774.92 for the verification of 417 anti-cancer medicines. This was based on
the average hourly salary of pharmacists in Singapore of $22.3. Hourly salary
of pharmacists ($23.3) in Korea are similar to that Singapore. [6]
Ø However, the average time for prescription verification in the study of 1.07
minutes was much shorter, bringing down the cost of the pharmacist and
increasing the net cost benefit.
Ø The negative cost-benefit analysis of -$655.07 showed that cost of
pharmacist’s verification is higher than the estimated cost avoidance. This is
because there are some pharmacist’s interventions that only improve
patient’s quality of care but may not necessary translate to a measurable
cost-avoidance.
Ø For the secondary objective, there was no correlation between prescriptions
with interventions and the number of co-morbidities present, type of co-
morbidities, number of chronic medicines, types of medicine screened,
medical discipline of prescribing doctor.
CONCLUSION
Ø This study demonstrated the clinical impact of pharmacist’s interventions in
an outpatient ambulatory chemotherapy unit.
Ø However, it did not demonstrate a positive economic impact as pharmacist’s
interventions that only improve patient’s quality of care but may not
translate to a measurable cost-avoidance.
Ø This study highlighted pharmacists’ efforts in reviewing the prescriptions of
oral anti-cancer drugs to ensure the safety of cancer patients.
Ø Limitations to the study includes under reporting of interventions made by
pharmacists as some might forget to document after completing the
intervention.
Ø Given the low intervention rate, future studies could look at increasing the
period of data collection and expanding the scope to include the patients
receiving systemic anti-cancer treatments that requires compounding.