It’s 8 a.m. on a beautiful summer morning. The sun is shining and all seems right with the world. Then, as I approach my first appointment of the clinic day, I am confronted with the harsh reality of what many patients experience: confusion, uncertainty, and anxiety about their treatment plan.
A clinic nurse leaving the exam room of my first patient tells me, “I just wanted to let you know that I think your patient seems confused, and she is crying.”
“Why do you think she’s confused, and why is she crying? Is she in pain?” I asked.
“No, but she seems confused as to what she is taking to treat her cancer,” the nurse responded. “She said she feels ‘anxious’ and ‘overwhelmed’ at the amount of medications she takes and the number of outpatient appointments currently scheduled. She brought her entire medicine cabinet in a paper bag with her today, but she doesn’t know what medications she is supposed to be taking and why. She also has several appointments in the cancer center for the next month, but she doesn’t know what the appointments are for, how long she will be in the clinic, or how she will get there. Can you help her?”
The above is a scenario that is all too common in treating patients with hematologic malignancies. This confusion can lead – intentionally or unintentionally – to non-adherence and, ultimately, poorer outcomes.
The APP’s Role in Adherence
Often, the reason for non-adherence is unintentional; the patients are simply not sure what medications to take, when to take them, and for how long to take them.1,2 As much as clinicians try to review the treatment plan and communicate their intentions with patients, these are not always received or processed by patients or family members.3
Patients battling blood cancers tend to be older, with chronic, comorbid health conditions. Most patients with cancer receive more than five medications.4 One of the biggest concerns patients express is clarity about their treatment plan and whether the prescribed treatment is right for them.4-6
Advanced practice providers (APPs) and the entire multidisciplinary care team share the responsibility of disease and treatment education, as well as monitoring therapy. As part of my institution’s standard outpatient clinic procedure, the nurses take patients’ vital signs, assess them for safety in the home, screen for depression and anxiety, and reconcile the current medication list. Reviewing this information lets me know whether an intervention is needed.
On a daily basis, I am charged with ensuring that patients receive medications as prescribed, evaluating patients’ knowledge of the treatment plan (what medications to take and when), assessing their willingness to adhere to the treatment plan (which involves coming to the clinic and taking medications correctly at home), and evaluating their support systems (who will help with general support and transportation to/from the clinic).
Without follow-through by oncology care teams to check that patients are taking medications as prescribed, our efforts to educate patients about the rationale behind therapeutic choices, potential side effects to expect, and the overall treatment plan while they’re in the clinic will go to waste.
Adherence and effective patient-provider communication are critical components to the success of a treatment plan. Here, I share my “Top 10 Tips” for helping maintain patient adherence.
1. Set aside time to discuss the risks, benefits, and alternatives to the treatment plan. One of the major barriers to adherence is that patients may not believe that they need the recommended therapy or fully understand the treatment plan. It is the duty of clinicians to assess patients’ and caregivers’ willingness to take the medications as prescribed and to educate patients – on their level – about the different components of the treatment plan. Personally, I like to draw pictures of the disease pathobiology and the drug’s mechanism of action to visually reinforce the concepts behind the treatment plan. I also encourage the patient or caregiver (family member, friend, or other caregiver) to be present and take notes.
2. Highlight common potential side effects of treatment. The prescribing information for anti-cancer drugs highlight a multitude of side effects based on clinical trial data. However, this may not reflect real-world experience and most patients reading through the potential adverse effects might be overwhelmed. To minimize confusion, when I am discussing a therapy with patients, I concentrate on the side effects they are most likely to experience. Clinicians should also emphasize that many of the side effects can be addressed and intervened on without having to disrupt therapy. Making patients aware of these options can encourage them to report their symptoms.
3. Determine how intravenous or oral medications are going to be secured. The rapid emergence of effective therapies to treat hematologic malignancies in the last 10 to 15 years has turned once-incurable cancers into chronic health conditions. The financial impact of living with cancer can be devastating; patients should not have to choose food over medications, but, tragically, it happens. I would like to think that we are all cognizant of medication costs, the time required to obtain prior authorizations for medications, the need for specialty pharmacies to dispense the drugs, and that these factors should be appropriately communicated to patients.
Before writing a prescription, I consider if the drug will be covered by the individual’s health insurance and discuss the timeframe in which the patient can expect to receive his or her medications (1 day, 1 week, 1 month, etc.). For patients who require more expensive, specialty medications, there are many co-payment assistance programs (available through organizations like the Chronic Disease Fund, the Patient Assistance Foundation, and The Leukemia & Lymphoma Society) to help under-insured and uninsured patients. Similarly, many pharmaceutical companies offer drug co-payment assistance and even supply funding for transportation to and from the clinic. These organizations also frequently sponsor call-in helplines for patients to discuss side effects and strategies for side effect management. We should make patients aware of these resources.
4. Make sure follow-up appointments are made before the patient leaves the clinic whenever possible. Work with your scheduling team and/or assistants to create a workflow for return appointments. Are appointments made automatically after each visit, or does a provider have to request the appointments? Some patients may think they do not need to see a clinician if no appointment is made. Creating a standard protocol in the office helps streamline the scheduling process. Also, if patients are aware of appointments ahead of time, they have time to arrange transportation and are more likely to obtain lab tests and treatments.
5. Help caregivers (family members or home care nurses) understand how to dispense medications. Caregivers need to be educated about the patients’ medications and ways to help patients maintain adherence. Pillboxes can help organize medications for patients but need to be laid out correctly in order for patients to take the prescribed medications correctly.
Eliciting the help of a family member or home care nurse to assess the correctness of the pillbox setup can be useful.
6. Use calendars, phone reminders, and automated electronic alarms. Extensive research into effective adherence strategies in chronic health conditions has shown that building paper-and-pencil or electronic calendars, using phone reminders, and setting up automated electronic alarms improve adherence. We need to use all of the tools at our disposal.
7. Collaborate with your multidisciplinary team to facilitate effective patient care. Work as a team with nurses, hematologists, and primary-care professionals to make sure patient concerns are addressed. For example, if a patient is experiencing steroid-induced hyperglycemia or uncontrolled hypertension, would he or she benefit from seeing an internist or APP to help manage this condition? Or, for a 90-year-old patient without risk factors for heart disease, could a cardiologist help determine if any medications, such as atorvastatin, could be eliminated from the treatment plan?
8. Help the patient by refilling medications on time. If your office has a standard system for refills, the patient needs to know how to request refills. In my practice, I find the fax reminders and side effect monitoring that specialty pharmacies send to be very helpful. By partnering with the specialty pharmacies, patients can be sure to receive the medications they need in a timely manner – and that they remain consistent in the dosing and scheduling of medication. To help, I also encourage that the patient always start the medication on a set day (i.e., at the beginning of the week on Monday) and to be consistent.
9. Ask patients to bring their medications to each visit to review. Not all providers have sufficient time to review medications and patients’ adherence to the regimen, but every once in a while, I make a point to set aside time for a thorough review – especially when patients report experiencing unexplained side effects. If I don’t have time, I will try to find a pharmacist or nurse in the office who has time to review the medications. For patients who are taking multiple medications, I will try to review the medications and the patients’ status to see if any can be eliminated to decrease pill burden and the possibility of drug-drug interactions.
10. Follow up with phone calls or appointments after hospitalization to assess for side effects. A quality improvement project conducted at Cleveland Clinic showed that non-surgical cancer patients who received a phone call follow-up within 48 hours of hospital discharge and had a follow-up appointment with a provider within one week of discharge were less likely to have an unplanned readmission.7 Although multiple factors influenced readmission (such as disease status, tumor type, and willingness to adhere to therapy), the study demonstrated that a protocol for telephone communication is a logical, systematic way of interacting with patients and addressing disease or treatment-related side effects and reinforcing the care plan.
We, as providers, ask a lot of our patients. Keeping these 10 tips in mind can help enhance adherence to therapy, which will hopefully decrease patients’ anxiety and confusion and improve their outcomes.
- Faiman B. Medication self-management: important concepts for advanced practitioners in oncology. J Adv Pract Oncol. 2012;2:26-34.
- Kurtin SE, Colson K, Tariman J, et al. Adherence, persistence, and treatment fatigue in multiple myeloma. J Adv Pract Oncol. 2016;7:71-7.
- Accordino MK, Hershman DL. Disparities and challenges in adherence to oral antineoplastic agents. Am Soc Clin Oncol Educ Book. 2013:271-276.
- Prithviraj GK, Koroukian S, Margevicius S, et al. Patient characteristics associated with polypharmacy and inappropriate prescribing of medications among older adults with cancer. J Geriatr Oncol. 2012;3:228-37.
- LeBlanc TW, McNeil MJ, Kamal AH, et al. Polypharmacy in patients with advanced cancer and the role of medication discontinuation. Lancet Oncol. 2015;16:333-41.
- Faiman B, Jacobsen P, Still N, et al. Patient reported symptoms, concerns and provider intervention in patients with multiple myeloma. Abstract JL314. Presented at JADPRO Live, November 5, 2015; National Harbor, MD.
- Montero AJ, Stevenson J, Guthrie AE, et al. Reducing unplanned medical oncology readmissions by improving outpatient care transitions: a process improvement project at the Cleveland Clinic. J Oncol Pract. 2016;12:594-602.
Attention APPs: Free CME Summit on Myelodysplastic Syndromes
Improving MDS Outcomes from Diagnosis to Treatment: A Multidisciplinary Approach
There are many complexities associated with myelodysplastic syndromes (MDS) that a multispecialty team must address as a clinical-care unit. These complexities include obtaining adequate bone marrow specimens, identification and classification of MDS, the comorbidity rate of MDS patients, and the decision-making process for treatment. To address educational gaps associated with these complexities, the American Society for Clinical Pathology (ASCP), the American Society of Hematology (ASH), and the France Foundation have designed comprehensive MDS-directed educational summits that feature live events designed by world-class subject matter experts. Participants of these summits will actively engage in multidisciplinary, interactive small-group activities including case-based tumor board discussions and four break-out sessions on:
- The role of molecular testing
- Distinguishing morphologic mimics from MDS
- Assessing low- or high-grade MDS
- Applying new prognostic scoring to cytogenetics
Who should attend?
- Medical oncologists
- General pathologists
- Pathologists’ assistants
- Physician assistants
- Hematology and oncology nurse practitioners and physicians assistants
- Medical laboratory scientists
Dates and Locations
November 4, 2016
Hyatt Regency Austin
Registered attendees at the ASCP Annual Meeting or the 58th ASH Annual Meeting and Exposition may register for the following events for free.
December 3-6, 2016
San Diego, CA
Held in conjunction with the 58th ASH Annual Meeting and Exposition