Improved oral anticancer medication (OAM) adherence/toxicity assessment documentation: A quality improvement initiative

Abstract

Introduction

Adherence and toxicity symptoms ideally are monitored within 7–14 days after initiating oral anticancer medication (OAM). After implementing a formal OAM program at our institution, we found our adherence and toxicity monitoring was suboptimal and sought to improve our processes to reduce patient risk, using a formal quality improvement methodology.

Patient and methods

Adult patients with a solid tumor or hematologic malignancy newly prescribed on OAM were included. We manually collected data from the EMR at baseline and monthly during Plan-Do-Study-Act (PDSA) cycles. An interprofessional, multidisciplinary team was formed and developed a workflow process map for a newly prescribed OAM. Nine key process measure tasks necessary to accurately document OAM adherence/toxicity following OAM initiation were identified. The outcome measure was percentage of these 9 key tasks. Balance measures (unintended consequences as result of process changes) included OAM related provider and emergency department (ED) visits, hospitalizations and telephone messages. Descriptive statistics were used. We used a statistical process control chart method to examine our outcome measure and two-sample (assuming equal variance) two-tailed t-test (alpha, 0.05) to compare process, outcome and baseline measures.

Results

At baseline, our outcome measure (percentage of 9 key process tasks completed) was 50%; individual process outcomes ranged from 4.2% to 95.8%. PDSA#1 included staff education about appropriate documentation of patient OAM education. Following this intervention, the outcome measure was 53% (process measures ranged 10–100%). PDSA#2 included nursing workflow retraining, which further improved outcome measure to 55% (process measures 11.5–100%) and balance measures. PDSA#3 included a more standardized process, training for new employees and OAM start date patient education sheet. The outcome measure significantly improved from 50% at baseline to 67% (p < 0.001). All process measures (the 9 key tasks) improved from baseline, with the most significant occurring with 1) informed consent signed (58.3% to 100%; p < 0.001); 2) patient education completed/documented (25% to 42.9%; p < 0.004); 3) OAM start date documentation (33.3% to 75%; p < 0.002); and 4) OAM adherence/toxicity assessment appointment scheduled (4.2 to 21.4%; p < 0.0001). Balance measures improved compared with baseline, with number of phone messages significantly reduced (41.7% vs 33%; p < 0.001). Sustainability of these improvements was shown up to 6 months following the last intervention.

Conclusion

This quality improvement initiative improved the percentage of toxicity/adherence documentation tasks necessary to ensure appropriate OAM adherence/toxicity monitoring was completed by day 10 of cycle 1 following a newly prescribed OAM. This also resulted in fewer OAM-related telephone messages, which not only decreases provider time but signifies fewer potential problems occurred with appropriate toxicity/adherence checks.