Expert: Critical to Establish ROI Model for Value of Clinical Pharmacists So All Patients Have a Pharmacist on Oncology Care Team

Pharmacy Times interviewed Benyam Muluneh, PharmD, BCOP, CPP, assistant professor at the University of North Carolina Eshelman School of Pharmacy, on his presentation at the Hematology/Oncology Pharmacy Association (HOPA) 2022 annual conference on HOPA’s Oral Chemotherapy Collaborative (OCC) and how it works to optimize care for patients taking oral anti-cancer agents.

Question: What is HOPA’s OCC, and why was it established?

Benyam Muluneh: Yeah, that's an excellent question. I think there's no surprise that oral chemotherapeutics have really exploded over the past 2 decades. We know that oral chemotherapeutics are used in the first line setting and in the metastatic setting in combination with intravenous chemotherapy, and have just become the mainstay of treatment in a variety of tumor types, both solid tumors and hematologic malignancies.

With that come a lot of benefits, [such as] patient empowerment, and really this idea of taking cancer treatment away from the infusion clinic where patients are hooked up to the IV pole to the patient's home. But with it are also important considerations and challenges that include patient on adherence, toxicities, and as well as costs, which can really be a problem given that a lot of these agents are novel branded drugs that are very expensive.

So many health systems are trying to figure out the best ways of managing patients on oral oncolytics. There are a variety of different processes that have been tried all across the country. I think that the [OCC] was established to create a standard to really understand and pinpoint existing gaps, to better characterize current practices, and really offer recommendations for clinicians across the country on the best approaches to managing patients on oral chemotherapy.

I'll just add, in parallel, we're hoping that this will be a proof of concept also for institutions to collaborate on research to form collaborative research partnerships so that we can come together and advance patient care across different institutions.

Question: How is the OCC helping to move practice forward?

Benyam Muluneh: Well, we believe that pharmacists are well positioned to lead in this space. Obviously, when it comes to patient education, pharmacists are specifically trained in this area, and we're able to provide patient-friendly education. When it comes to drug interactions, these drugs have a lot of drug-drug interactions when you look at their packaging inserts, and pharmacists are well positioned to address those interactions in a timely fashion.

Managing and mitigating toxicity is another area that's very important to patients, and pharmacists are, again, really well positioned. When it comes to affordability, too, I think pharmacists can work together with our medication assistance teams and our social workers to help find more affordable treatment options for our patients. So I think you can see that there are a lot of puzzle pieces.

I think that what we're hoping to do with this collaborative is bring all those puzzle pieces together and really offer a comprehensive approach to managing patients on oral chemotherapy, which we believe will advance patient outcomes forward. We know currently that clinical practice patients in clinical practice don't do as well as patients in clinical trials. We hope that the work we're doing in the OCC will fill that gap.

Question: What are some factors that impact the work and direction of HOPA’s OCC?

Benyam Muluneh: I think that's a great question. I think one of the major factors is really the people. I think that we are excited to have expertise across the country—specialty pharmacists, clinical pharmacists, and student and resident pharmacists. We also have researchers, PhDs, and health system researchers, and we believe that having the right people on the bus, if you will, is a critical factor that will determine success for the OCC.

We also think that the fact that the OCC is going to be integrated in all 4 pillars of HOPA will ensure maximal impact. So I think that leadership support is another factor that we have had. So we believe that we can make an impact in the patient care space, the research space, and the education and advocacy spaces over a long period of time.

Question: What are the advantages of establishing a pharmacist-led oral chemotherapy program?

Benyam Muluneh: I think that in our experience at our institution, we piloted a pharmacist-led oral chemotherapy program, and we were able to show improved adherence rates, improved patient symptoms, improved patient satisfaction and provider satisfaction, as well as increased revenue to our institution. So it really demonstrated the value that pharmacists can bring to managing cancer patients.

So I think there are some benefits obviously that others have also demonstrated. I think where we are hoping to move to the next level is number 1, we are in an academic medical center where we have lots of resources, but what does it mean when you are practicing in a rural area when you are treating patients who are the most vulnerable in our society, [and] how do we make sure that the interventions that we're designing are equitably implemented and sustained over time. So those are the things that I feel like we need to work on as a collaborative and as a pharmacy profession as a whole.

Question: I understand you co-authored the 2018 HOPA Best Practices for the Management of Oral Oncolytic Therapy. Why were these best practices important to establish, and how have they impacted pharmacy practice in this area?

Benyam Muluneh: Yeah, I think that's an excellent question. It was a real privilege to be involved in working on those standards. We feel like those were foundational pieces needed to consider when you're managing a patient on oral chemotherapy.

So we talked about: What should you think about when you're prescribing oral oncolytics, how should you educate patients on oral oncolytics, how do you monitor patients on their adherence and on their toxicities, and then, how do you put all those pieces together in your practice. So we offered foundational concepts and tips for clinicians who were looking at those standards.

I think that has really served as a foundation for the work we're doing in the OCC now. I'll say that those standards were aspirational and are where we want to get to, but, clearly, there are a lot of challenges to designing and sustaining these types of programs in in different settings. So what we're hoping in the OCC is really to understand what the current state is and then execute these standards in a comprehensive and equitable way across the country.

Question: What are some of the challenges clinical pharmacists face in the care of patients taking oral anti-cancer agents?

Benyam Muluneh: I would say that the biggest challenge is really justifying the financial value of clinical pharmacists. I think many, many people—clinicians, physicians, administrators—will tell you that clinical pharmacists bring a lot of clinical value to our patients. We just completed an interview study where we spoke with nurses, pharmacists, physicians, [and] administrators, and everyone loves pharmacists. But the question is, how do we turn that adoration into finances—how do we demonstrate financial value?

So I think that it's important to establish that return on investment model, so that cancer centers across the country, even those outside of an academic medical center, can properly justify clinical pharmacists so that all patients who are getting these drugs have access to a clinical pharmacist. So that's been, I would say, our biggest challenge to face.

Question: What initiatives are the OCC working on this year?

Benyam Muluneh: So there are 3 initiatives that we're focused on this year. Number 1 is really focused on understanding and characterizing current states. So we're doing a landscape analysis by doing 2 sets of interviews, interviewing clinical pharmacists as well as specialty pharmacists, to better understand what their current workflows look like on oral chemotherapy. So, how do they manage patients, how do they educate patients, what are challenges that they face with trying to get at barriers to facilitate optimal patient care—we're going to take some of those early data after we interview about 50 patients and then do a larger survey of oncology pharmacy professionals.

The second initiative is really focused on the point I made earlier about justifying clinical pharmacy positions. So we're trying to use different modeling strategies to create the justification, the return on investment framework for clinical pharmacists. So we're really excited about that novel work.

Then thirdly, we're also trying to figure out what is the optimal way to monitor and document interventions that we make with patients with oral chemotherapy. So we know we need to monitor adherence, we know we need to monitor symptoms, but how do we best do that? How do we leverage existing IT infrastructure to create quality dashboards and other documentation systems so that we can better capture the interventions that we're making as clinical pharmacists, so we're hoping to work on those initiatives during this upcoming year.