The impact of a supplementary medication review and counselling service within the oncology outpatient setting

British Journal of Cancer (2007) 96, 744 – 751 & 2007 Cancer Research UK All rights reserved 0007 – 0920/07 $30.00 www.bjcancer.com The impact of a supplementary medication review and counselling service within the oncology outpatient setting Clinical Studies H Read1, S Ladds1, B Rhodes1, D Brown*,2 and J Portlock2 1 Department of Pharmacy, Worthing and Southlands Hospitals NHS Trust, Lyndhurst Road, Worthing, West Sussex BN11 2DH, UK; 2School of Pharmacy and Biomedical Sciences, St Michael’s Building, White Swan Rd, Portsmouth, Hampshire PO1 2DT, UK The impact on the care of breast cancer patients, of a pharmacy technician-led medication review and counselling clinic, provided in an outpatient setting, was investigated using a controlled randomised study. Compared to the controls, clinic patients showed a significantly improved level of understanding of their chemotherapy support medication (95% CI for difference in mean knowledge rating scores ¼ 2.165 – 2.826, Po0.001) and a significant reduction in the median number of support items required (two compared to five in the control, Po0.001). This resulted in a significant reduction in mean medication expenditure per patient (d26.70 vs d10.20, 95% CI for the mean difference in cost d6.72 – d26.26, Po0.001). The clinic was also associated with significant reductions in chemotherapy delays (Po0.001) and dose reductions due to side effects (P ¼ 0.003). Other benefits from the clinic were a reduction in pharmacy dispensing time and a highly significant reduction in pharmacy time spent resolving post-clinic prescription queries (Po0.001). Taking into account the initial technician training cost, the scheme represented an annual saving to the Trust of over d15 000. The clinic serves as a model for those wishing to improve outpatient services to breast cancer patients. British Journal of Cancer (2007) 96, 744 – 751. doi:10.1038/sj.bjc.6603634 www.bjcancer.com Published online 20 February 2007 & 2007 Cancer Research UK Keywords: pharmacy; technician; medication review; breast cancer; controlled trial It is widely accepted that a cornerstone of effective breast cancer chemotherapy is to maximise the appropriate dose while minimising the often unpleasant and debilitating side effects. A recent study in women receiving chemotherapy in the first 12 months after diagnosis for breast cancer showed that the incidence of serious effects requiring emergency intervention in hospital (61%) is likely to be higher than that predicted from clinical trial data (Hassett et al, 2006). While support medication strategies have improved over the years, it is not uncommon for patients to become reluctant to continue with further cycles of treatment if they have already experienced side effects from initial cycles of chemotherapy (Craig and Powell, 1987; Atkins and Fallowfield, 2006). Chemotherapy support medication is co-prescribed with the intention of minimising side effects with the hope that this will improve chemotherapy concordance, which in turn will assist the success of chemotherapy. Research has indicated that cancer patients who concord with oral chemotherapy regimens have a higher survival rate than those who do not (Porzsolt et al, 1989; Spiegel, 1997). Concordance can be described as a process of prescribing and medicine taking in a prescriber – patient partnership (Stevenson, 2001). This is particularly important in situations like chemotherapy support medication, where the patient must first recognise the side effect of the chemotherapy, then select the correct drug and self-administer the right dose for the correct period, remote from her immediate healthcare team. All members in the healthcare *Correspondence: Professor D Brown; E-mail: Revised 4 December 2006; accepted 20 January 2007; published online 20 February 2007 team have a responsibility to foster concordant relationships with patients. Prescribing physicians may not be able to do this for a variety of reasons (Stevenson et al, 2000). These include lack of time to discuss individual medication issues such as potential side effects (what to look out for and what to do about them) and because the prescribing setting may not lend itself to effective counselling. Cancer patients face the challenges of understanding often complex and protracted chemotherapy regimens, their side effects and management, while at the same time coming to terms with a potentially life-threatening diagnosis. Acceptance of treatment is largely based on the reality of a terminal condition without it and patient understanding of how chemotherapy can be made less debilitating with support medication is fundamental to building a concordant relationship. Pharmacists and more recently, pharmacy technicians counsel patients on their medications in a variety of settings as part of routine clinical pharmacy practice. Patients may have good access to staff on the ward where they receive their chemotherapy, but a busy ward frequently is not conducive to effective information transfer. Studies conducted by pharmacists in other disciplines, such as anticoagulation (Radley and Hall, 1994; Boddy, 2001), dermatology (Tucker, 2004) and palliative care (Austwick et al, 2002) which showed improved quality of care, patient understanding and use of resources, suggest that the outpatient clinic may be a suitable alternative setting. Like many breast cancer clinics, patients are seen at Worthing Hospital under a shared care agreement with another local NHS Trust. A co-ordinated, multi-disciplinary team approach relies for its success on good communication between clinicians, Pharmacy technician-led medication review for breast cancer H Read et al 745 METHODS Approval for the study including all data collection forms and methods, was obtained from the West Sussex Local Research Ethics Committee (04/Q1911/45) and the Sussex NHS Research Consortium (0457/WASH/2004) on 23/11/04 and 6/1/05 respectively, prior to commencement of the study. Patient recruitment Patients with a diagnosis of breast cancer and on course 2, 3 or 4 of their chemotherapy, as identified from their records, were approached by the chief investigator (HR) on attending MDCU. Each patient was provided with verbal and written information about the research and asked to provide written consent. Patients receiving treatment for either adjuvant or metastatic disease receiving a variety of regimens, were included. Patients under 18 years old were excluded. Consenting participants were informed that on their next MDCU visit, they would be asked a series of questions testing their understanding of their support medication. Patient randomisation Patients were randomised to either the control arm, where they received conventional care, including routine ward counselling from a nurse on the use of their support medication prior to discharge, or to the experimental arm where they attended the pharmacy technician-led outpatient clinic. Randomisation was by (...truncated)