Impact of clinical pharmacists in an inpatient medical oncology service: A prospective study at a comprehensive cancer center in Jordan

Abstract

Introduction

Clinical pharmacy is considered an integral discipline in the health care system for optimizing therapy and reducing drug-related problems. The objective of this study was to evaluate the impact of clinical pharmacists in optimizing management in a medical oncology service.

Methods

A prospective study was conducted at King Hussein Cancer Center between July 2019 and September 2019 of patients admitted to the medical oncology service. The impact of clinical pharmacists was measured by evaluating their interventions, defined as actions that were expected to result in a change in patient management. Data were collected daily by routine review of patients' profiles and by recording clinical pharmacists’ interventions. The data collected were baseline characteristics of patients, numbers and types of clinical pharmacists’ interventions, their significance, medications involved, and rate of acceptance of clinical pharmacists’ interventions by physicians. The significance of each intervention was assessed by two clinical pharmacists on a Hatoum scale. Physicians’ acceptance was assessed by whether the recommendations were implemented.

Results

During the study period, 748 patients were included, of whom 605 required a total of 1683 clinical interventions. The mean age was 56.3 years (±15.5 SD). Of the interventions, 39% resulted in initiation of a drug and 25% in drug discontinuations. The drug group most commonly associated with clinical pharmacists’ interventions was antibiotics (26.5%). Physicians accepted 98% of the clinical pharmacists’ interventions, and 92.4% of the interventions brought care to a more appropriate level and were considered significant.

Conclusion

Most patients in the medical oncology service required clinical pharmacists’ interventions, as demonstrated by the high number of significant clinical pharmacists’ interventions. Studies should be conducted to follow up these findings with respect to patient outcomes and cost savings.

Keywords

Clinical interventions clinical pharmacy pharmacy service hospital Jordan

Introduction

Clinical pharmacy is considered an integral discipline in the health care system for optimizing therapy, promoting health and patient safety and improving medication use.^1–5 Pharmacist-based direct patient care has positive effects in both therapeutic outcomes and safety, adherence to medication, patient knowledge, and quality of life.^4,6–8

Drug-related problems are common and considered a major concern for patients’ safety,^9,10 and actions to optimize safety and reduce such errors have been taken.^11,12 Cancer patients are at high risk for such problems because of the complexity of their disease and the therapy they receive, including chemotherapy and targeted agents.¹³ Drug-related problems in hospitalized cancer patients can also be attributed to causes such as impaired organ function, polypharmacy and long hospital stay.^14,15

Although several studies have evaluated the impact of pharmacists in general, the role of clinical pharmacists in oncology has been evaluated in a few studies.^16–19 Most of these studies evaluated their roles in the outpatient settings,^17,19–22 and only a few were conducted among inpatients.^16,18,23,24 Therefore, we evaluated the impact of clinical pharmacists’ interventions (CPIs) in patients admitted to the medical oncology service at a comprehensive cancer center.

Methods

A prospective observational study was conducted at King Hussein Cancer Center (KHCC). Ethics approval was granted by the institutional review board on 23 June 2019. The approval number is 19 KHCC 49. KHCC is a 350-bed, internationally accredited cancer center in Amman, Jordan, which provides comprehensive care to adult and pediatric patients for all types of cancer in Jordan and the region. The medical oncology service at KHCC consists of five teams for patients with solid tumors, multiple myeloma and lymphoma, with two clinical pharmacists and one oncology clinical pharmacy specialist. An average of 480 patients are admitted to the service each month.

The study was carried out between July 2019 and September 2019. Any patient aged ≥18 years admitted to the medical oncology service during the study period were included in the study; follow-up was ended at discharge, transfer to another service or death. We excluded patients who had been transferred to another service or discharged <24 h before evaluation by a clinical pharmacist. The clinical pharmacists collected data daily during routine review of patients’ profiles and recorded CPIs, defined as any action by a pharmacist that directly resulted in a change in a patient’s therapy.⁸ A waiver of consent was requested because the data were collected by clinical pharmacists, whose regular duty is to evaluate and review inpatients’ profiles and medications.

Clinical pharmacists filled in special data collection forms, recording patient demographics, medical and medications history, primary cancer, admission diagnosis, length of hospital stay, number and types of interventions during the study, the name of the medication associated with CPIs, the significance of the intervention and physicians’ acceptance of those interventions. The significance of the interventions was assessed on the Hatoum scale,^25,26 a scoring system used to evaluate the potential clinical significance of CPIs on a scale of 1, “adverse significance,” indicating that the recommendations were inappropriate and could lead to adverse outcomes; 2, “no significance,” indicating that the recommendation was informational; 3, “somewhat significant,” indicating that the benefit of the recommendation for the patient could be neutral; 4, “significant,” whereby the recommendation would bring care to a more appropriate level; 5, “very significant,” indicating avoidance of potential major organ dysfunction; and 6, “extremely significant,” indicating that the intervention avoided death.

The CPIs were discussed with the treating physician, who could be either a medical resident, medical oncology fellow, hospitalist or medical oncologist. Physicians’ acceptance was measured as whether a CPI was implemented. Interventions that were both accepted and rejected by prescribers were included in the study.

During the study period, the data were collected by four different clinical pharmacists and each intervention was verified for its appropriateness and significance by two clinical pharmacists to minimize the potential bias. In cases of disagreement, a third clinical pharmacist was consulted.

Statistical analysis

Continuous data are presented as means and standard deviations (SDs), while nominal data are presented as numbers and percentages. The t-test or non-parametric tests were used to compare continuous data between two groups. All significant factors were modeled in multivariate analysis logistic regression; P ≤ 0.05 was considered significant. All analyses were performed in SAS version 9.4 (SAS Institute Inc, Cary, NC).

Results

During the study period, 748 patients were included. Of these, 605 patients required a total of 1683 CPIs. The mean age of the patients was 56.3 years (±15.5 SD); other baseline characteristics are summarized in Table 1. A mean of seven prescribed medications were recorded in the medical history and 10 at the time of admission to the medical oncology service.

Table 1.

Baseline characteristics of patients admitted to medical oncology service, July–September 2019.

	Number of patients (%)
Gender
Male	409 (54.6)
Tumor type
Gastrointestinal	152 (20.3)
Breast cancer	130 (17.4)
Lymphoma	126 (16.8)
Genitourinary	86 (11.5)
Lung	73 (9.8)
Sarcoma	24 (3.2)
Gynecological	43 (5.7)
Multiple myeloma	32 (4.3)
Head and neck	27 (3.6)
Other	55 (7.3)
On active antineoplastic agents	392 (52.4)
Medical history
Cardiac disease	330 (44.1)
Diabetes	205 (27.4)
Kidney disease	73 (9.8)
Hypothyroidism	53 (7.1)
Respiratory disease	36 (4.8)
Hepatic disease	17 (2.3)
Other	160 (21.4)
Admission diagnosis
Infectious disease	220 (29.4)
Elective chemotherapy	89 (11.9)
Gastrointestinal disease	58 (7.8)
Acute kidney injury	56 (7.5)
Respiratory disease	50 (6.7)
Pain crisis	42 (5.6)
Elective admission for procedure	35 (4.7)
Electrolyte disturbances	27 (3.6)
Cardiac disease	23 (3.1)
Bleeding	17 (2.3)
Thrombosis	17 (2.3)
Spinal cord compression	16 (2.1)
Hypercalcemia	10 (1.3)
Liver disease	8 (1.1)
Other	80 (10.7)
Mean length of stay (days)	6.3 (±5.3 SD).

Of the CPIs recorded, 39% resulted in initiation of a drug for untreated indication, 25% in drug discontinuation and 7.3% in a recommendation for drug monitoring (Table 2). The drug groups most commonly associated with CPIs were antibiotics (26.5%), anticoagulants (9.9%) and analgesics (9.3%) (Table 3). The medication that most commonly required interventions was Vancomycin (10.1%), followed by Actrapid® insulin (4.1%), Tinzaparin (4.0%) and Heparin (3.4%). The most common antibiotics that associated with CPIs were Vancomycin (10.1%), Piperacillin/tazobactam (3%), Levofloxacin (3%) and Meropenem (1%).

Table 2.

Clinical interventions by clinical pharmacists.

Intervention	Number (%)
Initiation of drug for untreated indication	652 (38.7%)
Drug discontinuation	420 (25%)
Drug monitoring recommended	123 (7.3%)
Renal dose adjustment	116 (6.9%)
Electrolyte correction recommended	101 (6%)
Dose modification due to sub/supra-therapeutic drug level	87 (5.2%)
Changing wrong dose	62 (3.7%)
Changing route of drug	28 (1.7%)
Hepatic dose adjustment	23 (1.4%)
Changing therapy due to drug–drug interactions	20 (1.2)
Changing wrong frequency	15 (0.9)
Changing Chemotherapy dose	8 (0.5)
Other	28 (1.7)
Total	1683

Table 3.

Drug groups involved in clinical pharmacists interventions.

Drug group	Number (%)
Antibiotics	447 (26.6)
Anticoagulants	166 (9.9)
Analgesics	156 (9.3)
Electrolytes	129 (7.7)
Hypoglycemic agents	124 (7.4)
Antihypertensive drugs	119 (7.1)
Antiemetic drugs	63 (3.7)
Steroids	53 (3.1)
Proton pump inhibitors	51 (3.0)
Antineoplastic drugs	45 (2.7)
Laxatives	30 (1.8)
Colony-stimulating factors	27 (1.6)
Antilipidemic drugs	27 (1.6)
Antiepileptic drugs	27 (1.6)
Respiratory system-related drugs	18 (1.1)
Urology-related drugs	13 (0.8)
Antiplatelet drugs	12 (0.7)
Nervous system-related drugs	11 (0.7)
Bisphosphonates	10 (0.6)
Others	155 (9.5)
Total	1683

The drug groups most commonly associated with the intervention of drug initiation for untreated indication were antibiotics (15.5%), anticoagulants (14%), hypoglycemic agents (13%) and antihypertensive drugs (10.7%), whereas the most common medications that required discontinuation were antibiotics (24.5%), anticoagulants (14%), pain medications (11.4%) and antiemetic drugs (8%). The medications that commonly required a recommendation of drug monitoring were Vancomycin (79%), Mannitol (10%) and Phenytoin (3%).

On the Hatoum scale, 92.4% of the interventions were significant, whereby they brought care to a more acceptable, appropriate level, and very significant interventions that might have prevented major organ dysfunction accounted for 2%. The acceptance rate of recommendations by prescribing physicians was 98%. CPIs were associated with a longer hospital stay (P = 0.0000), a medical history of renal disease (P = 0.029), the number of medications in the medical history (P = 0.0012), and the number of medications prescribed upon admission (P = 0.0109). The factors associated with CPIs in multivariate analyses were length of stay (OR 0.875; 95% CI 0.825–0.929; P < 0.0001) and the number of medications in the medical history (OR 0.946; 95% CI 0.897–0.997; P = 0.0381).

Discussion

In this study, most patients required significant CPIs. In a cross-sectional prospective study in a breast and gynecology oncology ward in Brazil, 248 patients were evaluated and 294 interventions were done.¹⁶ We included patients with solid tumors, lymphoma and multiple myeloma. Patel et al. investigated adverse drug reactions to antineoplastic agents and the impact of clinical pharmacists in minimizing reactions,¹⁸ which we did not assess directly. In a prospective study in France in which 489 adult cancer patients were admitted to a hematology/oncology department over one year, the pharmacists identified 552 drug-related problems which accounted for 12.6% of reviewed prescription.²⁴ Patients with lung cancer were not included in the study, whereas 10% of patients in our study had lung cancer and required frequent admission because of their disease and the complicated treatment.

We found that the most common intervention was addition of medications, followed by discontinuation of medications, while Delpeuch et al. reported that the most interventions were related to treatment discontinuation.²⁴ We found that the highest number of most interventions concerned antibiotics, as the most common cause of admission was infectious diseases. Delpeuch et al. reported a similar finding. In our study, only 2.7% of interventions were associated with antineoplastic agents, perhaps because most antineoplastic agents in our center are given in the ambulatory chemotherapy clinic.

On the Hatoum scale, 98% of the interventions in our study were significant. Daupin et al. reported that 69.8% of interventions were scored as having at least a significant impact for patient safety,²⁶ and Han et al. found that 50.4% of their interventions were considered clinically more than significant.⁷ In a study in Singapore, about half of the documented interventions by pharmacists were clinically significant or very significant.²¹

An important finding of our study was the high acceptance rate of CPIs by physicians, with 98% of interventions accepted. Similar high acceptance rates were found in studies in other settings.^{7,16,17,21,23,24} In retrospective study by Han JM and colleagues, the acceptance rate was 71%.⁷ In a prospective study in Singapore in an ambulatory cancer center, the acceptance rate was 93%.²¹

The strengths of our study were its prospective design, which minimized the risk of underreporting CPIs. Furthermore, the significance of CPIs was assessed objectively on a standardized scale and by independent clinical pharmacists, which minimized subjectivity in determining the significance of interventions. One of the limitations of this study is that we did not evaluate the impact of the interventions on specific outcomes, such as length of stay. In addition, the short duration of the study which might limit generalization to different periods and the medical oncologists were not involved in determining the significance of the interventions which could be a source of bias. However, the interventions were reviewed by four different clinical pharmacists and verified by independent clinical pharmacists for the appropriateness and significance of those interventions which could minimize the potential bias.

Conclusion

Clinical pharmacists have a major role in the health care team in the inpatient medical oncology service at our comprehensive cancer center, as we found a very high proportion of significant CPIs. Clinical pharmacists should be considered vital members of medical teams, where their interventions directly improve patient care. Studies should be conducted to follow up these findings with respect to patient outcomes and cost savings.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no ﬁnancial support for the research, authorship, and/or publication of this article.

ORCID iD

Nour Faqeer

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