The overall quality of oral cancer drug delivery was improved across the province of Ontario, according to the results of a 2-year quality improvement initiative presented by Katherine Enright, MD, MPH, at the 2020 ASCO Quality Care Symposium. According to Dr Enright and colleagues from Cancer Care Ontario, this model of quality improvement has the potential to be adopted across health systems, as it allows for shared learning and shared tools across multiple sites at the same time.
As a result of this project, all participating sites saw improvement in at least 1 prespecified domain, she reported. Factors contributing to the improvement of oral cancer drug delivery included engagement with a multidisciplinary team and the effective use of technology, whereas common barriers were a lack of onsite dispensing pharmacy integration and technology limitations.
Ontario Health – Cancer Care Ontario (OH-CCO)
Ontario is a province of about 14.5 million people. Cancer services within the province are coordinated by OH-CCO and are locally implemented through 14 regional cancer programs representing 73 systemic treatment facilities.
“The systemic therapy program within Cancer Care Ontario identifies and prioritizes quality gaps with respect to the delivery of systemic therapy, and then conducts annual quality improvement projects in collaboration with the 14 regional cancer programs to try and bridge these gaps,” said Dr Enright. Previous improvement projects have focused on things like optimizing toxicity management and increasing the use of computerized physician order entry for safe oral systemic therapy prescribing.
As part of this project, the investigators identified gaps and variations in care with respect to education and monitoring that led to decreased adherence and increased toxicity among patients receiving oral systemic therapy. Their overarching goal was expanding the use of patient-specific monitoring plans to optimize treatment adherence and toxicity management among these patients.
Improvements Across the Board
Year 1 of the project focused on a baseline data assessment, a gap analysis, and the development of local quality improvement project charters, and year 2 focused on implementing those quality improvement charters. To ensure the consistency of measurements across the participating groups, a measurement framework was developed and circulated; this framework was composed of 4 different composites measuring different aspects of clinical care.
The 4 composites were treatment plan documentation, patient education, adherence/toxicity monitoring, and treatment outcome as a result of toxicity. Within each of the first 3 composites were different process measures developed in accordance with CCO guidelines for oral systemic therapy, ASCO/Oncology Nursing Society chemotherapy safety standards, and preexisting ASCO Quality Oncology Practice Initiative quality measures. For example, process measures related to treatment plan documentation included dose, administration schedule, lab/toxicity monitoring, and frequency of visits.
“The fourth composite comprised outcome measures related to toxicity on treatment, with the assumption that improved patient education and toxicity monitoring would result in decreased toxicity and drug discontinuation as a result of treatment,” she noted.
A total of 16 sites participated, representing all 14 regional cancer programs. Sites focused on one or more of the process composites, depending on their local needs.
“While the interventions varied widely across the region, common themes included standardization of patient education materials (and embedding the patient education material into standard workloads or EMRs [electronic medical records]), improvement or digitalization of documentation for oral chemotherapy, and improved workloads or accountabilities to ensure work sharing between physicians, pharmacists, and nursing,” said Dr Enright.
Overall, postimplementation data revealed improvements in performance across the board.
“All participating sites showed improvement in at least 1 composite, with the majority of 14 out of 16 sites showing improvement in the composites they specifically targeted,” she reported. “And 13 out of 16 sites actually met the prespecified quality improvement goal.”
In regard to the fourth composite (in which lower toxicity equated to higher performance), outcomes were more variable, but the investigators did observe a general trend toward decreased toxicity, she added.
Future work within OH-CCO will focus on continuing to improve the quality of oral systemic therapy delivery, as well as focusing on better pharmacy integration.