Pharmacy contribution to patient care

The opening ceremony welcoming the delegates to Melbourne was also the point at which Carole Chambers, Pharmacy Director of Cancer Services at Alberta Health Services, and Terry Maunsell, Director of Pharmacy, Prince Alfred Hospital, Sydney, were presented with the Helen McKinnon award in recognition of their contributions to both ISOPP and to the promotion of oncology pharmacy practice.

The first keynote speaker was David Currow, Professor of Palliative and Supportive Services at Flinders University in Adelaide. His presentation on improving cancer outcomes and the role of the pharmacist covered three main areas:

• Variations in outcome
• Managing the whole person
• Opioid availability.

He presented data showing a three-to-five-fold difference in outcome between best and worst countries and variation continued even in resource-wealthy countries. He also showed that survival had improved by 30% in the last 20 years across all age groups (except the over 90s), that the absolute numbers of patients also continued to increase and that the burden of cancer in the community was now greater than any other disease, including cardiovascular disease. The bigger question, he said, was whether those diseases with poorer outcome should be treated more aggressively or required earlier introduction of palliative care.

Lifestyle issues, in particular infections, and specifically viral hepatitis and human papilloma virus, were likely to be the biggest factor worldwide impacting on cancer incidence and survival. He also highlighted the importance of health literacy and that 60% of patients in Australia had health literacy levels below minimum, and that this alone could be changed with little or no cost by:

• Improving quality of advice
• Advising people on how and where to seek more information
• Helping translate information into actions
• Removing the nihilism associated with cancer diagnosis.

He concentrated on the impact of the number of drugs and comorbidities affecting patients at end of life when managing the whole person, not just the cancer: stopping therapies and avoiding treating drug side-effects with more drugs and creating more side-effects in a vicious circle; and a need to consider number needed to harm as much as number needed to treat when looking at therapies, and also the number of patients affected and likely length of treatment.

The most thought-provoking part of the presentation was around opioid availability internationally. That 56% of all opioids used globally were used to treat just 5% of the population was both surprising and, in the words of Professor Currow, “a global tragedy”.

Improving patient outcomes and safety was the topic of the next keynote session. Carole Chambers gave an overview of the joint project between ISOPP and the Institute for Safe Medication Practices (ISMP), ISMP Canada and ISOPP (see Resources). The project has produced a web-based self assessment tool for oncology, the aim of which is to produce a baseline for safe medication practices for oncology and to help individual respondents identify opportunities for improvement. (The submission deadline for the self-assessment has now been extended to 30 September 2012.) It is a multidisciplinary project for local teams to collect data from their organisations covering a range of topics:

• Patient information
• Drug information
• Communication of drug orders and other drug information
• Drug labelling, packaging and nomenclature
• Drug standardisation, storage and distribution
• Medication device acquisition, use and monitoring
• Environmental factors, workflow and staffing patterns
• Staff competency and education
• Patient education
• Quality processes and risk management.

The link between the two sessions is obvious and more importantly shows that joint working is required to improve patient care throughout the world. We heard that it would take approximately three two-hour sessions to gather the data for completion and that multidisciplinary involvement was essential.

Later on the first day, another ISOPP audit tool was discussed by Robbie McLauchlan (Dispensary Manager, Austin Health, Melbourne) and some initial data presented. The tool relates to pharmacy aspects of standards of care but also requires multidisciplinary involvement. Approximately 24 hospitals had completed the audit, which is available via the ISOPP website. The experience of completion was provided by a delegate from Portugal, Sara Gato, Assistant Lecturer, Escola Superior de Technologia da Saude de Lisboa, who provided feedback on how the tool had identified local issues requiring further work including:

• Education and training, including transport
• Facilities – temperature control monitoring, HEPA air volumes (and particle monitoring)
• Glove change frequencies
• Using gloves when handling vials outside clean room areas
• Use of goggles, for example, when cleaning.

Local follow-up audits identified additional problems but also allowed these problems to be tackled. Re-completion of the audit tool was encouraged, not only to see how improvements were going but also to further identify where clarification of the tool was required, for example, terminology used and interpretation. The initial data presented included the lack of use of gloves when handling cytotoxics outside of aseptic areas and the lack of use of safe vials that were less likely to cause a spillage if dropped. It highlighted that reducing exposure risk was everyone’s responsibility – suppliers and users.

Delegates were encouraged to undertake the audit because it:

• Was a comprehensive quality check of the service (manufacturing and facilities)
• Allows comparison between hospitals
• Highlights deficiencies in current practice
• Can be used to argue for additional resources.

It was also emphasised that the audit tool should be seen as additional to the ISMP assessment tool.

Another universal problem was the subject of the session by Johan Vandenbroucke (Adjunct Hoofdapotheker, Universitair Ziekenhuis Gent, Belgium), the outgoing ISOPP president; that is, drug shortages. While it was accepted that the problem was not unique to oncology, it was clear that the problems were getting worse and primarily affected intravenous drugs. In 2010 there were 178 drugs affected and >230 in 2011, and we had not had a good start to 2012.

He presented data from the USA that showed:

• 50 drugs were made by only one manufacturer
• 75% of drugs have a maximum of three suppliers.

He presented the impact of these shortages as affecting everyone in the process from making changes which could include:

• Treatment with a lower dose
• Using an alternative agent (11%)
• Delaying treatment (up to 20%)
• Stopping treatment.

These, he showed, impacted on patient safety (30% increase in medication errors), hospital resources (sourcing alternatives, education, managing side-effects, stock allocation, changes to policies) as well as financial implications. He reported a study by Kakkeh and colleagues from the USA that estimated annual costs of around $216 million per annum (see Resources). The impact on industry was also recognised.

A review of the causes was presented, showing just how complex the issue was, although the common denominator was that “everyone loses”. Issues he showed that should be considered included:

• Raw material sourcing and an increasing use of ‘chemical production unit’ rather than ‘pharmaceutical production unit’ and what that could mean for the raw material quality
• 54% of shortages were related to GMP issues in manufacturing and the temptation to continue to supply whilst trying to identify the problem may not be the best way and that stopping may provide easier identification of problems
• Maximising manufacturing capacity may not be good for GMP compliance and also means that increasing capacity is limited by existing infrastructure. It also meant that companies often outsourced and a single manufacturer was often responsible for a number of brands and a number of products within the same facility.
• 11% of shortages were a result of production stoppages because of insufficient returns. This was also affected by mergers and the resultant increase in the market(s) to which their drugs were supplied
• Regulation had a role and the fact that some companies both manufactured and distributed meant that loss of licence could have a bigger impact.
• Pricing policies (national and local), tendering/purchasing discounts coupled with ‘just in time’ and lean management trends mean that stock levels are kept low.

Unfortunately, he then informed us that there was no magic solution but called on everyone to work together:

• Allow a fair price and a fair profit
• Strategic manufacturer stores of unlabelled vials to allow shipping to many countries
• Information and alert structure for shortages
• Promote/mandate minimum/maximum competitors
• Ensure redundant capacity is resourced
• National strategic safety stocks.
• Limit to stopping production of ‘essential drugs’
• Most of all adopt a common sense approach – all parties need to do this.

The second day began with a discussion on credentialing of oncology pharmacy practice. A panel comprising Krissy Carrington (Assistant Director of Pharmacy Cancer Services, Royal Brisbane Hospital, Australia), Lita Chew (Head of Pharmacy Department, National Cancer Centre, Singapore), David Thomson (Lead Pharmacist, Yorkshire Cancer Network, UK and Chair, BOPA), Barry Goldspiel (Deputy Chief, NIH Clinical Center Pharmacy Department, Bethesda, USA), Johan Vandenbroucke (Belgium) and Carlo De Angelis (Pharmacy Clinician Scientist, Odette Cancer Centre, Toronto, Canada) presented the current positions in their relevant countries. What was apparent was that there was an appetite for doing this and that each country had progressed to different degrees. Indeed, as part of his closing speech, John Wiernikowski (Clinical Pharmacist Paediatrics, McMaster University, Hamilton, Canada, and incoming President of ISOPP) asked what ISOPP could do to facilitate and promote credentialing of practice. A discussion of what activities should be covered and how assessments could be undertaken showed just how complex this could be but that locally (individual countries or individual provinces) can overcome and it was pleasing to see that all panellists were willing and keen to work together and share their experiences. These discussion continued well beyond the session and indeed the meeting itself.

The posters provided a range of interesting topics from: pharmacy practice (including olanzapine for nausea and vomiting, toxicity in obesity, interventions and adverse drug reactions); innovation and patient education (including patient compliance tools, pharmacist training, workplace contamination); technology and informatics (including use of robotics, chemical degradation of antineoplastic agent); case reports (including use of eculizumab for paediatric paroxysmal nocturnal haemoglobinuria); medication safety (including medication error review and carboplatin dosing in the overweight and obese); and additional categories. Helping to judge some of the posters was a rewarding experience; being able to explore the topics more widely provided me with lots of ideas for the future as well as re-examining some areas.

Alongside the platform presentations from the posters was an interactive session that covered a huge range of topics and involved a range of ‘presenters’ who held table discussions. Nine participants were involved in each discussion and the presenter moved tables every 30 minutes. This session was also very well attended and proved to be well received by both the presenters and attendees. Areas of topics were clinical practice, education, research, palliative care, supportive care, management, paediatrics and future gazing.

The discussions were lively and it was great to see the multinational integration that this brought, allowing sharing of experience and knowledge – the cornerstones of what ISOPP stands for.

Two of the clinical sessions I attended were Pharmacogenomics: integration into an oncology pharmacist’s daily practice by Jill Kolesar, (Professor of Pharmacy, University of Wisconsin Carbone Cancer Center, Wisconsin, USA) and Translational Research, what this means for the patient, by Dan Mellor (Deputy Director of Pharmacy, Peter MacCallum Cancer Centre, Melbourne).

Dan’s presentation was a fascinating insight into how translational research was impacting on patient care. He showed the impact on time to clinical use from discovery:

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