Advanced Practice Perspectives
In this column, we will hear from an increasingly represented and crucial
component of hematology/oncology care: advanced practice professionals
(APPs). In this edition, Beth Faiman, CNP, PhD, offers her advice for improving
patient adherence to medication.
Top Ten Tips and Tricks for
Treatment Adherence and
Side Effect Management
It’s 8 a.m. on a beautiful summer morning. The sun is
shining and all seems right with the world. Then, as I
approach my first appointment of the clinic day, I am
confronted with the harsh reality of what many patients
experience: confusion, uncertainty, and anxiety about
their treatment plan.
A clinic nurse leaving the exam room of my first patient tells me, “I just wanted to let you know that I think
your patient seems confused, and she is crying.”
“Why do you think she’s confused, and why is she crying? Is she in pain?” I asked.
“No, but she seems confused as to what she is taking to treat her cancer,” the nurse responded. “She said
she feels ‘anxious’ and ‘overwhelmed’ at the amount of
medications she takes and the number of outpatient appointments currently scheduled. She brought her entire
medicine cabinet in a paper bag with her today, but she
doesn’t know what medications she is supposed to be
taking and why. She also has several appointments in the
cancer center for the next month, but she doesn’t know
what the appointments are for, how long she will be in the
clinic, or how she will get there. Can you help her?”
The above is a scenario that is all too common in
treating patients with hematologic malignancies. This
confusion can lead – intentionally or unintentionally – to
non-adherence and, ultimately, poorer outcomes.
The APP’s Role in Adherence
Often, the reason for non-adherence is unintentional; the
patients are simply not sure what medications to take,
when to take them, and for how long to take them.1,2 As
much as clinicians try to review the treatment plan and
communicate their intentions with patients, these are
not always received or processed by patients or family
members.3
Patients battling blood cancers tend to be older, with
chronic, comorbid health conditions. Most patients with
cancer receive more than five medications.4 One of the
biggest concerns patients express is clarity about their
treatment plan and whether the prescribed treatment is
right for them.4-6
Advanced practice providers (APPs) and the entire
multidisciplinary care team share the responsibility of
disease and treatment education, as well as monitoring
therapy. As part of my institution’s standard outpatient
clinic procedure, the nurses take patients’ vital signs,
assess them for safety in the home, screen for depression
and anxiety, and reconcile the current medication list.
Reviewing this information lets me know whether an
intervention is needed.
20
ASH Clinical News
On a daily basis, I am charged with ensuring that
patients receive medications as prescribed, evaluating
patients’ knowledge of the treatment plan (what medications to take and when), assessing their willingness to
adhere to the treatment plan (which involves coming
to the clinic and taking medications correctly at home),
and evaluating their support systems (who will help with
general support and transportation to/from the clinic).
Without follow-through by oncology care teams to
check that patients are taking medications as prescribed,
our efforts to educate patients about the rationale behind
therapeutic choices, potential side effects to expect, and
the overall treatment plan while they’re in the clinic will
go to waste.
Adherence and effective patient-provider communication are critical components to the success of a treatment plan. Here, I share my “Top 10 Tips” for helping
maintain patient adherence.
1. Set aside time to discuss the risks, benefits, and
alternatives to the treatment plan. One of the major
barriers to adherence is that patients may not believe
that they need the recommended therapy or fully understand the treatment plan. It is the duty of clinicians
to assess patients’ and caregivers’ willingness to take
the medications as prescribed and to educate patients
– on their level – about the different components of
the treatment plan. Personally, I like to draw pictures
of the disease pathobiology and the drug’s mechanism
of action to visually reinforce the concepts behind
the treatment plan. I also encourage the patient or
caregiver (family member, friend, or other caregiver)
to be present and take notes.
2. Highlight common potential side effects of treatment.
The prescribing information for anti-cancer drugs
highlight a multitude of side effects based on clinical
trial data. However, this may not reflect real-world
experience and most patients reading through the
potential adverse effects might be overwhelmed. To
minimize confusion, when I am discussing a therapy
with patients, I concentrate on the side effects they are
most likely to experience. Clinicians should also emphasize that many of the side effects can be addressed
and intervened on without having to disrupt therapy.
Making patients aware of these options can encourage
them to report their symptoms.
3. Determine how intravenous or oral medications are
going to be secured. The rapid emergence of effective
therapies to treat hematologic malignancies in the last
10 to 15 years has turned once-incurable cancers into
chronic health conditions. The financial impact of
living with cancer can be devastating; patients should
not have to choose food over medications, but, tragically, it happens. I would like to think that we are all
cognizant of medication costs, the time required to
obtain prior authorizations for medications, the need
for specialty pharmacies to dispense the drugs, and
that these factors should be appropriately communicated to patients.
Before writing a prescription, I consider if the
drug will be covered by the individual’s health insurance and discuss the timeframe in which the patient
can expect to receive his or her medications (1 day, 1
week, 1 month, etc.). For patients who require more
expensive, specialty medications, there are many
co-payment assistance programs (available through
organizations like the Chronic Disease Fund, the
Patient Assistance Foundation, and The Leukemia
& Lymphoma Society) to help under-insured and
uninsured patients. Similarly, many pharmaceutical
companies offer drug co-payment assistance and even
supply funding for transportation to and from the
clinic. These organizations also frequently sponsor
call-in helplines for patients to discuss side effects
and strategies for side effect management. We should
make patients aware of these resources.
4. Make sure follow-up appointments are made before
the patient leaves the clinic whenever possible. Work
with your scheduling team and/or assistants to create
a workflow for return appointments. Are appointments made automatically after each visit, or does a
provider have to request the appointments? Some patients may think they do not need to see a clinician if
no appointment is made. Creating a standard protocol
in the office helps streamline the scheduling process.
Also, if patients are aware of appointments ahead of
time, they have time to arrange transportation and are
more likely to obtain lab tests and treatments.
5. Help caregivers (family members or home care
nurses) understand how to dispense medications.
Caregivers need to be educated about the patients’
medications and ways to help patients maintain
adherence. Pillboxes can help organize medications
for patients but need to be laid out correctly in order
for patients to tak e the prescribed medications correctly. Eliciting the help of a family member or home
September 2016