Pharmacist Effect on Discharge Follow-Up Education in Pediatric Oncology Outpatient Clinics: A Quality Improvement Study

Abstract

OBJECTIVE

We aimed to describe the effect of education provided by a clinical pharmacy specialist at a patient's follow-up appointment after discharge, and to assess caregiver satisfaction.

METHODS

A single-center, quality improvement study was conducted. A standardized data collection tool was created to characterize interventions made by clinical pharmacy specialists during an outpatient clinic appointment scheduled shortly after discharge. Pediatric patients with cancer who met the following criteria were included: 1) initial diagnosis without receiving chemotherapy, 2) first course of chemotherapy after initial diagnosis or relapsed disease, and 3) post-hematopoietic stem cell transplantation or cellular therapy. A survey was provided to families after the follow-up discharge appointment to assess the caregiver's satisfaction of the new process.

RESULTS

From January to May 2021, a total of 78 first-time discharge appointments were completed. The most common reason for follow-up was discharge after first course of chemotherapy (77%). The average duration of each appointment was 20 minutes (range, 5–65). The clinical pharmacy specialist made an intervention during 85% of appointments. The most common intervention made during the visit was reinforcement of medications (31%). Thirteen surveys were completed by caregivers; 100% of the caregivers reported the follow-up appointment was helpful. Additionally, they reported the most useful resource provided at discharge was the medication calendar (85%).

CONCLUSIONS

Investing clinical pharmacy specialist time with patients and caregiver after discharge appears to have a meaningful effect on patient care. Caregivers report this process is helpful in better understanding their child's medications.

Introduction

Studies have demonstrated transitions of care are risk points for medication errors, particularly when involving high-risk drugs and/or patients.¹ Improvements in the medication reconciliation process across these transitions are associated with lower risk of errors. Some approaches to improvements include detailed pharmacist-mediated comprehensive medication review at hospital admission, pharmacist-conducted medication reconciliation at discharge, and providing documentation for patients to assist with communication when transitioning from secondary to primary care.¹ Both professional and regulatory organizations address the importance of adequate attention to medication reconciliation.^2–5 Pediatric oncology patients are particularly challenging because both the patients and their medication regimens are complex, potentially putting them at high risk for medication errors.

The initial discharge after a cancer diagnosis can be an overwhelming experience for patients and their caregiver(s). Caregivers are defined as a family member or a person who regularly cares for a sick child. Children with medical complexity are more vulnerable to medication errors than those without medical complexity.⁶ Gold et al⁶ suggest that to minimize medication errors, discharge medication education should provide a critical safety checkpoint before medication management is transitioned back to the caregiver. Additionally, they suggest that medication education requires the engagement of caregivers, which can be a major factor to successfully transitioning home.⁶ Four major themes were discussed with caregivers to better understand their needs, which included quality of information, information delivery, personalization and/or individualization, and self-efficacy.⁶ Overall, caregivers prefer high-quality discharge medication education provided by experts that allows them to feel confident in their ability to care for their child once at home.⁶

Pharmacist-led discharge medication reconciliation review with caregivers has the potential to identify medication discrepancies and reduce potential harm, according to many studies.^7–10 More specifically, clinical pharmacy services provide direct pharmaceutical care to patients to ensure the optimal use of medications.⁸ A study conducted by Tuffaha et al⁸ observed clinical pharmacy services in outpatient pediatric oncology clinics. They found the most common clinical interventions made by clinical pharmacy specialists were related to education and safety, followed by clarification and therapeutic interventions.⁸ Clinical interventions under the education category were defined as patient education provided to patients and/or caregivers. Interventions related to safety were divided into 5 different categories: chemotherapy evaluation, non-chemotherapy evaluation, drug interactions, adverse drug reactions, and medication errors. Clarification interventions were defined as the pharmacist needing to clarify an order with a prescriber. Lastly, chemotherapy or non-chemotherapy changes were interventions documented under the therapeutic category.⁸ Involving a clinical pharmacy specialist in the outpatient setting is crucial in optimizing continuity of care and preventing adverse events from occurring. A study conducted by Ali et al⁹ found that inclusion of a clinical oncology pharmacist into a specialized outpatient clinic plays an integral role in minimizing the adverse effect(s) of medications and readmission into the hospital. Another study aimed to describe the key activities performed by a clinical pharmacist in an outpatient pediatric hematology, oncology, transplant clinic.¹⁰ The authors reported the most frequent activities in the outpatient clinic were obtaining best possible medication histories, providing medication counseling, and creating adherence aids.¹⁰

Clinical pharmacy specialists at our institution are closely integrated into interdisciplinary teams in both the inpatient and outpatient settings and provide a variety of medication-focused services. These individuals collaborate with care teams in ensuring the best possible outcomes of medication therapy in these complex pediatric and adolescent patients, some of whom are non-English speaking. Patients may be discharged following an inpatient stay with as many as 24 different medications, attesting to the complexity of therapy. All patients are counseled by a pharmacist prior to being discharged from the hospital.

To ensure that patients and caregivers understand and comply with their medication regimen, an outpatient appointment with a clinical pharmacy specialist shortly following discharge is conducted with the patient and their caregivers. Our specific project aim was to evaluate the effect of pharmacist interventions made during first-time discharge appointments conducted shortly after a patient was discharged from the hospital. Our goal was to describe the possible benefits of this approach to patient management, thus improving caregiver satisfaction on transitions of care. The primary outcomes of the study were to describe the effect of pharmacy interventions made at first-time discharge follow-up education appointments and to assess caregiver satisfaction with the follow-up discharge education process. The secondary outcome was to identify tools used at discharge that best facilitated patient and caregiver understanding of medications.

Materials and Methods

Participants and Setting. This was a single-center, quality improvement study conducted at a specialized pediatric hospital in southeastern US region. This project was granted quality improvement designation following review by the Institutional Review Board. Patients were included in the study if: 1) it was their first discharge from the hospital after diagnosis with new medications added as part of their treatment, 2) they were discharged after first course of chemotherapy, 3) they were a relapsed or refractory patient with a new chemotherapy regimen, or 4) it was a first discharge after hematopoietic stem cell transplant. These points of care were chosen for inclusion in the study given the complexity of medication regimens and patients and caregivers having limited experience administering and managing multiple medications at home. Except in rare circumstances, all medications and medication supplies were dispensed from the St. Jude Children's Research Hospital outpatient pharmacy. Decisions for dispensing medications were made without consideration of insurance reimbursement. Patients were not excluded from the study based on language, cultural, or socioeconomic barriers. Video, telephone, or in-person language interpreters were used for non–English-speaking patients or caregivers.

Procedure. Outpatient follow-up appointments in the clinic were scheduled at patient discharge by either the clinical pharmacy specialist or another pharmacist conducting discharge counseling on the day of patient discharge; this appointment was coordinated to occur on the same day of follow-up appointment with medical providers. These follow-up appointments with medical providers typically occurred within a few days (2–3) after discharge. The outpatient clinical pharmacy specialist was responsible for conducting the follow-up education; in most cases this clinical pharmacy specialist was not involved with the initial discharge from inpatient status. Interventions made by this individual during the appointment were documented using a standardized data collection tool. The following information was collected in the standardized data collection tool and in a patient education form in the electronic health record: appointment details (i.e., clinic location, reason for follow-up appointment, duration of visit), medication information (i.e., number of medications, type of medications), pharmacist interventions (i.e., reinforcement of medication regimen, adjusting antiemetic or bowel regimens, drug-food interactions, etc.), and barriers identified during the appointment (i.e., required language interpreter, reprinting of medication calendar, etc.).

At the time of the first-time discharge follow-up appointment, the clinical pharmacy specialist provided a survey to the caregivers. The survey consisted of 16 questions related to all phases of the discharge process. The survey included Likert-type, multiple-choice, and fill-in-the-blank questions (Supplemental Figure). Originally the survey was offered to patients using an institutional Web-based platform. However, when early experience demonstrated that no caregivers were using this tool, we made the decision to switch to a printed paper copy which was provided directly to caregivers when the appointment was completed. The survey was then completed anonymously and returned to the patient's corresponding clinic and collected by the clinical pharmacy specialist.

Responses on the standardized data collection tool and the survey were tabulated and presented as percentages and ranges, where applicable.

Results

Seventy-eight first-time discharge follow-up appointments were conducted from January to May 2021. The most common primary location was the solid tumor or neuro-oncology clinic (48%), followed by the leukemia clinic (42%). The most common reason for follow-up was discharge after first course of chemotherapy (77%). The average number of medications a patient was receiving was 10 (range, 3–24). Additionally, approximately 26 patients (33%) were receiving a medication that was given intravenously, intramuscularly, or subcutaneously. The median duration of each appointment was 17 minutes (range, 5–65; Table 1). In addition, clinical pharmacy specialists spent a median of 10 minutes (range, 2–60) reviewing the patient's electronic health record prior to the appointment.

Table 1.

Baseline Characteristics

Characteristic	Value, N = 78
Clinic location, n (%)
Solid tumor or neuro-oncology clinic	37 (48)
Leukemia clinic	33 (42)
Bone marrow transplant clinic	8 (10)
Duration to review patient’s profile prior to appointment, median (range)	10 min (2–60)
Duration of follow-up appointment, median (range)	17 min (5–65)
Reason for follow-up appointment, n (%)
Discharge after first course of chemotherapy	60 (77)
First-time discharge after transplant or cellular therapy	8 (10)
Relapsed or refractory patient starting new chemotherapy regimen	6 (8)
First discharge from hospital after diagnosis without receiving chemotherapy	4 (5)
Number of medications, mean (range)	10 (3–24)
Intravenous, intramuscular, or subcutaneous medications, n (%)	26

A clinical pharmacy specialist made at least 1 intervention with a patient, caregiver, or other health care provider in 85% of the first-time discharge follow-up appointments. Additionally, multiple interventions were made in 46% of cases (Figure 1). The most common intervention made during the appointment was reinforcement of medication regimen (31%). Adjusting antiemetic regimens and bowel regimens were the second and third most common interventions documented, at 19% and 9%, respectively. Modification of medication regimen to address drug-food interactions (5%), correction of timing or frequency medication errors (5%), and changed medication formulation (5%) were also documented interventions during the appointment. Other interventions documented during the first-time discharge follow-up appointment included, but were not limited to, correction of inappropriate dosing, discussing stability of medications, conducting a drug-allergy investigation, and ordering drug blood or serum concentrations to assist with pharmacokinetic interpretation (Table 2). Some of the clinical pharmacy specialists noted providing education to improve adherence of liquid medications. For example, 1 strategy provided by the clinical pharmacy specialists was hiding the medication in a small amount of juice, chocolate milk, applesauce, or pudding. Additionally, the clinical pharmacy specialists suggested, for large-volume doses, to break the administration into small amounts to complete the full dose within 30 minutes. A correction of inappropriate dosing was documented twice by clinical pharmacy specialists; in both situations, the pharmacist documented the caregiver was administering the wrong dose, although the correct dose was on the label; 1 of these was directly related to the patient's chemotherapy.

Figure 1.

Number of interventions at first-time discharge follow-up appointments.

Table 2.

Interventions Made During First-Time Discharge Appointment

Intervention	No. (%), n = 119
Reinforcement of medication regimen	37 (31)
Adjust antiemetic regimen	22 (19)
Adjust bowel regimen	11 (9)
Drug-food interaction addressed	6 (5)
Incorrect timing or frequency of medication	6 (5)
Change in medication formulation	6 (5)
Incorrect dose	2 (2)
Other	29 (24)

Thirteen surveys were completed and returned by caregivers; 100% of the caregivers reported the follow-up appointment was helpful. All but 1 caregiver reported they learned something new about their patient's medications during the follow-up appointment. One caregiver reported having a problem with their patient's medications at discharge, which was due to a missing medication (Figure 2). All caregivers reported they felt more comfortable with their patient's medications after the first-time discharge follow-up appointment (Figure 3). Additionally, caregivers reported the most useful resource provided at discharge was the medication calendar (85%). Other helpful tools noted by caregivers were a paper handout with medication information (62%) and a pill box (15%; Table 3).

Figure 2.

Caregiver responses to satisfaction survey (yes or no questions).

Figure 3.

Caregiver responses to satisfaction survey (5-point Likert scale).

Table 3.

Most Helpful Resources at Initial Discharge as Noted by Caregiver Report

Resource	No. (%), N = 13
Medication calendar	11 (85)
Paper handout with medication information	8 (62)
Pill box	2 (15)
St. Jude Pharmacy booklet	1 (8)

Discussion

This quality improvement study demonstrated pharmacists play a vital role in helping manage complex pediatric hematology and oncology medication regimens at follow-up discharge appointments. One of the primary goals of this study was to describe the effect of a pharmacist during these first-time discharge follow-up appointments; the results describing the number and the type of interventions affirm the positive effect of a clinical pharmacy specialist. As previously described in the literature, including a pharmacist in the outpatient setting can play a vital role in minimizing adverse drug events and readmission of patients to the inpatient setting.^1,7–10 This particular study focused on the specific effect of pharmacist interaction with a patient or caregiver—only one subset of the many interactions involving a clinic-based pharmacist.

Reinforcement of medication regimen was the primary intervention documented by clinical pharmacy specialists. This intervention was defined as reeducating the caregiver on any and potentially all medications at the discretion of the clinical pharmacy specialist if they felt the caregiver did not have an adequate understanding of the child's medications. Additionally, there were many different types of interventions documented by the clinical pharmacy specialists. If these interventions were not conducted, medication errors affecting patients might have resulted. More specifically, one of the corrections of inappropriate dosing documented by the clinical pharmacy specialist was directly related to the patient's chemotherapy. If this intervention was not performed, this could have resulted in negative patient outcomes.

Clinical pharmacy specialists at our institution are credentialed members of the medical staff and are able to modify medication regimens under a collaborative practice agreement. Interventions could have included adjustments to medication regimens based on verbal interaction with patients or caregivers, recommendations to other clinic providers, or direct prescribing or discontinuing of medications. It is also important to note that this study solely focused on one role that the clinical pharmacy specialist plays in the outpatient clinics. They are also responsible for many other tasks daily while in clinic.

The other primary goal of this study was to evaluate caregiver satisfaction of the first-time discharge follow-up appointment. Overall, all caregivers reported this process was helpful to better understand their child's medications. In addition, all but 1 caregiver reported they learned something new about their patient's medications during the appointment. It has been reported that the initial discharge after diagnosis is extremely overwhelming, especially for families of children with medical complexity.⁶ This study provides additional support for providing a follow-up appointment after the initial discharge in order to ensure any missing information is provided to caregivers and the caregiver's questions are fully answered.

The provision of the medication calendar at discharge was reported as the most helpful tool for caregivers. As suggested in previous studies, caregivers described 4 main themes to better understand their needs transitioning to the outpatient setting: quality of information, information delivery, personalization and/or individualization, and self-efficacy.^6,10 Creating individualized medication calendars to families provides a personalized method of ensuring medications are given to the patient at the correct dose, time, and frequency.

There are several limitations to this study. First, this is a single-center quality improvement study at a specialized pediatric oncology hospital. Therefore, the complexity of medication regimens at our institution may be more significant in our patient population or not easily translatable to other institutions. In addition to complexity, it is also important to note the diversity of patients (i.e., international) at our institution, which can contribute to language barriers and potential misunderstanding between the pharmacist and caregiver(s). Also, the study was conducted during approximately 4 months, which is a relatively short duration of time. However, the consistency of feedback provided by caregivers and the documented interventions by clinical pharmacy specialists support this new process. Furthermore, survey participation was limited. Accrual of additional caregiver surveys would enhance our confidence in the data provided. It can be hypothesized survey participation was low for multiple reasons. Initially, the institutional Web-based platform required many data entry fields that took a notable amount of time to complete, potentially deterring families from completing. On the other hand, once the survey was transitioned to paper, caregivers could have misplaced the survey after the appointment or failed to remember to return the survey. Finally, the unique setting of our organization (essentially all medication provided to patients by our pharmacy, regardless of insurance approval or ability to pay) may mean that the findings described here are more unique to our institution.

This first-time discharge follow-up appointment in the outpatient clinics led by a clinical pharmacy specialist was well received by caregivers at our institution. The number of interventions documented throughout this 4-month period demonstrated a broad array of issues that are addressed by this pharmacist and demonstrate that there is an integral role for the pharmacist to provide services and possibly minimize adverse effects related to their medication management. Given the complex nature of the patients and treatments seen in our oncology population, we believe that a pharmacist who has deep understanding of the rationale and risks of pharmacotherapy for these patients, and of patient-specific discussions or decisions by the caregiving team, serves as the best source for this first-time education of patient and caregiver(s). However, this investment does require resources; on average, a clinical pharmacy specialist spends a total of 27 minutes per patient to adequately conduct the appointment; this includes a median of 10 minutes to review the patient's profile and 17 minutes for the in-person interview. These results may warrant further expansion of personnel to ensure this service is sufficiently conducted. After completion of this project, first-time discharge follow-up appointments will continue in all outpatient clinics at our institution. Caregiver feedback will be periodically assessed to ensure the appointment is executed as intended.

Conclusion

This description provides evidence that direct interaction between clinical pharmacy specialists and patient or caregiver results in a beneficial effect on those patients. Interventions completed by clinical pharmacy specialists during the appointment could be considered medication errors and, if not caught, may have negatively affected patient outcomes. Overall, caregivers were satisfied with the new discharge process and reported they felt more comfortable with their patient's medications after the first-time discharge follow-up appointment. Key future directions will be to educate personnel on the most useful tools used during the initial discharge and potentially refine roles for the different provider staff during the initial discharge. Ultimately, first-time discharge follow-up appointments were widely accepted by caregivers and can potentially have a positive effect on patient care.