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Strategies to Increase Adherence

Peter L. Salgo, MD; Carl T. Henningson, MD; Noa Biran, MD; and Steven L. D’Amato, RPh, BSPharm, share different strategies to increase adherence, including a multidisciplinary approach to treatment.
Published Online: Feb 07,2018

Peter L. Salgo, MD: In practice, with all of these barriers, they’re just related to human factors, right? What are your strategies to making people adhere better and to help them? Not as an adversarial thing, but what do you do, practically, to get these things taken care of the right way?

Carl T. Henningson, MD: We actually have a navigator now. Hopefully, this is going to be an important change in our practice. Just during this last week, I noticed this with a patient that I wrote a prescription for. The patient was in rehab. She came back to see me 2 weeks later. I wanted to monitor her side effects, and she wasn’t on the drug. She never received the drug. Now, we’re going to have the navigators make sure that these things work more smoothly.

The other thing is—this is actually one of the things that was brought up at the ASCO annual meeting in plenary sessions—they have this web-based program for reporting side effects. It is not just for oral chemotherapies but with all chemotherapies. It was real time. They would send e-mails to the physicians’ offices. The nurses would answer those e-mails. It turned out that it improved survival by 5 months, which is greater than a lot of our oral drugs, still. It also improved quality of life. It decreased hospitalizations and decreased emergency room visits. And so, I think that’s probably the direction that we’ll be moving. Whether it’s an app on a phone or a web-based program, I think that we’ll be doing more of that.

Noa Biran, MD: Some of the manufacturers, the drug companies, have their own nurse who is assigned to an area. That nurse will only have maybe a half of a state or a small geographic area. They’re assigned to follow up with the patient. They call the patient. So, you can take advantage of the manufacturers. They have a lot of services and nurses that they’ll provide to help with this.

Peter L. Salgo, MD: At $30,000 a month.

Noa Biran, MD: Exactly. They better, right?

Carl T. Henningson, MD: I ran into a problem with this once. A patient was on one of the oral drugs for renal cell cancer and started having a really bad rash. The patient called the nurse, and the nurse said, “Just keep taking the drug. Don’t worry about it.”

Noa Biran, MD: Wow.

Carl T. Henningson, MD: Not “Go talk to your doctor.”

Noa Biran, MD: You have to be careful.

Carl T. Henningson, MD: They really have to know their limitations and make sure that they’re referring the patients back to the doctor.

Peter L. Salgo, MD: So, we have a nurse, perhaps assigned from the pharmaceutical company. We’ve got all sorts of electronic devices and follow-ups. Is there anything else?

Steven L. D’Amato, RPh, BSPharm: Well, we have a team-based approach—a pharmacist and primary nurse model—that works with every patient. We have triggers built in to our electronic health record regimens. So, every oral regimen goes into the EHR with multiple oral triggers that nursing and pharmacy act on—from calling the patient. For 24 to 48 hours, we get ahold of the patient after the first dispense. They’re back into the office at least a week later, just like a patient receiving intravenous therapy. We follow those patients just like they’re receiving intravenous therapy. We pull them in and make sure they don’t have any early toxicities. To Noa’s point, especially in multiple myeloma, a lot of these agents have multiple toxicities that you need to stay on top of. The way we do that is through our care teams. It works fairly well. I think having that close patient contact with your pharmacist and primary nurse is key.