Impact of a pharmacist-led oral chemotherapy monitoring clinic at the South Texas Veterans Health Care System.

As cancer treatments shift from traditional intravenous chemotherapy to inclusion of oral oncolytics, there is a critical need for structured oral chemotherapy monitoring and follow-up programs. To provide continuous care and minimize clinical gaps to Veterans receiving oral chemotherapy, the hematology/oncology clinical pharmacy practitioners designed and initiated a pilot, pharmacist-driven, Oral Chemotherapy Monitoring Clinic at the South Texas Veterans Health Care System supported by an oral chemotherapy certified pharmacy technician. A retrospective evaluation of patients receiving oral chemotherapy at the South Texas Veterans Health Care System was performed before (Phase I) and after (Phase II) pilot implementation to assess the impact of an Oral Chemotherapy Monitoring Clinic on compliance with drug-specific lab and symptom monitoring. Complete monitoring was defined as 100% of recommended labs and symptoms assessed per cycle, partial monitoring was <100%, but >0%, and incomplete monitoring was defined as 0%. The primary outcome assessed the proportion of patients receiving complete monitoring in Phase II compared to Phase I. Most patients were male (94%), with a median age of 72 years. The most common oncolytic was abiraterone acetate. Overall, drug-specific baseline and follow-up laboratory and symptom monitoring was complete at a statistically significantly higher rate in Phase II compared with Phase I (p-value < 0.01). A significantly higher portion of patients in the Phase II cohort had a clinical pharmacy practitioner intervention (44% vs. 90%; p < 0.01). Monitoring for Veterans receiving oral chemotherapy was optimized with clinical pharmacy practitioner and certified pharmacy technician involvement while simultaneously alleviating Oncologist and nurse oral chemotherapy workload.

Premix versus On-Demand Workflow Models in a Veterans Affairs Hematology/Oncology Pharmacy: Impact on Estimated Waste Costs and Patient Wait Time.

Background: The balance between reducing patient wait time and mitigating waste of parenteral products has not been well described in literature. Objective: Evaluate the patient wait times and cost-effectiveness of employing a premix versus an on-demand workflow model for compounding parenteral admixtures in a hematology/oncology infusion setting. Methods: This single center, retrospective cost analysis compiled manually documented monthly waste reports and estimated drug pricing for the institution to calculate the cost of waste during both premix and on-demand compounding workflows. Time to administration was audited for one week with both models. Results: Over a period of 28.5 months following the premix model, 564 products were documented as wasted ($1,196,014.01 in estimated drug purchasing cost). Over a period of 3 months following the on-demand model, 12 products were wasted ($34,823.98 in estimated drug purchasing cost). Switching models reduced the monthly average number of wasted products from 20 to 4 per month; the average cost of waste was reduced from $41,965.40 to $11,607.99 per month (P < .0001). Overall patient wait time from clearance until administration, excluding any recommended wait times after premedication administration (if applicable), was similar in both models: an average of 38.26 minutes in the premix model and 40.97 minutes in the on-demand model. Conclusion: Premixing parenteral admixtures was not cost effective at our institution. After resuming an on-demand compounding model, the monthly cost of waste (based on drug pricing alone) was reduced by over 70%. The wait time from clearance to treatment administration was similar in both models.

Outcomes in Patients With Curative Malignancies Receiving Filgrastim as Primary Prophylaxis.

Background: Granulocyte colony-stimulating factor prophylaxis has been shown to reduce the risk and duration of chemotherapy-induced neutropenia and febrile neutropenia and is recommended for at-risk patients receiving chemotherapy. Within the South Texas Veterans Health Care System, daily filgrastim injections remain the preferred formulation of granulocyte colony-stimulating factor for primary prophylaxis of febrile neutropenia. Methods: This retrospective, single-center cohort study included 59 patients who received daily filgrastim as primary prophylaxis with a curative cancer diagnosis and a chemotherapy regimen at the South Texas Veterans Health Care System from September 1, 2015 to September 24, 2020. Patients had either a high risk for febrile neutropenia or a chemotherapy regimen with an intermediate risk for febrile neutropenia and additional risk factors. The primary outcome was the incidence of neutropenia/febrile neutropenia leading to treatment delays. Secondary outcomes included chemotherapy dose decreases or discontinuations, hospitalizations, days of hospitalization, infections, extended duration of filgrastim, and transitions to pegfilgrastim due to neutropenia/febrile neutropenia. Results: Patients received a median (IQR) of 7 (5-10) doses of filgrastim for primary prophylaxis. Overall, 10 patients (17%) experienced treatment delays due to neutropenia/febrile neutropenia. Fifteen patients (25%) were hospitalized with a median (IQR) length of stay of 5 (4-7) days, 9 patients (15%) had documented infections, and 2 patients (3%) required a chemotherapy dose reduction. Additionally, 9 patients (15%) required an additional median (IQR) of 2 (2-5) doses of filgrastim, and 9 (15%) patients were transitioned to pegfilgrastim. Conclusions: These results suggest that additional measures such as tracking postnadir absolute neutrophil counts should be performed to ensure patients receive an appropriate number of filgrastim doses to prevent complications associated with neutropenia/febrile neutropenia.

Incidence of invasive fungal infections in patients with chronic lymphocytic leukemia receiving ibrutinib within the veteran's healthcare administration.

PURPOSE: Ibrutinib is a tyrosine kinase inhibitor that is increasingly prescribed in chronic lymphocytic leukemia (CLL). Invasive fungal infections (IFIs) have been reported early after ibrutinib initiation. Timing of IFIs is within 6 months and commonly reported fungal infections include Cryptococcus, Aspergillus, and Pneumocystis. Currently, there are no recommendations for routine prophylaxis against IFIs in patients receiving ibrutinib for CLL. OBJECTIVE: The objective of this study was to evaluate the incidence of IFIs in patients receiving ibrutinib for CLL in first-line and relapsed/refractory (R/R) settings. METHODS: This was a retrospective, cohort study of patients diagnosed with CLL and initiated on ibrutinib in the Veterans Health Administration (VHA) from October 1, 2013 to March 31, 2018. Patients were included if diagnosed with a proven or probable IFI from the start date of ibrutinib to 30 days after the last dose of ibrutinib. RESULTS: Fourteen out of 1069 patients met inclusion criteria for IFI while on ibrutinib for CLL. All patients included were male with a median age of 78 years. Fifty percent of patients were initiated on ibrutinib within 3 months of last chemotherapy. IFIs occurred within 3 months (50%) and 6 months (71%) of ibrutinib initiation. Seventy-one percent of patients were continued on ibrutinib with concurrent IFI diagnosis. CONCLUSION: The reported IFI incidence of 1.3% is comparable to current estimates of 1.2%. Future studies should examine the relationship of ibrutinib and incidence of IFIs in first-line and R/R settings in addition to identifying clinical risk factors predisposing patients to IFIs.

Long-Distance Caregivers: What are Their Experiences with Formal Care Providers?

OBJECTIVES: Extensive literature has documented the experiences of informal caregivers and their interactions with formal care providers, yet this research is almost entirely limited to caregivers who live near their care-recipients. This study aims to describe long-distance caregivers' (LDC) experiences (e.g., satisfaction and challenges) with formal care providers. Subgroup differences were examined based on the care-recipient's (CR) dementia status and residential setting (community versus residential care). METHODS: Data were collected from 296 LDCs (Mage = 56.64, SD = 12.40) categorized into four subgroups based on CR dementia status and residential setting. Participants rated their overall satisfaction, satisfaction with communication and information, and described challenges faced in their interactions with formal care providers. RESULTS: Challenges related to formal care providers were significantly greater and satisfaction significantly lower among LDCs of CRs in residential care, irrespective of dementia status, when compared to LDCs of CRs in the community. CONCLUSIONS: This study provides insights into the experiences of a growing segment of the caregiver population managing care from a distance, specifically in their interactions with formal care providers. CLINICAL IMPLICATIONS: The results of this study point to the possible necessity for the development of novel interventions to improve and enhance communication and collaboration between FCPs and informal caregivers.

The impact of formal and informal support on emotional stress among non-co-resident caregivers of persons with dementia.

OBJECTIVES: The purpose of this study was to examine the prevalence of formal and informal support between non-co-resident and co-resident family caregivers of persons with dementia and to investigate the impact of receiving formal or informal assistance on family caregivers' residential status and their perceived emotional stress. METHOD: We used secondary data from the 2018 National Survey of Older American Act conducted by the Administration for Community Living. We selected 751 primary family caregivers of persons with dementia and conducted regression analyses to explore our research questions. RESULTS: Non-co-resident caregivers of persons with dementia were younger, racially and ethnically diverse, employed, and had higher income than co-resident caregivers. They were less likely to utilize formal support, such as caregiver training or education (p = .005) and respite care (p = .019) but more likely to rely on informal support in their social networks (p = .002), compared to co-resident caregivers. Non-co-resident caregivers who had better informal support systems showed less emotional stress than co-resident caregivers (p = .024). CONCLUSION: Findings from our study suggest the importance of engaging informal networks to alleviate emotional stress of non-co-resident caregivers of persons with dementia. Furthermore, it is critical to help them utilize adequate caregiver training and education as well as respite care before their loved ones experience dramatic functional and health declines.

Use of Home Care Services Reduces Care-Related Strain in Long-Distance Caregivers.

BACKGROUND AND OBJECTIVES: Prior work examining the role of older adult home care service use in alleviating strain in family caregivers has resulted in contradictory findings. However, prior research has been entirely limited to caregivers who live within close geographical proximity to their care recipients. Long-distance caregivers are a unique caregiving subgroup that has remained understudied. Guided by the stress process model, this study examined if the association between primary caregiving stressors (the care recipient's functional and cognitive status) and secondary stressors (perceived role strains related to work and to other family responsibilities) in long-distance caregivers was mediated by the care recipient's utilization of home care services. RESEARCH DESIGN AND METHODS: The sample included 166 long-distance caregivers in the United States who provide and manage care to a community-dwelling care recipient living 2 or more hours away. Participants reported on their care recipient's cognitive and functional status, perceived interference of caregiving with work and other family responsibilities, and the care recipient's use of home care services. RESULTS: Path analyses show that home care use by the care recipient fully mediated the association between care recipients' functional impairment and caregiver strains (work and family). Furthermore, home care use partially mediated the effects of care recipients' cognitive impairment on caregiver strains. DISCUSSION AND IMPLICATIONS: Results indicate that the care recipient's home care service utilization may serve as a protective factor against care-related strain in long-distance caregivers. These findings can be used to inform intervention efforts focused on a family-centered care approach that can be specifically tailored to long-distance caregivers.

The Social Context of Driving Cessation: Understanding the Effects of Cessation on the Life Satisfaction of Older Drivers and Their Social Partners.

Older adults with vision loss and a friend or family member were interviewed over a 2-year period. We examined the effects of driving cessation on life satisfaction among older adults and a social contact. Drivers' use of public transportation was examined as a moderator. Driving cessation was associated with a decline in life satisfaction among social partners but not for the drivers. Drivers' use of public transportation at baseline moderated the effects of cessation on changes in well-being among social partners, but had little effect on the life satisfaction of the drivers. Life satisfaction was greater among the social partners of ex-drivers who used public transportation more frequently. The association between driving cessation and well-being should be studied in the context of older drivers' social networks. Infrastructure (e.g., subways and buses) that supports transportation needs plays an important role in mitigating the effects of cessation on older adults' social networks.

Transportation and Aging: An Updated Research Agenda to Advance Safe Mobility among Older Adults Transitioning From Driving to Non-driving.

Engagement in civic, social, and community life plays an important role in health, well-being, and quality of life, and requires individuals to be mobile in their environment. In this article, we review what is currently known about 2 areas relevant to safe mobility for older drivers and identify future research in these areas. Using a framework for transportation and safe mobility, 2 key areas were selected for review: the process of transitioning to non-driving and the maintenance of mobility after driving has ceased. This article serves as a companion to another article that used the same approach to explore safe mobility issues for older adults who are still driving. We found that although there has been progress in supporting transitioning process to non-driving and improving mobility options for older adults following driving cessation, many knowledge gaps still exist. We identified several research topics that would benefit from continued scientific inquiry. In addition, several themes emerged from the review, including the need for: multidisciplinary, community-wide solutions; large-scale, longitudinal studies; improved education and training for older adults and the variety of stakeholders involved in older adult transportation; and the need for programs and interventions that are flexible and responsive to individual needs and situational differences.

A population study of correlates of social participation in older adults with age-related vision loss.

OBJECTIVE: To examine personal characteristics, disease-related impairment variables, activity limitations, and environmental factors as correlates of social participation in older adults with vision loss guided by the World Health Organization's International Classification of Functioning, Disability and Health Model. DESIGN: Baseline data of a larger longitudinal study. SETTING: Community-based vision rehabilitation agency. SUBJECTS: A total of 364 older adults with significant vision impairment due to age-related macular degeneration. MAIN MEASURES: In-person interviews assessing social participation (i.e. frequency of social support contacts, social/leisure challenges faced due to vision loss, and of social support provided to others) and hypothesized correlates (e.g. visual acuity test, Functional Vision Screening Questionnaire, ratings of attachment to house and neighborhood, environmental modifications in home). RESULTS: Regression analyses showed that indicators of physical, social, and mental functioning (e.g. better visual function, fewer difficulties with instrumental activities of daily living, fewer depressive symptoms) were positively related to social participation indicators (greater social contacts, less challenges in social/leisure domains, and providing more support to others). Environmental factors also emerged as independent correlates of social participation indicators when functional variables were controlled. That is, participants reporting higher attachment to their neighborhood and better income adequacy reported having more social contacts; and those implementing more environmental strategies were more likely to report greater challenges in social and leisure domains. Better income adequacy and living with more people were related to providing more social support to others. CONCLUSION: Environmental variables may play a role in the social participation of older adults with age-related macular degeneration.