“We have been talking about the problem of nonadherence long enough. Now we need to start solving it!" This was a message I heard loud and clear when talking with an oncology nurse educator a few weeks ago. The sense of urgency and frustration in her voice radiated.
A key stakeholder in addressing adherence to oral medications is the nurse. The nurse typically coordinates efforts with others on the oncology team, patients and families, and the pharmacist (including the specialty pharmacist). More specifically, the nurse collaborates with the team to assess, educate, and manage patients on oral therapies. And it is often the nurse who impacts patients’ knowledge of treatment and empowers patients to make behavior change, which includes being adherent.
At the annual Oncology Nursing Society (ONS) meeting, held in Boston, the same sense of urgency that the oncology nurse voiced was echoed. One of the key sessions I attended, Adherence to Oral Oncolytics: A Critical Look at a Complex Issue, highlighted the importance of addressing the problem and the significant role nurses play.
- There are more than 40 oral oncolytics approved by FDA currently
- 25% of the 400 oncolytics in the pipeline are oral therapies
- Compared with intravenous therapy, oral therapy holds many advantages, as well as challenges, for patients
- In particualr, the shift in responsibility can be a potential challenge for healthcare providers (HCPs):
- The responsibility is on the patient to fill the prescription, follow the instructions about how to take the medicine, and communicate his or her needs to overcome any potential barriers
- Few studies have measured adherence outcomes in oncology, and reported adherence varies widely (20%-100%)
- Adherence needs to be built into end points and outcomes of studies so that researchers understand which interventions are working and which are not and why
Debra Winkeljohn, RN, MSN, AOCN, CNS, a presenter at the symposium, posed a straightforward question to the roomful of oncology nurses: “How many of you have some sort of protocol or guidelines for your patients who are on oral therapies?”
I looked around the room and was both surprised and a bit alarmed to see only a few hands pop up. This highlighted the disparity between the documented issues around and solutions to nonadherence and what is the reality in practice. The reality is that many nurses do not have a standard of practice for managing patients on oral therapy. They are busy just getting through their day, wearing the many hats they do to care for their patients. This gap was reiterated by a survey, completed in 2008, of 1116 oncology nurses in 15 countries. The study revealed that 47% of nurses had had no formal education on oral therapies. In addition, it is often unclear who is responsible for educating the patient on the oral therapy. Is it the doctor, the nurse, or the pharmacist—or all oncology HCPs?
Nonadherence to medication is certainly recognized as a major concern and has been getting more attention than it once did across therapeutic areas. In oncology, though, there are many assumptions that people, including HCPs, make regarding the adherence rates to medications. Of course someone with cancer will be adherent to his or her medication regimen, right? Wrong. People with cancer face many of the same barriers as people taking other medications.
As the options for oral therapies in oncology continue to grow, there need to be systems in place to first help healthcare professionals select the right patients for oral therapies. And once the patient is started on treatment, practice protocols and guidelines will help HCPs assess, educate, monitor, and support the patient throughout treatment. But this is just half of the equation. Patients also need education and support tools—tools that employ health literacy principles—to help them to overcome barriers and better adhere to treatment regimens. This is critical because in the end, patients are responsible for taking their own medicine, and HCPs have little control over adherence.
So, what else can be done to further these efforts? Build a body of evidence for interventions to assess, monitor, and ultimately improve adherence by integrating adherence into research as an end point. It is not optional at this point but essential.
Expanding the team to include pharmaceutical companies can further the collaboration needed to help the extended team address adherence to oral therapies. The teams can provide support by helping HCPs to identify the barriers, conduct research, and develop enduring solutions. As mentioned, conducting research is a first step to collecting evidence of the challenges and solutions. This in turn will help to identify methodologies for practice management—including education that uses the principles of health literacy. This collaborative approach can show Return on EducationTM, an analytical framework developed by HealthEd that can be used to measure the effectiveness of patient education and marketing efforts to enhance patient health outcomes, including behavior change. Ultimately, the goal is to improve medication adherence, which will hopefully correlate to an improvement in patient outcomes.
Rita Williams, MS, CHES
Senior Health Educator, Health Education