Transforming care for Portland’s chemotherapy patients

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Sean Cosgriff, PharmD, BCOP, is one of a kind at the Portland Veterans Affairs (VA) Medical Center. Patients travel as far as 300 miles to receive cancer care at the VA’s chemotherapy infusion clinic and at the oral chemotherapy clinic, a pilot program currently being tested by Cosgriff. As the only clinical pharmacy specialist in hematology/oncology, Cosgriff touches the lives of patients in Oregon and Southwest Washington by providing efficient, lifesaving care.

Prescriptive authority

Working at the VA allows Cosgriff to be a health care provider with responsibilities that extend beyond traditional pharmacist roles. “I can write certain prescriptions within a scope of practice, I can order labs, and that’s really exciting,” said Cosgriff. “It allows me to practice pharmacy the way I think pharmacy should be practiced.” 
The Portland VA Medical Center has 150 staff members in the pharmacy group, including pharmacy technicians. Although the hospital is located in Portland, pharmacists are located throughout the Portland metro area, as well as in Salem and Bend. There is also a facility in Vancouver, WA. “We have a large area that we service, so having pharmacy staff members located in various places helps reduce how long it takes a patient to interact with a pharmacist,” explained Cosgriff.
“Pharmacists can deal with prescriptions locally and expedite the process for patients.”

Thinking ahead

Speed and organization are essential when it comes to treating oncology patients who are spread across a vast geographic region. “How do we expedite getting medications to patients? How do we get oral medications in patients’ hands so we don’t delay therapy?” said Cosgriff. “I’m always thinking about what the next step is going to be and how to get set up for it.”
Working closely with the hospital’s purchasing department, Cosgriff makes sure that chemotherapy orders for patients are written the day before therapy is administered to make sure there are enough drugs in stock. Advance planning is also necessary when working with certain medications that need to be ordered a few days before the patient is due for therapy. “There’s nothing like having a run on a drug, having five or six patients have the same drug that day, and not having enough stock on hand,” explained Cosgriff. “We use tight purchasing controls to try to ensure that we have enough stock.”
The VA system has an extensive mail-out pharmacy program to get medications to patients as quickly as possible. Oral chemotherapy agents and antiemetics are often mailed out to patients via overnight mail. “If a patient comes in and we aren’t able to give them their entire prescription, we often give them a partial prescription and mail out the remaining balance,” said Cosgriff, who is the first nonphysician president of the Association of VA Hematology/Oncology.

Infusion clinic

Cosgriff works with three nurse practitioners at the chemotherapy infusion clinic. “Once a patient’s oncologist says this is the regimen I’d like the patient to receive, I take it from there,” said Cosgriff. “I write the orders, verify that the patient is ready to take the therapy, and do symptom management.” 
Working within a defined scope of practice, Cosgriff writes prescriptions for many medications commonly used at the clinic. There is a double-check system in place to ensure that the right medications have been ordered. “Of the four of us who work at the clinic, it requires two individuals to write the order—one person to write it and the other person to check it—before the order can be signed,” said Cosgriff. “In emergencies, one person is able to write the order, but I’ve only had to do that one time in my 10 years here at the VA.”
It takes two people to sign chemotherapy orders, and Cosgriff is a provider for antiemetics that patients take at home on an as needed basis.
In addition to writing orders, Cosgriff spends much of his time making sure the right dose is given, the regimen is correct, and that there aren’t any issues with renal or hepatic function that require dose reductions. “Things like CT scans, EKGs, MRIs, and PET scans all need to be evaluated before we can give certain types of chemo,” said Cosgriff. “I’ll evaluate the scan results and if the patient is stable, then we’ll give the chemotherapy. If the scan shows cancer progression, then I’ll alert the oncologist and we’ll determine how to go about managing it.”

Oral chemo clinic

Cosgriff is also involved with a pilot oral chemotherapy clinic. He has been working for more than 2 years to get it off the ground. Once a provider says a patient is eligible for an oral chemotherapy agent, Cosgriff takes over. “We meet with the patient to provide education about the agent, talk about side effects, and tell patients how to call us if there are problems,” he said. “The drug is then mailed to the patient. We call to make sure they received it and ask if they have any questions.” After that, Cosgriff and a nurse practitioner provide close follow-up care for adverse effects and keep the patient’s oncologist updated. “If we need to do a dose escalation, then we’ll notify the patient that we’ll be sending out more prescriptions, call them to confirm they received the medications, and provide follow-up support,” Cosgriff added.
It is Cosgriff’s hope that with frequent follow-up phone calls and medication education, patients will be more adherent to their medications, which ultimately reduces hospital costs. “If we catch side effects early, then we can keep patients from being admitted,” he said. Increasing adherence has also been shown to improve outcomes as it relates to the disease state, Cosgriff noted.
In addition to coordinating medications, Cosgriff manages refills, arranges for labs to be drawn, and monitors lab results. If there is a problem, he will notify the patient’s oncologist. “By coordinating these aspects of care, we take follow-up off the shoulders of the provider,” said Cosgriff.

Keep Portland weird

Portlanders pride themselves on being unique, which can often provide interesting challenges for Cosgriff. With bumper stickers touting the city’s unofficial slogan, “Keep Portland Weird,” coupled with the National Naturopathic College located in the city, Cosgriff often deals with patients who have herbal or alternative medications prescribed by a naturopath or recommended by a friend. “There is a strong urge to use a lot of alternative medicine therapies, so it becomes a situation of how do we manage what the patient wants to take as far as naturopathic products with what we’re giving them,” explained Cosgriff.
There are often interactions and potential problems when it comes to combining traditional and alternative medicines. “It’s always a fun challenge,” said Cosgriff. “Sometimes patients bring in something I’ve never even heard of, so trying to do the literature searches for that is sometimes entertaining.”
Sometimes it is okay for herbal products to mix with chemotherapy, and sometimes it’s not. Cosgriff recently had a patient with hepatocellular carcinoma who wanted to take milk thistle. Cosgriff did the research and found that milk thistle and what the patient was being prescribed have some pretty big issues. The patient, whose condition was terminal, wanted to stick with the milk thistle because the chemotherapy would make him feel worse. “I told him that’s great, but we can’t give you therapy because of the interactions,” said Cosgriff. “The patient understood and was fine with that.”

Behind the scenes

In addition to working in the clinics, Cosgriff has an ever-increasing administrative role. The VA is a national system with a national formulary, but each facility has the ability to write its own use criteria, although it can often take time to develop it. “Chemotherapy agents tend to be very expensive and some have limited benefit,” Cosgriff explained. “With these high-cost drugs, cost containment is an issue, and we follow use criteria to make sure they are being used appropriately.” 
Another aspect of Cosgriff’s job is precepting students for two local colleges of pharmacy—Oregon State University and Pacific University. He also serves as the preceptor for the hospital’s postgraduate year 1 residency program. 
Cosgriff encourages student pharmacists who are interested in specializing in oncology to become board certified. “It provides a standard that a person is knowledgeable to provide pharmacy services in an oncology setting,” said Cosgriff. “The field of oncology is constantly growing, and there is a lot of side effect management that requires special knowledge about why it is occurring, how to fix it, and contraindications.”
Cosgriff is often asked about the difficulty of working with patients who may not have the best prognosis. “There have been so many recent advancements made in treating patients with cancer that it’s actually a very exciting field,” said Cosgriff. “And even if a patient has a terminal malignancy, they always seem to be appreciative of the attention and care we give them. Being able to have a positive impact, to me, is very fulfilling, and I can’t imagine doing anything else.”
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