originalcontribution care delivery · 2017. 8. 7. · office-based...

Touro University California, Vallejo, CA;Touro College and University System, NewYork; Stony Brook University Hospital,Stony Brook; Albany College of PharmacyandHealth Sciences, Albany, NY; Universityof Iowa, Iowa City, IA; Duke UniversityHospital, Durham; Cone Health CancerCenter Pharmacy, Greensboro, NC; NewEngland Cancer Specialists, Brunswick,ME;Kaiser Permanente Northwest, Portland,OR; Koontz Oncology Consulting, Houston,TX; St Luke’s Mountain States TumorInstitute, Boise, ID; The University ofArizona Cancer Center, Tucson, AZ;UniversityofOklahoma,OklahomaCity,OK;University of Colorado Skaggs School ofPharmacy and Pharmaceutical Sciences,Aurora, CO; Samford UniversityMcWhorterSchool of Pharmacy, Birmingham, AL; andUniversityofMarylandSchool ofPharmacy,Baltimore, MD

Corresponding author: Robert Ignoffo,PharmD, FASHP, FCSHP, Touro UniversityCalifornia, 1327 Grand Ave, San Rafael, CA94901; e-mail: [email protected].

Disclosures provided by the authors areavailable with this article atjop.ascopubs.org.

DOI: 10.1200/JOP.2015.008490;published online ahead of print atjop.ascopubs.org on March 22, 2016.

Board-Certified Oncology Pharmacists: Their PotentialContribution to Reducing a Shortfall in Oncology Patient VisitsRobert Ignoffo, PharmD, FASHP, FCSHP, Katherine Knapp, PhD, FAPhA, Mitchell Barnett, PharmD,Sally Yowell Barbour, PharmD, MS, BCOP, CPP, Steve D’Amato, BSPharm, BCOP, Lew Iacovelli, PharmD, BCOP, CPP,Jasen Knudsen, PharmD, BCPS, BCOP, Susannah E. Koontz, PharmD, BCOP, Robert Mancini, PharmD, BCOP,Ali McBride, MS, BCPS, BCOP, Dayna McCauley, PharmD, BCOP, Patrick Medina, PharmD, BCOP,Cindy L. O’Bryant, PharmD, BCOP, FCCP, Sarah Scarpace, PharmD, MPH, BCOP, Steve Stricker, PharmD, MS, BCOP, andJames A. Trovato, PharmD, MBA, BCOP, FASHP

QUESTION ASKED: In light of the projected shortage of oncologists, is there evidencethat pharmacists couldhelp fill the gap and, if so,what particular clinical services could theyprovide during those visits?

SUMMARYANSWER: We estimated that by year 2020, over 3,000 pharmacists who areboard-certified in oncology could contribute 2.6 to 3.3 million 30-minute patient visits.Specific clinical services were identified by board-certified oncology pharmacists (BCOPs)using multiple surveys (Table 1).

METHODS: We used available data to estimate how many BCOPs could be available byyear 2020. We also used a Delphi expert panel process to identify clinical services BCOPscould provide along with how many 30-minute patient visits they could potentiallycontribute.

BIASES, CONFOUNDING FACTOR(S), DRAWBACKS: The Delphi panel consistedsolely of oncology pharmacists; other health care team members might have respondeddifferently to survey questions. Estimates could be subject to changes in data trends. It islikely that the estimate of available BCOPs by 2020 is high because available data includeinternational BCOPs. A confounding factor is that current regulations from the Center forMedicare and Medicaid Services (CMS) do not recognize pharmacists as health careproviders, thereby limiting reimbursement for clinical services. Until the CMS modifiesthese regulations, the employment of pharmacists to provide patient care will likely berestricted.

REAL-LIFE IMPLICATIONS: These results suggest that practicing oncologists maybenefit by utilizing BCOPs to see some of their patients that need particular clinicalservices. The clinical services that BCOPs could provide that received the strongestconsensus (. 80%) are shown in Table 1. These services overlap and also complementthose provided by nurse practitioners andphysician assistants. Oncology practiceswishingto improve capacity, breadth, and/or efficiency are encouraged to consider using BCOPs,particularly for those services identified in this study.

The full version of this articlemay be viewed online atDOI: 10.1200/JOP.2015.008490

Copyright © 2016 by American Society of Clinical Oncology jop.ascopubs.org 1

Original Contribution CARE DELIVERYOriginal Contribution CARE DELIVERY

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mailto:[email protected]://jop.ascopubs.orghttp://jop.ascopubs.org/lookup/doi/10.1200/JOP.2015.008490http://www.jop.ascopubs.orghttp://jop.ascopubs.org/lookup/doi/10.1200/JOP.2015.008490http://jop.ascopubs.org

Table 1. Characteristics of Delphi Panelists

Characteristic Description

Practice setting 10 academic, 3 office based

Geographic location States represented by US Census region:

Northeast: Maine, New York (2)

Midwest: None

South: Alabama, Maryland, North Carolina (2), Oklahoma,Texas

West: Arizona, Colorado, Idaho, Oregon

Hold or have held BCOP status 13 (100%)

Experience, years Median, 16; mean, 16.8 (SD, 9.0)

PGY2 oncology pharmacy residency 9 of 13 (69%)

PGY1 pharmacy residency 8 of 13 (62%)

Abbreviations: BCOP, Board-certified oncology pharmacist; PGY1, postgraduate year 1; PGY2, postgraduate year 2; SD, standard deviation.

2 Journal of Oncology Practice Copyright © 2016 by American Society of Clinical Oncology

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Touro University California, Vallejo, CA;Touro College and University System, NewYork; Stony Brook University Hospital,Stony Brook; Albany College of PharmacyandHealth Sciences, Albany, NY; Universityof Iowa, Iowa City, IA; Duke UniversityHospital, Durham; Cone Health CancerCenter Pharmacy, Greensboro, NC; NewEngland Cancer Specialists, Brunswick,ME;Kaiser Permanente Northwest, Portland,OR; Koontz Oncology Consulting, Houston,TX; St Luke’s Mountain States TumorInstitute, Boise, ID; The University ofArizona Cancer Center, Tucson, AZ;UniversityofOklahoma,OklahomaCity,OK;University of Colorado Skaggs School ofPharmacy and Pharmaceutical Sciences,Aurora, CO; Samford UniversityMcWhorterSchool of Pharmacy, Birmingham, AL; andUniversityofMarylandSchool ofPharmacy,Baltimore, MD

ASSOCIATED CONTENT

Appendix DOI: 10.1200/JOP.2015.008490

DOI: 10.1200/JOP.2015.008490;published online ahead of print atjop.ascopubs.org on March 22, 2016.

Board-Certified OncologyPharmacists: Their PotentialContribution toReducingaShortfallin Oncology Patient VisitsRobert Ignoffo, PharmD, FASHP, FCSHP, Katherine Knapp, PhD, FAPhA,Mitchell Barnett, PharmD, Sally Yowell Barbour, PharmD, MS, BCOP, CPP,Steve D’Amato, BSPharm, BCOP, Lew Iacovelli, PharmD, BCOP, CPP,Jasen Knudsen, PharmD, BCPS, BCOP, Susannah E. Koontz, PharmD, BCOP,Robert Mancini, PharmD, BCOP, Ali McBride, MS, BCPS, BCOP,Dayna McCauley, PharmD, BCOP, Patrick Medina, PharmD, BCOP,Cindy L. O’Bryant, PharmD, BCOP, FCCP, Sarah Scarpace, PharmD, MPH, BCOP,Steve Stricker, PharmD,MS, BCOP, and James A. Trovato, PharmD,MBA, BCOP, FASHP

AbstractPurposeWith an aging US population, the number of patients who need cancer treatment will

increase significantly by 2020. On the basis of a predicted shortage of oncology physicians,

nonphysician health care practitionerswill need tofill the shortfall in oncologypatient visits,

and nurse practitioners and physician assistants have already been identified for this

purpose. This study proposes that appropriately trained oncology pharmacists can also

contribute. The purpose of this study is to estimate the supply of Board of Pharmacy

Specialties–certified oncology pharmacists (BCOPs) and their potential contribution to the

care of patients with cancer through 2020.

MethodsData regarding accredited oncology pharmacy residencies, new BCOPs, and total BCOPs

were used to estimate oncology residencies, new BCOPs, and total BCOPs through 2020.

A Delphi panel process was used to estimate patient visits, identify patient care services

that BCOPs could provide, and study limitations.

ResultsBy 2020, therewill be an estimated 3,639BCOPs, and approximately 62%of BCOPswill have

completed accredited oncology pharmacy residencies. Delphi panelists came to consensus (at

least 80% agreement) on eight patient care services that BCOPs could provide. Although the

estimatesgivenbyourmodel indicatethatBCOPscouldprovide5to7million30-minutepatient

visits annually, sensitivity analysis, based on factors that could reduce potential visit availability

resulted in 2.5 to 3.5million visits by 2020with the addition of BCOPs to the health care team.

ConclusionBCOPs can contribute to a projected shortfall in needed patient visits for cancer treatment.

BCOPs, along with nurse practitioners and physician assistants could substantially reduce,

but likely not eliminate, the shortfall of providers needed for oncology patient visits.


Original Contribution CARE DELIVERYD

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INTRODUCTIONIn 2005, the American Association of Medical Colleges(AAMC) Center forWorkforce Studies was commissioned bythe American Society of Clinical Oncology (ASCO) to analyzethe oncology workforce in the United States. The Center forWorkforce Studies survey showed that by 2020 there wouldbe a48% increase inpatient visits but only a 14% increase in thesupply of oncologists.1,2 The resulting shortage was estimatedto range between 2,550 and 4,080 oncologists and 9.4 to 15.4millionpatient visitsmissed annually.2,3 Factors believed to beresponsible for this shortage include the increasing elderlypopulation, the increasing incidence of cancer, theincreasing number of survivors of cancer, new complicatedtherapies (eg, oral chemotherapy), the aging oncologyworkforce, and fewer newly trained oncologists.3 A 2014update from ASCO reaffirmed shortages through 2025.4

Furthermore, it was estimated that these numbers couldincrease by approximately 9% as a result of an additional 32million people now insured under the Affordable Care Act.4

Several scenarios have been proposed to resolve theshortage, including training more oncologists and improving

the efficiency of oncology care and the use of nonphysicianpractitioners (NPPs).1,3 Results from the survey showed that56% of oncologists used NPPs in advanced practice roleswithin their practice.3 Advanced practice roles of nursepractitioners and physician assistants consisted of assistingwith new patient consults, ordering routine chemotherapy,and performing invasive procedures. Although it was esti-mated that the use of nurse practitioners and physicianassistants would yield 1.9 to 2.1 million additional patientvisits annually, a deficit of 7.6 to 13.1million of 61million totalvisits was projected by 2020.1,3 The AAMC study did notexamine or mention the position of the oncology pharmacistas an NPP who could potentially reduce the shortage.

Roles of Oncology PharmacistsHolle and Michaud5 discuss the evolving role that oncologypharmacists play in cancer treatment; this article referencedthe oncology scope-of-practice document from the Hema-tology Oncology Pharmacy Association.6 The authors describethe training of oncology pharmacists and highlight core func-tions performed in collaborative practices, including patienteducation, medication teaching, especially oral anticancerdrugs, education of other health care practitioners, devel-opment of therapeutic guidelines, safe handling of medi-cation practices, medication therapy management, prescribing

of specified drugs under an approved protocol, and clinicalresearch. Several other studies have described the role of anoncology pharmacist working in a collaborative practicesetting.7-12Although there aremajor differences in the specialtytraining and skills between nurse practitioners, physicianassistants, and oncology pharmacists, their roles seem to becomplementary and suggest that a team approach couldimprove efficiency of care.

Financial concerns influence the feasibility of addingBCOPs to a care team and are beyond the scope of this study.Although state-level legislation is currently expanding clinicalroles for pharmacists, for example, in California,13 nationallegislation is required to name pharmacists as NPPs and allowfor reimbursement of their services.

Pharmacist Education, Training, and BoardCertificationAccredited Doctor of Pharmacy (PharmD) programs require$ 2yearsofprerequisite college coursework inmathandscience,are generally 4 years in length, focus on medications and theirrelationship to health and illness, and include$ 1 year of clinical

training.Advanced training in the clinical arena has traditionally

occurred through pharmacy residencies. TheAmerican Societyof Health-System Pharmacists (ASHP) accredits pharmacyresidency programs on the basis of rigorous standards.14,15

Currently, ASHP accredits two tiers of residency programs:postgraduate year 1 (PGY1) pharmacy residencies and post-graduate year 2 (PGY2) specialized residencies, which mayinclude oncology.15

Beyond training, pharmacists can demonstrate knowledgein oncologypractice bypassing a Boardof Pharmacy Specialties(BPS) certification examination in oncology, which leads tothe designation BCOP. BPS defines a BCOP as “[a pharmacist]who recommends,designs, implements,monitors, andmodifiespharmacotherapeutic plans to optimize outcomes in patientswithmalignant disease.”16 Eligibility to sit for the BPS oncologyexamination requires completion of a specialty (PGY2) resi-dency in oncology pharmacy; or a PGY1 residency plusan additional 2 years of practice after pharmacist licensurewith$ 50% of the time spent in oncology pharmacy activities;or 4 years of practice experience, after pharmacist licensure,with$ 50% of the time spent in oncology pharmacy activities.16

The combination of a PGY2 oncology residency and BPSoncology certification provides maximum assurance to cre-dentialing committees and others in hospitals, clinics, and


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office-based practices that a BCOP is prepared to participateon the oncology team in a patient care role. Although bothadvanced training and Board certification are important foracceptance into clinical roles, we elected to limit our study tothose pharmacists with BPS oncology certification, the majorityof whom have completed an oncology residency.

The purpose of this study was to estimate available BCOPsthrough 2020, to identify services BCOPs could provide tooncology patients, and to estimate their impact on the patientvisit deficit.

METHODS

Institutional Review Board ReviewThis study received exempt status approval from the TouroUniversity California Institutional Review Board.

Delphi Panel Process and ObjectivesThe Delphi process, which involves using experts to developconsensus through a process of iteration and feedback, was

used for this study because sufficient data were not availableto predict outcomes.17 We used the Delphi process to iden-tify services that BCOPs could most reliably contribute tooncology patient care and to estimate howmany patient visitsBCOPs could provide. Consensuswas defined as$ 80%of thepanel reaching agreement for clinical services and con-vergence of responses for Likert scale items.17

TheDelphi Process included three rounds (see Appendix).Round 1 elicited responses to baseline data regarding BCOPclinical functions, patient visit length, weekly visit numbers,and growth projections for PGY2 oncology residencies, newBCOPs, and total BCOPs through 2020. Comments weresolicited for each category. Round 2 elicited responses to thesame issues after Round 1 feedback was provided as well asresponses to Round 1 comments regarding factors that couldinfluence projections. Round 3 revisited the same issues afterRound 2 feedback. This round was presented in manuscriptform and comments were elicited.

Between rounds, reminder emails were sent at approx-imately 2-week intervals. After 5weeks, feedback on responsesfrom that round was emailed to panelists. Approximately1 week later, the next round was started.

Supply EstimatesData regarding the BCOP workforce from 2008 through 2014were compiled from BPS and ASHP data.18-25 Three variables

were tracked for each year: the number of PGY2 oncologyresidencies filled, the number of new BCOPs, and the totalnumber of BCOPs (Appendix Table A1). These variables werechosen because they reflect the pipeline for oncology practicetraining and known information about the BCOP workforce.For each variable, the size of the cohort was plotted over time.Data about BCOPs attempting recertification were excludedfrom the estimates. In 2014, nine of 41 attempts at recerti-fication were unsuccessful.18 The rationale for not includingthese data were uncertainty regarding whether pharmacistswill recertify at some point and rejoin the BCOP cohort.International BCOPs, however, were included because therewere no reliable data regarding their location or currentlicensure status. Data on the number of BCOPs who wouldleave the workforce through retirement, death, or change ofoccupation were not available.

Time trend equations (linear and nonlinear) were exam-ined for best fit to the data for each of the three variables usingExcel 2007 and SAS (SAS/STAT User’s Guide, Version 9.2;SAS Institute, Cary, NC; SAS OnlineDoc Version 8, Ch 8).

Theequations that resultedwereused toestimate values for

the variables through 2020 by using the SAS AUTOREGprocedure and a maximum likelihood approach. The max-imum likelihood method is generally preferred in favor ofordinary least squares approachwhenworkingwith time seriesdata because it provides more robust handling of autore-gressive errors.26 In addition, linear trend lines were plottedfor the 95% lower and upper confidence limits and wereextrapolated into time as an estimate of likely ranges for eachvariable.

Estimating BCOP Annual Patient Visits Through 2020Annual patient visits were calculated separately for academic-and office-based BCOPs as the AAMC Study found thatoncology physicians in the academic setting saw approx-imately one half as many patients per week as did office-basedphysicians.3 The total annual patient visits were estimatedusing a modified method similar to that used in the AAMCStudy. (Total annual patient visits = [total BCOPs 3 patientvisits per week per BCOP 3 48 weeks 3 0.85] where totalBCOPswere derived fromBPSdata; patient visits perweek perBCOPwas the average reported byDelphi panelists by practicesite [academic v office based]; 48 weeks is the average numberof weeks worked each year; and 0.85 is a correction factortaken from the AAMC study methods that relates to otheractivities that reduce time for patient care, such as drug


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distribution, administrative duties, and teaching.) The sepa-rate estimates for academic- and office-based BCOPs resultedin a range that depended on practice setting.

RESULTS

Delphi Panel CharacteristicsThirteen (87%) of 15 oncology pharmacists who wereinvited to participate in the study accepted the invitation.Characteristics of these panelists are listed in Table 1. Thepanelist response rates for Round 1 and Round 2 were both100%.

BCOP FunctionsTable 2 describes the top 13 services identified through theDelphi process, most of which are tested for in the BCOPcertification exam. Eight services met the consensus cri-terion of being identified by $ 80% of panelists as thosefrequently or often provided by BCOPs. These serviceswere put forth as contributions that BCOPs can reliablymake to oncology patient visits. Three other services werecited by $ 60% of panelists as being offered frequently oroften.

BCOP Patient Visits per WeekDelphipanelists inbothgroupsreported theaverage timespent

per visit as 30 minutes. The high level of agreement regarding

visit length led us to adopt a 30-minute standard for patient

visits inbothsettings.Panelists fromacademicpractice settings

reported 35 pharmacist visits perweek,whereas panelists from

office-based settings reported 47 visits per week, which is

similar to the findings for oncology physicians in the AAMC

study.3 These differences led us to retain two distinct cohorts

in our analyses and projections.The considerable variation in reported patient visits per

week was partially explained by Delphi panel responses.

Panelists who reported the number of visits per week to be

Table 1. Characteristics of Delphi Panelists

Characteristic Description

Practice setting 10 academic, 3 office based

Geographic location States represented by US Census region:

Northeast: Maine, New York (2)

Midwest: None

South: Alabama, Maryland,North Carolina (2), Oklahoma, Texas

West: Arizona, Colorado, Idaho, Oregon

Hold or have heldBCOP status

13 (100%)

Experience, years Median, 16; mean, 16.8 (SD, 9.0)

PGY2 oncologypharmacyresidency

9 of 13 (69%)

PGY1 pharmacyresidency

8 of 13 (62%)

Abbreviations: BCOP, Board-certified oncology pharmacist; PGY1, post-graduate year 1; PGY2, postgraduate year 2; SD, standard deviation.

Table 2. Services Identified by 13 Delphi Panelists asProvided by BCOPs Frequently or Often

Service

Fraction Reporting This ServicePerformed by BCOPsFrequently or Often, (%)

Participating in clinical studies 13 of 13 (100)

Adjusting chemotherapy 12 of 13 (92)

Assessing chemotherapyresponse and/or toxicity

12 of 13 (92)

Managing nausea, vomiting,and antiemetic therapy

12 of 13 (92)

Managing symptoms andproviding supportive care

12 of 13 (92)

Providing patient counselingand education

12 of 13 (92)

Pain management 11 of 13 (85)

Participating inprotocol-based initiatives

11 of 13 (85)

Managing or administeringgrowth factor(s)

10 of 13 (77)

Assisting with newpatient consults*

8 of 13 (62)

Medication reconciliation 8 of 13 (62)

Managing anticoagulationtherapy

6 of 13 (46)

Ordering routinechemotherapy*

5 of 13 (38)

Abbreviation: BCOP, Board-certified oncology pharmacist.*AAMC study lists these advanced practices for physician assistants andnurse practitioners.


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greater than average cited exceptionally busy practices, highdaily census, and longer work days as reasons for the greatervolume. Panelists who reported the number of visits to be lessthan average cited other responsibilities (administrative,academic, and/or student mentoring), only working withspecific patients (new patients receiving chemotherapy oncycle 1), and a lack of a full week coverage on the service asreasons for the lower volume. These patterns are likely topersist. Because of the wide variation in availability, we con-ducted sensitivity analyses at the 75% and 50% availabilitylevels.

PGY2 Oncology Residency, New BCOP, and TotalBCOP Supply DataFigure 1 shows 2008 to 2014 actual values and 2020 pro-jections for three variables. Linear trend lines are shown toreflect the data fit. Figure 1 also shows trend line equations,including the correlation coefficient squared (R2) values.All trend lines are linear. The trend equations were used toproject 2020 estimates for each variable. All projected valuesremainedwithin the extrapolated 95%confidence limit trend

lines.Most panelists agreed or strongly agreed with the pro-

jections in Figure 1: 75% growth for residencies and 62% fornew BCOPs and total BCOPs. The remaining panelists wereneutral (25%, 31%, and 31% respectively) or disagreed orstrongly disagreed (0%, 8%, and 8% respectively). Reser-vations included the lack of knowledge regarding the future

practice locationof internationalBCOPsandwhether employerswould require oncology pharmacists to have a BPS oncologycertification.

Estimated BCOP Annual Patient Visits Through 2020Using AAMC Study methods (see “Estimating BCOP AnnualPatient Visits Through 2020”) for academic or office-basedpractice, an estimated range of approximately 3.0 to 4.0 million30-minute patient visits were available in 2015 and approx-imately 5.0 to 7.0 million in 2020. The possibility of BCOPspracticing only in a hospital setting, outside the United States,totally in administrative roles, and other considerations wouldyield fewer available visits: 2.2 to 3.3 million (2015) and 3.9 to5.2 million (2020) at 75% availability, and 1.5 to 2.0 million(2015) and 2.5 to 3.5 million (2020) at 50% availability. Evenunder these conservative assumptions, the potential exists forBCOPs to substantially decrease the shortfall in patient visits.

DISCUSSION

Delphi Process and Clinical ServicesWe used the Delphi process to identify specific services thatBCOPs could contribute to oncology patient visits. Followingthe recommendation that research that involves the Delphiprocess report the definition of consensus, we arbitrarilychose$ 80% agreement to define consensus.17; however, wenote that several services were frequently or often offered by. 50% of BCOPs and might, therefore, be considered.

2008 2009 2010 2011 2012 2013 2014 2020

Filled PGY2 oncology 40 52 61 78 91 99 113 188

New BCOP 112 122 121 171 171 220 198 303

Total BCOP 860 982 1,103 1,274 1,445 1,665 1,863 3,639

0

500

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1,500

2,000

2,500

3,000

3,500

0

50

100

150

200

250

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350

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ept T

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Year

Filled PGY2s: y = 168.46x + 639.29, R 2 = 0.99New BCOP: y = 18x + 87.286, R 2 = 0.86Total BCOP: y = 12.25x + 27.286, R 2 = 0.99

FIG 1. Filled postgraduate year 2 (PGY2) oncology residency positions, new (first-time) Board-certified oncology pharmacist (BCOP) examination passers, andtotal BCOPs: 2008 to 2014.18-25 Adapted from National Pharmacy Residency Match Data with permission from American Society of Health-SystemPharmacists.



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Despite 10of 13panelists practicing in anacademic setting,there was a high degree of consensus (Table 2) regarding eightclinical services that BCOPs could contribute to oncologypatient care and visits. The list of clinical services could differif the Delphi panel included other practitioners, such asoncologists. Table 2 also illustrates that services for whichBCOPs have training and experience, in some cases, aredistinctly different from those of other NPPs. This findingsuggests that BCOP pharmacists could provide services thatare complementary to those offered by other NPPs and couldexpand the range of services potentially offered by a team. Onthe basis of these findings, we suggest that BCOPs could addvalue to patient care teams.

PGY2 Oncology ResidenciesThe Delphi panel agreed that PGY2 oncology residencypositions will continue to grow and be filled through 2020, afinding that is supported by recent data that, in 2015, 93% ofavailable PGY2 oncology residency positions were filled.27

Panelists cited the increasing competition for residencyprograms as supporting this trend. Increasing numbers of

pharmacists completing PGY2 oncology residencies shouldcontinue to add to the number of potential candidates for theBPS oncology certification examination.

New BCOPsAlthough projections suggest that PGY2 oncology residencesaccount for approximately 62% of new BCOPs annually, esti-mated new BCOPs from 2008 to 2014 are consistently higherthan the number of filled PGY2 residencies. Growth patternssuggest that the BCOP cohort is growing faster than are PGY2residencies. These findings suggest that pharmacists are pur-suing BPS certification with training avenues that are differentthan accredited PGY2 oncology residencies. From the availabledata, we cannot determine how many new BCOPs may havecompleted unaccredited oncology residencies or achieved BPScertification eligibility through practice experience.

Panelists observed that there are factors that work both forand against pharmacists seeking BPS certification in oncology.On one hand, an increasing emphasis on credentialing and thedynamics of team-driven patient care both favor individualpharmacists carrying the highest possible specialty certification.On the other hand, if there is no salary differential or if thepractice site is willing to have pharmacists practice in specialtyareaswithoutBoardcertification,pharmacistsmaychoosetonotpursue the examination or to allow their certification to lapse.

Total BCOPsProjections regarding total BCOPs through 2020 were highlylinear and CIs were fairly narrow, which suggests that these

projections have a solid foundation; however, Delphi pan-

elists noted that international BCOPs were included in the

data sets even though they may not contribute to potential

patientvisits in theUnitedStates. In2014, approximately16%

of the BCOP population was listed by the BPS as being lo-

cated outside the United States.28 Although the rationale for

including them is that BPS does not report licensure data

about exam takers, the inclusion of international BCOPs

likely results in an overestimate of the total BCOP cohort size.

In addition, we could not estimate how many BCOPs would

separate from the workforce through retirement, death, or

change of occupation because these data were not available,

which potentially caused overestimation. We note, however,

that as the BPS oncology certification exam was first offered

in 2005, the BCOP population is relatively young. Thus, the

number leaving the workforce for these reasons would likely

be small.TheAAMCStudy–based formula to estimate visits, which

included an 85% use factor to account for time not spent on

patient visits, predicted 5 to 7million patient visits available by

2020. Sensitivity analysis on the basis of factors that could

further reduce visit availability still resulted in a significant

number of potential visits (2.5 to 3.3 million) by 2020 with the

addition of BCOPs to the health care team.In conclusion, BCOPs can provide clinical services that

could yield a substantial number of patient visits and could

potentially contribute to reducing the shortage of oncology

patient visits. An expert panel came to consensus on eight

clinical services that are performed frequently or often

by BCOPs. These services partially overlap but also comple-

ment the activities and services provided by other NPPs.

The population of BCOPs is expected to continue growing

through 2020, with about 62% of the new BCOP workforce

havingcompletedPGY2oncologypharmacyresidencies.Our

findings suggest that oncology pharmacists could potentially

increase patient visit capacity and couldbe added tootherNPPs

who provide clinical services to oncology patients.

AcknowledgmentThis work was supported by Touro University California. We acknowledge theconsultation of Timothy Tyler, MD, Comprehensive Cancer Center, DesertRegional Medical Center, and Joseph Hill, Director of the Government RelationsDivision and Douglas Schecklehoff, Vice President, Office of PracticeAdvancement, American Society of Health-System Pharmacists. We also thankWilliam Ellis, Executive Director, Board of Pharmacy Specialties.


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Authors’ Disclosures of Potential Conflicts of InterestDisclosures provided by the authors are available with this article atjop.ascopubs.org.

Author ContributionsConception and design: Robert Ignoffo, Katherine KnappCollection and assembly of data: Robert Ignoffo, Katherine Knapp,Mitchell Barnett, Sally Yowell Barbour, SteveD’Amato, Lew Iacovelli, JasenKnudsen, Susannah E. Koontz, Robert Mancini, Dayna McCauley, PatrickMedina, Sarah Scarpace, Steve StrickerData analysis and interpretation: Robert Ignoffo, Katherine Knapp,Mitchell Barnett, Ali McBride, Dayna McCauley, Patrick Medina, Cindy L.O’Bryant, Sarah Scarpace, Steve Stricker, James A. TrovatoManuscript writing: All authorsFinal approval of manuscript: All authors

Corresponding author: Robert Ignoffo, PharmD, FASHP, FCSHP, TouroUniversity California, 1327 Grand Ave, San Rafael, CA 94901; e-mail: [email protected].

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19. Board of Pharmacy Specialties: Board of Pharmaceutical Specialties announcesresults of Spring 2014 certification and recertification exams. http://www.bpsweb.org/2014/07/02/board-of-pharmacy-specialties-announces-results-of-the-spring-2014-certification-and-recertification-exams/

20. Ellis W: Board of Pharmacy Specialties exam results history 2008. http://www.bpsweb.org/specialty-exams/exam-results-history/



23. Board of Pharmacy Specialties: Board of Pharmaceutical Specialties announces resultsof Fall 2011 certification and recertification exams. http://www.pharmacist.com/board-pharmacy-specialties-announces-results-2011-certification-and-recertification-exams

24. Board of Pharmacy Specialties: Board of Pharmaceutical Specialties announcesresults of Fall 2012 certification and recertification exams. http://www.prnewschannel.com/2013/02/26/board-of-pharmacy-specialties-announces-results-of-2012-certification-and-recertification-exams/

25. Board of Pharmacy Specialties: Board of Pharmaceutical Specialties announcesresults of Fall 2013 certification and recertification exams. http://www.workerscompensation.com/compnewsnetwork/news/18338-board-of-pharmacy-specialties%C2%AE-announces-results-of-2013-certification-and-recertification-exams.html

26. SAS Institute Inc. SAS/ETS® 13.2 User’s Guide: High-Performance Procedures.Cary, NC, SAS Institute, 2014

27. American Society of Health-System Pharmacists: ASHP resident matchingprogram. https://www.natmatch.com/ashprmp/aboutstats.html

28. Board of Pharmacy Specialties: Certification stats by location. http://www.workerscompensation.com/compnewsnetwork/mobile/news/18338-board-of-pharmacy-specialties%C2%AE-announces-results-of-2013-certification-and-recertification-exams.html



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http://jop.ascopubs.orgmailto:[email protected]:[email protected]://www.asco.org/sites/default/files/oncology_workforce_report_final.pdfhttp://www.asco.org/sites/default/files/oncology_workforce_report_final.pdfhttp://dx.doi.org/10.1200/JOP.2014.001386http://dx.doi.org/10.1200/JOP.2014.001386http://www.hoparx.org/uploads/files/2013/HOPA13_ScopeofPracticeBk.pdfhttp://www.ashp.org/menu/News/PharmacyNews/NewsArticle.aspx?id=2310http://www.ashp.org/menu/News/PharmacyNews/NewsArticle.aspx?id=2310http://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201320140SB493http://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201320140SB493http://www.ashp.org/doclibrary/accreditation/newly-approved-pgy1-standard-september-2014.pdfhttp://www.ashp.org/doclibrary/accreditation/newly-approved-pgy1-standard-september-2014.pdfhttp://www.ashp.org/doclibrary/accreditation/newly-approved-pgy1-standard-september-2014.pdfhttp://www.ashp.org/DocLibrary/Accreditation/PGY2-Residency-Accreditation-Standard.pdfhttp://www.ashp.org/DocLibrary/Accreditation/PGY2-Residency-Accreditation-Standard.pdfhttp://www.bpsweb.org/bps-specialties/oncology-pharmacy/http://www.bpsweb.org/bps-specialties/oncology-pharmacy/http://www.bpsweb.org/2014/12/04/board-of-pharmacy-specialties-announces-results-of-fall-2014-certification-and-recertification-exams/http://www.bpsweb.org/2014/12/04/board-of-pharmacy-specialties-announces-results-of-fall-2014-certification-and-recertification-exams/http://www.bpsweb.org/2014/12/04/board-of-pharmacy-specialties-announces-results-of-fall-2014-certification-and-recertification-exams/http://www.bpsweb.org/2014/07/02/board-of-pharmacy-specialties-announces-results-of-the-spring-2014-certification-and-recertification-exams/http://www.bpsweb.org/2014/07/02/board-of-pharmacy-specialties-announces-results-of-the-spring-2014-certification-and-recertification-exams/http://www.bpsweb.org/2014/07/02/board-of-pharmacy-specialties-announces-results-of-the-spring-2014-certification-and-recertification-exams/http://www.bpsweb.org/specialty-exams/exam-results-history/http://www.bpsweb.org/specialty-exams/exam-results-history/http://www.bpsweb.org/specialty-exams/exam-results-history/http://www.bpsweb.org/specialty-exams/exam-results-history/http://www.bpsweb.org/specialty-exams/exam-results-history/http://www.bpsweb.org/specialty-exams/exam-results-history/http://www.pharmacist.com/board-pharmacy-specialties-announces-results-2011-certification-and-recertification-examshttp://www.pharmacist.com/board-pharmacy-specialties-announces-results-2011-certification-and-recertification-examshttp://www.prnewschannel.com/2013/02/26/board-of-pharmacy-specialties-announces-results-of-2012-certification-and-recertification-exams/http://www.prnewschannel.com/2013/02/26/board-of-pharmacy-specialties-announces-results-of-2012-certification-and-recertification-exams/http://www.prnewschannel.com/2013/02/26/board-of-pharmacy-specialties-announces-results-of-2012-certification-and-recertification-exams/http://www.workerscompensation.com/compnewsnetwork/news/18338-board-of-pharmacy-specialties%C2%AE-announces-results-of-2013-certification-and-recertification-exams.htmlhttp://www.workerscompensation.com/compnewsnetwork/news/18338-board-of-pharmacy-specialties%C2%AE-announces-results-of-2013-certification-and-recertification-exams.htmlhttp://www.workerscompensation.com/compnewsnetwork/news/18338-board-of-pharmacy-specialties%C2%AE-announces-results-of-2013-certification-and-recertification-exams.htmlhttps://www.natmatch.com/ashprmp/aboutstats.htmlhttp://www.workerscompensation.com/compnewsnetwork/mobile/news/18338-board-of-pharmacy-specialties%C2%AE-announces-results-of-2013-certification-and-recertification-exams.htmlhttp://www.workerscompensation.com/compnewsnetwork/mobile/news/18338-board-of-pharmacy-specialties%C2%AE-announces-results-of-2013-certification-and-recertification-exams.htmlhttp://www.workerscompensation.com/compnewsnetwork/mobile/news/18338-board-of-pharmacy-specialties%C2%AE-announces-results-of-2013-certification-and-recertification-exams.htmlhttp://www.workerscompensation.com/compnewsnetwork/mobile/news/18338-board-of-pharmacy-specialties%C2%AE-announces-results-of-2013-certification-and-recertification-exams.htmlhttp://jop.ascopubs.org

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Board-Certified Oncology Pharmacists: Their Potential Contribution to Reducing a Shortfall in Oncology Patient Visits

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships areself-held unless noted. I = Immediate Family Member, Inst =My Institution. Relationships may not relate to the subject matter of this manuscript. For moreinformation about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or jop.ascopubs.org/site/misc/ifc.xhtml.

Robert IgnoffoNo relationship to disclose

Katherine KnappNo relationship to disclose

Mitchell BarnettNo relationship to disclose

Sally Yowell BarbourConsulting or Advisory Role: Amneal, Hospira, Sunesis PharmaceuticalsTravel, Accommodations, Expenses: Tesaro

Steve D’AmatoHonoraria: Merck, Takeda Pharmaceuticals, Eli Lilly, Celgene, Amgen,GenentechConsulting or Advisory Role: ION Pharma, Eli Lilly, CelgeneSpeakers’ Bureau: Merck, Takeda Pharmaceuticals, Eli Lilly, Celgene,Amgen, Genetech

Lew IacovelliConsulting or Advisory Role: Bristol-Myers Squibb, Amgen, Celgene,Takeda Pharmaceuticals, Gilead Sciences, IncyteSpeakers’ Bureau: Bristol-Myers Squibb, Amgen, Celgene, TakedaPharmaceuticals, Gilead Sciences, Incyte

Jasen KnudsenNo relationship to disclose

Susannah E. KoontzHonoraria: BTG InternationalConsulting or Advisory Role: Sigma-Tau Pharmaceuticals, Amgen

Robert ManciniSpeakers’ Bureau: Millennium Pharmaceuticals, Pfizer

Ali McBrideNo relationship to disclose

Dayna McCauleyNo relationship to disclose

Patrick MedinaNo relationship to disclose

Cindy L. O’BryantConsulting or Advisory Role: Amgen, Reata PharmaceuticalsSpeakers’ Bureau: AmgenResearch Funding: Pfizer, Bayer AG, AstraZenecaTravel, Accommodations, Expenses: Amgen

Sarah ScarpaceSpeakers’ Bureau: Eli Lilly, Pfizer, Merck

Steve StrickerSpeakers’ Bureau: Millenium PharmaceuticalsTravel, Accommodations, Expenses: Millenium Pharmaceuticals

James A. TrovatoNo relationship to disclose

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http://www.asco.org/rwchttp://jop.ascopubs.org/site/misc/ifc.xhtml

AppendixDelphi Panel Process and Objectives

For this study, a Delphi process was used to identify services that Board-certified oncology pharmacists (BCOPs) could most reliably

contribute to oncology patient care and to estimate how many patient visits BCOPs could provide. Delphi processes involve the use of

experts to develop consensus through a process of iteration and feedback.1,3,4 Experts provide responses to questions and/or problems that

are shared with fellow experts. Generally, consensus develops as questions and feedback go through a series of iterations or rounds. The

Delphi process is particularly useful when sufficient data are not available to predict outcomes.15 For the purpose of this study, consensus

was defined as $ 80% of the panel reaching agreement for clinical services and convergence of responses for Likert scale items.16

Fifteen oncology pharmacists, recognized as leaders in the field, were invited to serve as Delphi panelists. The Delphi process was

explained to the potential panelists before beginning the iterative process.

Round 1

A Round 1 survey asked each panelist to respond to questions in four sections.

Section 1.1. The frequency of BCOP activity (frequently, occasionally, and rarely/never) for the three services: assisting with new patient

consults, ordering routine chemotherapy, and performing invasive procedures. These services were identified in the American

Association of Medical Colleges Study as clinical contributions that nonphysician practitioners could make.3

Section 1.2. Other activities and functions that BCOPs could contribute to oncology patient care were reported as open-ended comments.

Section 1.3. The estimated length of an average patient visit and the estimated number of patient visits each week. On the basis of the

American Association of Medical Colleges Study, panelists were asked to identify their practice site as academic or office based.

Section 1.4. The level of agreement with the estimated supply projections for postgraduate year 2 oncology residencies, new BCOPs, and

the total BCOP workforce. Panelists responded with open-ended comments. The comments were used to identify limitations of the

study.

Reminder e-mails were sent to panelists at approximately 2-week intervals. After 5 weeks, responses from Round 1 were compiled,

summarized, and sent to the panelists for their review.

Round 2

A second survey (Round 2) was sent approximately 3 weeks after panelists received the results of Round 1. The goal of the Round 2 survey

was to develop consensus around Round 1 responses. This survey included four sections.

Section 2.1. The goal for this section was to develop a consensus list of services that BCOPs performed frequently or often. During

Round 1, panelists were given the opportunity to comment on the vocabulary describing services, and these comments were shared

in the Round 1 report. This was done to facilitate a common understanding of what each service entailed. We used the comments to

refine the description of each service. In the final list, we combined the three services from Section 1.1 (Round 1) with an additional

12 services most often mentioned in Section 1.2 responses (Round 1). The functions were listed in alphabetical order. Panelists were

asked to answer yes/no to each of the 15 services on the basis of whether that function was frequently or often performed by BCOPs.

Section 2.2. The goal for this section was to develop a better understanding of the variability of average number of visits weekly in Round

1. Panelists were asked to identify their practice setting as academic or office based, and on the basis of comparing their patient visits

per week with average values for visits to comment on why their estimates were different from the average.

Section 2.3. The goal of this section was to measure consensus regarding the Round 1 comments on projections regarding the future

supply of postgraduate year 2 oncology residencies, new BCOPs, and total BCOPs. Panelists were asked to indicate their level of

agreement with the supply projections for each of the three variables and with three limitations related to interpreting the data

using a five-point Likert scale (strongly agree, agree, neutral, disagree, strongly disagree). The limitations were drawn from panelist

comments. Lastly, the panelists were offered the opportunity to comment on their responses.

Round 2 reminder e-mails were sent to panelists at approximately 2-weeks intervals. After approximately 5 weeks, responses from Round

2 were compiled, summarized, and sent to the panelists for their review. A description of the study, including results and discussion, was

prepared and panelists were invited to review and comment on the final report. Panelists who elected to participate in the last step were invited

to coauthor the paper.

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Table A1. Projections for Three Variables on the Basis of Data From 2008 to 2014

Year

Estimated Filled PGY2Residency Positions(extrapolated 95% CI)

Estimated New BCOPs(extrapolated 95% CI)

Estimated Total BCOP(extrapolated 95% CI)

2015 126 (124 to 127) 213 (186 to 278) 2,081 (1,927 to 2,665)

2016 138 (137 to 139) 231 (209 to 294) 2,325 (2,212 to 2,870)

2017 151 (150 to 152) 249 (232 to 310) 2,599 (2,299 to 3,075)

2018 163 (162 to 164) 267 (255 to 326) 2,907 (2,484 to 3,280)

2019 176 (173 to 178) 285 (278 to 342) 3,252 (2,670 to 3,486)

2020 188 (185 to 192) 303 (301 to 357) 3,639 (2,855 to 3,691)

Abbreviations: BCOP, Board-ceritfied oncology pharmacist; PGY2, postgraduate year 2.

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jopr008490recap.pdfBoard-Certified Oncology Pharmacists: Their Potential Contribution to Reducing a Shortfall in Oncology Patient Visits

jopr008490.pdfBoard-Certified Oncology Pharmacists: Their Potential Contribution to Reducing a Shortfall in Oncology Patient VisitsINTRODUCTIONRoles of Oncology PharmacistsPharmacist Education, Training, and Board Certification

METHODSInstitutional Review Board ReviewDelphi Panel Process and ObjectivesSupply EstimatesEstimating BCOP Annual Patient Visits Through 2020

RESULTSDelphi Panel CharacteristicsBCOP FunctionsBCOP Patient Visits per WeekPGY2 Oncology Residency, New BCOP, and Total BCOP Supply DataEstimated BCOP Annual Patient Visits Through 2020

DISCUSSIONDelphi Process and Clinical ServicesPGY2 Oncology ResidenciesNew BCOPsTotal BCOPs

AcknowledgmentReferencesAppendix

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