Applying the concept of "Lean Management": evaluation of a pioneer off-site injection program for androgen deprivation treatment of prostate cancer

Purpose: Due to the large number of prostate cancer patients who require androgen deprivation therapy (ADT), and the frequent monthly administration of a new gonadotropin-releasing hormone (GnRH) antagonist, our province pioneered off-site injection programs in Regina, which is the first of its kind in Canada.  The objective is to decentralize services out of the acute care setting.  We aimed to assess the acceptance and challenges of such programs and hypothesized that the off-site program is feasible.

Materials and Methods: Nurses in “community oncology program of Saskatchewan” (COPS) of major rural hospitals, designated drug stores and home injection programs are trained by the nurses of the two tertiary cancer clinics in Regina and Saskatoon. In Regina since 2012, nurses hired by drug companies run off-site injection programs in a few community clinics or drug stores. Patients who have difficulty going to the injection clinics would receive home injections from these nurses. These programs are paid by the drug companies to relieve the workload of nurses in the cancer clinic in Regina. Cancer clinic physicians inform drug companies or COPS by fax who and when should ADT be given, with written consent of patients regarding the process. Drug company staff coordinates the timing of the injection by calling patients with appointment for injection at the assigned sites. Oncologists are given feedback by telehealth follow up of rural patients regarding side effects and compliance or by faxed reports from company nurses. The cancer clinic pharmacy generated a list of all patients on ADT for the arbitrarily chosen year 2014, from which 60 patients were randomly selected for detailed incident data collection. No specific quantification tool was used; feedback was based on nurse reports and telehealth follow-up.

Results: According to our pharmacy records in 2014, 662 patients were on ADT.

Rural patients appreciate care at a closer facility. Miscommunication with home injection services resulted in no show of nurses for three home injections. In one instance a patient declined injection till clarification with the physician about the necessity to change the brand of ADT. One of the rural COPS sites was noted to have more local skin reactions after injection. The nurses there were retrained. Our experience after 4 years found that notification faxes had to be sent one week prior to injection to provide enough time for processing. One patient missed injection since he was mentally challenged and forgot the date. There are advantages of the program not realized before. The program was particularly welcome by “snowbird” patients traveling to the United States carry drugs dispensed from the cancer clinic pharmacy to American injection sites and later drug companies reimburse them the injection fees. The prostate-specific antigen (PSA) was easily monitored as the nurses reminded patients to do this. A particular rural hospital was found to have more drug reactions due to improper injection techniques. The sales representative went to the hospital again and retrained the nurses. Due to communication breakdowns, a few lapses occurred in reordering degarelix and scheduling injection appointments.

Conclusions: The program benefits patients, nurses and oncologists. The COPS in major rural hospitals provide care for patients in their drainage area.  It runs smoothly now.  Notification faxes must be sent at least one week prior to injection to allow sufficient time for processing. Improving communication with patients, family doctors and drug companies will further enhance the program. The idea of decentralization of services to free up resources in acute care clinics/hospitals is important in delivery of care.

Lorent Sijarina, MD, graduated from the University of Prishtina, Faculty of Medicine. He actively participates in international research collaborations and is mentored by Professor Patricia Tai, a world- renowned expert in oncology. With a strong commitment to evidence-based practice and global health, Lorent strives to contribute to the advancement of medicine through clinical research, innovation, and interdisciplinary collaboration. His goal is to help improve healthcare outcomes and promote scientific excellence on a global scale.