Transcript Cost Analysis: Intrathecal Drug Therapy

Role of Intrathecal
Polyanalgesia- Its Cost Impact
and Role in Recapturing Pain
Control
Dr. Krishna Kumar, M.B., M.S., F.R.C.S. (C), F.A.C.S.
Syed Rizvi
Sharon Bishop BNurs., MHlthSci.
Objective
• Practice is changing: increasing use of
polyanalgesia
• Which patient groups require monotherapy vs
polyanalgesia?
• When is the introduction of a second agent
indicated?
• The cost implication of polyanalgesia and does it
pay off with improved pain control?
Study Design
• We present a retrospective study of 110 patients
receiving IDT for treatment of spasticity and CNMP
110
patients
Mean IDT
duration:
94.2
months
Chronic
Pain: 81
Spasticity:
29
Males: 62
Females:
48
IDT Drug Regimens
Monotherapy:
110 patients
63:
monotherapy
Avg 500 days
47: dual-drug
admixture
Avg 79 days
51: same drug
12: different
drug
Avg 240 days
36: dual-drug
admixture
11: triple-drug
admixture
43% of patients require polyanalgesia
Relationship between IDT & Pain Type
Monotherapy (morphine or hydromorphone)
• Nociceptive
Dual-drug therapy (morphine or hydromorphone) +
(bupivacaine or ropivacaine)
• Mixed
Triple-drug therapy
(fentanyl or hydromorphone) + baclofen + bupivacaine
• Neuropathic + spasticity (± myclonus)
Monotherapy: Morphine Dosage Escalation
20
18
16
14
12
10
Mean dose (mg) /day
VAS
8
6
4
2
0
# of patients
7
Baseline
-1
0
20
20
1
2
16
13
12
3
4
5
Time (years)
10
6
Monotherapy- Morphine
9
7
8
Dual-admixture dosage escalation
eg. Hydromorphone+Bupivacaine
9
8
7
6
Mean dose per day
5
dilaudid (mg)
bupivacaine (mg)
VAS
4
3
2
1
0
# of patients
-2
Monotherapy
-1
9
0
9
9
8
1
2
3
Time (years)
8
4
6
5
6
In most cases, patients are able to reduce narcotic doses and
restore effective pain control
Comparison Pain relief
10
9
8
7
VAS
6
monotherapy
dual-drug admixture
triple-drug admixture
5
4
3
2
1
0
Baseline
-2
-1
0
1
2
3
4
5
Time (years)
6
7
8
Prior to initiating IDT patients were reporting high
levels of pain
Trends in Polyanalgesia
Prescribing trends have changed over time
• Patients implanted pre-2004
▫ Initiated dual-drug admixture at 28.01 months (average)
▫ Avg. Time DiagnosisIDT: 6.23 years
COMPARED TO
• Patients implanted post-2004
▫ Initiated dual-drug admixture at 5.38 months (average)
▫ Avg. Time DiagnosisIDT: 4.56 years
On average patients implanted post 2004 reported 30% better
pain relief at the 5 year mark when compared to those pre
2004.
VAS score
Pain Relief: Dual Drug Therapy Subgroup
Comparison
10
9
8
7
6
5
4
3
2
1
0
pre-2004
post-2004
Monotherapy
-2
-1
0
1
2
3
4
5
Time (years)
6
7
8
Subgroup Analysis: Pain Relief
9
Oral Analgesia: Post IDT
• 20 (18%) patients discontinued the usage of oral
narcotics
• The remainder of patients used low dose oral
narcotics daily to manage breakthrough pain:
Typical: hydromorphone 4-7 mg BID
Morphine IR 10 mg BID
IDT Monotherapy: Average Daily Drug Costs
$12.00
$11
$10.00
$8.00
$7
IDD ($/day)
CPT ($/day)
$6.00
$4.00
$2.97
$3.25
$2.84
$3
$2.00
$0.00
morphine
hydromorph
dilaudid
baclofen
Comparative Costs
C2-TREND Chart
At 10 years compared to monotherapy
35.0
•Dual-drug therapy: 27% higher cost
C ost per day ($)
C8-TREND Chart
C5-TREND Chart
26.3
35.0
•Triple-drug therapy: 54% higher cost
35.0
C11-TREND Chart
44.0
26.3
26.3
33.0
17.5
Conventional Pharmacotherapy
22.0
17.5
Triple-drug IDT
11.0
Dual-drug IDT
8.8
8.8
8.8
0.0
0.9
0.0
0.0 0.9
0.9
0.0
0.9
3.4
5.9
8.4
10.9
3.4
5.9
8.4
10.9
3.4
5.9
8.4
10.9
3.4
5.9
8.4
10.9
Single-drug IDT
Time (years)
ARIMA (Autoregressive Intermediate Moving Average) model
Conclusion
• Over the longterm
▫ IDT monotherapy is effective in 57% of cases
▫ Dual drug admixtures were required in 33% of
cases, triple drug admixtures in the remaining 10%
▫ Polyanalgesia escalates the average daily cost (20200% depending on the drugs used)
▫ Polyanalgesia is effective in restoring decay in pain
control
▫ It appears better results are achieved when
polyanalgesia is initiated earlier in treatment
planning (30% better pain control at 5yrs)