Transcript Hospice Pharmaceutical Care 2015 and Beyond

Getting Medications Right For
Your Patients and Your Program
Lorin Yolch, PharmD, CGP, FASCP
Washington State Hospice & Palliative Care
Organization
Cumulative Impact of CMS Reform
The cumulative impact will almost certainly
wreak havoc on hospice service models and will
heavily influence quality of care unless funds are
made up by reducing costs or increasing
revenue with the latter being a tougher
assignment in most cases….
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Direct Costs
“Anything associated with direct care”
Medication Costs
Supplies
DME
Salaries
Nursing, Aides, SW, Chaplain….
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Indirect Costs
Supportive costs such as marketing,
administrative salaries, information
management supplies, utilities, rent, staff
education, depreciation, etc…
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For example
ADC 100, patient days = 37,000
Net patient revenue $6,000,000.
Experiences remainder of the 2% per year
scheduled CMS cuts through 2019:
The hospice may experience an approximate
$120,000 less in reimbursement per year
totaling $480,000 K over the next 4 years (2019)
The 2% sequester will continue indefinitely…
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There is Good News…
Medication costs CAN be reduced!
Let’s discuss how to do this through a
comprehensive Pharmaceutical Care initiative
for your hospice.
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Pharmaceutical Care
The direct, responsible provision of medicationrelated care for the purpose of achieving
definite outcomes that improve a patients
quality of life.
Medication related + Care related + Outcome related
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Medication related
Includes decision to or not to use medications as
well as judgements regarding medication
selection, dose, route, frequency and method
of administration plus patient education.
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Care related
The pharmacist providing direct personal
concern (i.e. care) for the well-being of another
person just as nursing and medicine does.
Integrated, collaborative and cooperative
domains of care including medical care, nursing
care and pharmaceutical care.
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Outcome related
• Identifying potential and actual medicationrelated problems
• Resolving actual medication-related problems
• Preventing potential medication-related
problems
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Quality Use of Medicine Framework
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6.
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10.
Ascertain current medications
Identify patients at high risk of or experiencing ADE
Estimate life expextancy of high risk patients
Define overall care goals in context of life expectancy
Define and confirm current indications for ongoing treatment
Determine the time until benefit for disease modifying medications
Estimate the magnitude of benefit versus harm for each medication
Review the relative utility of each medication in use
Identify drugs which may be discontinued
Implement and monitor a drug utilization plan
Medication-related problems
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Untreated indication
Improper medication selection
Subtherapeutic dosage
Failure to receive medication
Overdosage
Adverse drug reaction
Drug–Drug and Drug-Food Interaction
Medication use without an indication
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CMS F Tag 329
“Unnecessary Medications”
1.Excessive Dose or Duplicate Therapy
2.Excessive Duration
3.Medication Given Without Adequate Indication For
Use
4.Medication Given Without Adequate Monitoring
5.Presence of Adverse Consequences Which Indicate
The Dose Should Be Reduced or Discontinued
6.Any Combination of the Reasons Above
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Hospice CoPs 2008
• Defined the role of the pharmacist for
Hospice.
• As an industry, have we met the CoPs ?
• Let’s take a look at select sections…
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Medicare Part D & Hospice
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Was reform necessary?
Has continuity improved?
Have outcomes improved?
Medicare Part D reform affirmed the right of
hospices to use a formulary and resulted in
approximately 25% increase in the cost of
medications for the hospice industry.
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Medication Cost
What is cost?
Cost is defined by the buyer!
Pharmacy
Hospice
Cost is NOT average wholesale price !
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Are Medication Costs Rising?
Yes, at rates never seen before….
Brand name medications:
Generic medications:
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Why Medication Prices Are Rising
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Industry consolidation
Drug shortages
Raw material shortages
Unanticipated demand
Manufacturing difficulties
Regulation
Business and economic issues
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Medication Price Increases
Medication
Approximate Hospice Cost
2013
Approximate Hospice Cost
2015
Amitriptyline 100mg Tablet $4.00
$91.00
Atropine Opth. Soln 1%-5
$21.00
$9.00
Erythromycin Estolate Susp $25.00
400 mg/5ml; 240 ml
$350.00
Morphine 60 mg ER; #100
$75.00
$125.00
Morphine 20 mg/ml; 30ml
$9.00
$18.00
Nystatin Susp 100,000 U
240 ml
$25.00
$42.00
Oxycodone 20 mg/ml;30ml $57.00
$284.00
Tetracycline 250 mg cap
#100
$236.00
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$3.50
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Necessary Hospice Infrastructure
Pharmacotherapeutic Support System
3 Essential Components:
a. Pharm D
b. Preferred Drug List
c. Pharmacy & Therapeutics Committee
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PharmD
“My Hospice can’t afford to hire a pharmacist!”
Really?
“Your Hospice can’t afford not to hire a
pharmacist!”
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Hospice PDL
Composed by symptom and by medication.
Must be a dynamic document!
⏏Update quarterly!
Patient specific!
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P & T Committee
Multidisciplinary hospice stakeholders meet on a scheduled
basis to oversee all issues relative to hospice medication use.
• Adding or deleting medications from PDL
• Adverse drug reaction reporting
• e-Prescribing protocol
• Medication diversion and error review
• Medication cost per patient day
• Patient education tools
• Pharmacy QA
• Symptom management algorhythms
• Therapeutic interchange
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Hospice Preferred Drug List
Please see sample provided
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Therapeutic Categories That
Matter The Most
• Antiemetics
– Olanzapine (Zyprexa®)
– Select “older” medications are now $$$$
• Prochlorperazine suppositories (Compazine®)
• Promethazine suppositories (Phenergan®)
• Anitipsychotics
– Typical
• Chorpromazine (Thorazine®)
– Atypical
• Opioids
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Target Drugs
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Benzonatate capsules
Doxycycline Hyclate
Dronabinol
Fentanyl IR (not transdermal!)
Hydrocodone SR
Hydromorphone SR
Inhalers - all
Memantine
Megestrol Acetate
Mupirocin
Oxycodone CR and concentrate 20 mg/ml
Phenobarbital IV
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Benchmark Medication Costs
• National PPD goal = $8.00
– Post Medicare Part D reform = $10.00 ?
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Goal Opioid Utilization for Hospice
Opioid
Buprenorphine
Codeine
Fentanyl
Hydromorphone
Morphine
Methadone
Oxycodone
Oxymorphone
Hydrocodone SR
Tramadol
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% Utilization
0
0
20
15
30
20
10
0
0
5
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Separating “Good From Great”
Great management of PDL = medication cost
PPD of $6.00 or less.
Good = $8.00 or less.
Ask what is different.
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Benchmarking Hospice Performance
Drug
Hospice A Hospice B
PPD < $6 PPD < $8
Hospice C
PPD <
$10
Hospice D Target
PPD <
Drug
$12
Unique
Drug
Formulary
Status
“Inhalers”
$265.00
$350.00
$2,350.00
$3,300.00
Yes
Yes
No
Methadon
e
$910.00
$628.00
$550.00
$ 35.00
Yes
Yes
Yes
Fentanyl
Transderm
$401.00
$650.00
$1,935.00
$6,200.00
No
No
Yes
Morphine
IR + CR
$3,800.00
$2600.00
$3,018.00
$1,700.00
No
No
Yes
Memantine
$152.00
$711.00
$1,425.00
$1510.00
Yes
Yes
No
Oxycodone
20 mg/ml +
SR
1,000.00
$1,900.00
$1975.00
$2825.00
Yes
No
IR Tabs
Only
Hydromorphone
$225.00
$0.00
$0.00
$310.00
Yes
No
No
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Oral Morphine Equivalents
Please see handout provided
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Adverse Drug Reaction Reporting
Required by JCAHO!
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ADR Predictors
Predictors of ADRs in the Elderly
Taking more than four medications*
Longer than 14-day hospital stay
Having more than four active medical
problems
General medical unit admission instead
of a geriatric ward
Two to four new medications added
during a hospitalization
Lower Mini-Mental State Exam score
Alcohol use history
Use of certain medications (diuretics,
NSAIDs, antiplatelets, digoxin)*
Older Age*
Comorbidities*
* Indicates predictors for severe ADRs
Lee JK, Mendoza DM, Mohler, MJ, Morris, SJ. Geriatrics. In: DiPiro JT, Talbert RL, Yee GC, et al., eds.
Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York City: McGraw-Hill; 2011:7-21.
Preventing ADRs
Strategies to Prevent ADRs in the Elderly
Evaluate comorbidities, frailty, and
cognitive function
Identify caregivers to take responsibility
for medication management
Evaluate renal function and adjust doses
Monitor drug effects
Recognize that clinical signs or symptoms
can be an ADR
Minimize the number of medications
prescribed (combination products)
Adapt treatment to patient’s life
expectancy
Realize that self-medication and
nonadherence are common and can lead
to ADRs
Lee JK, Mendoza DM, Mohler, MJ, Morris, SJ. Geriatrics. In: DiPiro JT, Talbert RL, Yee GC, et al., eds.
Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York City: McGraw-Hill; 2011:7-21.
ADRs in the Elderly
• Be careful when drugs that alter cognition are
prescribed (antipsychotics, benzodiazepines,
antiarrhythmics, opioids, etc.)
• Falls can be one of the most damaging ADRs
– Increase mortality
– Strong association with benzodiazepines,
antidepressants, and antipsychotics
Lee JK, Mendoza DM, Mohler, MJ, Morris, SJ. Geriatrics. In: DiPiro JT, Talbert RL, Yee GC, et al., eds.
Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York City: McGraw-Hill; 2011:7-21.
e-Prescribing Protocol
e-Prescribing of controlled substances, including
CII’s is now legal in all 50 states.
2015: 4 million e-Rx’s for controlled substances
thus far!
Regulations may vary, state by state.
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Medication Diversion & Error Review
• Individual states are now imposing new
regulations aimed at preventing diversion of
opioids from the home of hospice patients.
– Example: State of Virginia now requires hospice to
report patient death to the distributing pharmacy
of record.
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Nonadherence
• Elderly patients are at an increased risk for
medication non-adherence
• Barriers to adherence
– Lack of understanding/provider education
– Inconvenience
– Polypharmacy
– Complex regimens
– Treatment of asymptomatic conditions
– Cost
Lee JK, Mendoza DM, Mohler, MJ, Morris, SJ. Geriatrics. In: DiPiro JT, Talbert RL, Yee GC, et al., eds.
Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York City: McGraw-Hill; 2011:7-21.
Medication Nonadherence Factors
3+ chronic conditions
Living alone
5+ chronic medications
Recent hospital discharge
Increased dosing frequency (TID or more
than 12 doses/day)
Reliance on a caregiver
4+ medication changes in the last year
Low literacy level
3+ prescribers
Medication costs
Significant cognitive or physical
impairments
History of medication nonadherence
Lee JK, Mendoza DM, Mohler, MJ, Morris, SJ. Geriatrics. In: DiPiro JT, Talbert RL, Yee GC, et al., eds.
Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York City: McGraw-Hill; 2011:7-21.
Assessing Nonadherence
1. How do you take your
medications?
2. How do you organize
your medications?
3. How do you schedule
your meal and
medication times?
4. How do you pay for
your medications
5. How do you think the
medications are working
for your condition?
6. How many times in the
last week/month have you
missed a dose?
Lee JK, Mendoza DM, Mohler, MJ, Morris, SJ. Geriatrics. In: DiPiro JT, Talbert RL, Yee GC, et al., eds.
Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York City: McGraw-Hill; 2011:7-21.
Improving Adherence
• Patient education
• Making dosing
regimens more
convenient
• Serial follow-up with
patients
• Must keep in mind
specific belief-related
variables for each
patient
– Personal
– Cultural
Lee JK, Mendoza DM, Mohler, MJ, Morris, SJ. Geriatrics. In: DiPiro JT, Talbert RL, Yee GC, et al., eds.
Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York City: McGraw-Hill; 2011:7-21.
Patient Education Tools
• Hospice patient population medication
specific written material left in the home for
patient and care giver education.
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Pharmacy QA
• Pharmacy dispensing error reporting
• Patient satisfaction
• Nurse satisfaction
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Therapeutic Interchange
Defined as the dispensing of a drug that is
therapeutically equivalent to but chemically different
from the drug originally prescribed by a physician or
other authorized prescriber.
Example: Substitution of ipratropium bromide
inhalation solution(Atrovent)® for Spiriva® or Tudorza®
Example: Substitution of oral prednisone 10 mg per day
for Pulmicort® nebulization solution.
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Therapeutic Interchange
• Although usually of the same pharmacologic
class, drugs appropriate for therapeutic
interchange may differ in chemistry or
pharmacokinetic properties, and may possess
different mechanism of action, adversereaction, toxicity, and drug interaction
profiles.
• In most cases, the interchanged drugs have
close similarity in efficacy and safety profiles.
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Symptom Management
Algorhythms
Please see sample provided
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Pharmacology in End-of-Life Care
Olanzapine (Zyprexa®)
The replacement for haloperidol?
Why?
Olanzapine = Ondansetron(Zofran®) + haloperidol !
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Pathophysiology
of nausea / vomiting
Chemoreceptor
Trigger Zone (CTZ)
Vomiting Center
Neurotransmitters
 Serotonin
 Dopamine
 Acetylcholine
 Histamine
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Cortex
Vestibular
Apparatus
GI Tract
EPEC Project 1999
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Intestinal
distension
Abdominal
Radiotherapy
Opioids,
Digoxin
Raised
Intracranial
pressure
Hypercalcemia/
Uremia
Cytotoxic
Chemotherapy
Gastric
irritants
Fear/
Anxiety
Movement/
Vertigo
Clonidine
?
5HT3
Gut Wall
5HT3
D2
ά2
Chemoreceptor Trigger
Zone
Cerebral Cortex
GABA
5HT
Vestibular nuclei
AChm
H1
AChm =anticholinergics
Vomiting Center
5HT=serotonin type 2,3,&
undefined
D2=dopamine type 2
H1 =histamine type 1
GABA=gammaaminobutyric acid
ά2 = alpha adrenergic type
2
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AChm
H1
Μu-opioid
5HT2
Gastric atony
Retroperistalsis
Thoracic & abdominal muscle contractions
Palliative Care Pocket Consultant 2001
Modified from Twycross et al., 1997
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The Top 3 EOL Care Comorbidities
Metabolic Syndrome (Diabetes et al)
COPD
Heart Failure
Metabolic Syndrome
Any 3 criteria from the list below:
Hyperglycemia
Hypertension
Hypertriglyceridemia
HDL-C(Men < 40 mg/dL; Women < 50 mg/dL)
Waist circumference > 40” (men) &
> 35” (women)
EOL Care of Diabetes
Guidelines: ADA
Does diabetes contribute to terminal prognosis?
EOL Care Goal
Glycemic Control in Palliative Care
• Less stringent goals may be necessary
– A1C <8%
• Remaining life-expectancy and extent of
comorbid conditions must be evaluated in
order to set realistic goals for glycemic control
Standards of medical care in diabetes--2013. Diabetes Care. 2013;36 Suppl 1(Supplement 1):S11-66.
Standards of Medical Care in DM
Table 9d Summary of glycemic recommendations for many nonpregnant adults with diabetes
A1C <7.0%
Preprandial capillary plasma glucose 70–130 mg/dL
Peak postprandial capillary plasma glucose† <180 mg/dL

*Goals should be individualized based on:
o duration of diabetes
o age/life expectancy
o comorbid conditions
o known CVD or advanced microvascular complications
o hypoglycemia unawareness
o individual patient considerations

More or less stringent glycemic goals may be appropriate
for individual patients

Postprandial glucose may be targeted if A1C goals are
not met despite reaching preprandial glucose goals
†Postprandial glucose measurements should be made 1–2 h after the beginning of the meal, generally peak
levels in patients with diabetes.
Standards of medical care in diabetes--2013. Diabetes Care. 2013;36 Suppl 1(Supplement 1):S11-66.
From the Palliative Care Literature
HBA1C goal of < 7.5% in the terminal phase of
cancer may be beneficial for survival.
Kondo S, Kondo M, Kondo A. Glycemia control using A1C level in terminal
cancer patients with preexisting type 2 diabetes. J Palliat Med.
2013;16(7):790-3.
EOL Care Symptom Management
• Prevention of hyperglycemia
– Diabetic Keto-Acidosis
– Confusion
– Blurred vision
• Prevention of hypoglycemia
– Agitation
– Confusion
– Diaphoresis
• Prevention of polyuria
– Decrease risk of urinary tract infections in the
immobile patient
Diabetes
Remember: The HBA1C goal is no longer 7% !
Autonomic dysfunction?
Neuropathic Pain?
Renal Function?
Vision?
Initiation of once-daily insulin therapy for type 2 diabetes mellitus
in children and adults
Treatment naïve: A1C ≥ 10% or < 10%
when considering early insulin initiation
Oral agent failure:
A1C above target
Initiate insulin therapy with daily glargine or detemir or bedtime NPH
Beginning dosage: 10 units or 0.1-0.25 units/kg
Suggested titration schedule—Adjust every 2-3 days
If FPG:
>180 mg/dL
Add 6 units
If 141-180 mg/dL
Add 4 units
or Add 1 unit insulin each day until
If 121-140 mg/dL
Add 2 units
fasting SMBG is at goal
If 100-120 mg/dL
Add 1 unit
If 80-99 mg/dL
No change
If < 80 mg/dL
Subtract 2 units
If A1C remains > A1C goal over 3 months, discontinue oral secretagogue, continue oral
insulin sensitizer(s), and initiate multidose insulin or intensive insulin therapy or
consult an endocrinologist
FPG: Fasting plasma glucose
SMBG: self-monitored blood glucose
Adapted from: Triplitt CL, Repas T, Alvarez CA. Diabetes Mellitus. Figure 57-9, Insulin algorithm for type 2 DM in children and adults (reprinted with permission from Texas
Diabetes Council). In: DiPiro JT, Talbert RL, Yee GC, et. al. Pharmacotherapy: A Pathophysiologic Approach. 9th ed. New York, NY: McGraw-Hill; 2014: 1178.
Oral Agents for the Treatment of Type 2
Diabetes Mellitus
Drug Class
Special Precautions
Sulfonylureas (1st and 2nd generations)
Severe hypoglycemia, weight gain; dose adjustment in
renal impairment
Short-acting insulin secretagogues
CYP 2C8/9 and 3A4 metabolism
Biguanides
CHF(lactic acidosis), GI side effects; dose adjustment
in renal and hepatic impairment
Thiazolidinediones
Caution in hepatic impairment, bladder cancer;
contraindicated in CHF (causes edema)
α-Glucosidase inhibitors
Caution in renal impairment, elevated LFTs;
contraindicated in chronic intestinal diseases
Dipeptidyl peptidase-4 (DPP-4) inhibitors
Pancreatitis; dose adjustment in renal impairment
(except linagliptin)
Bile acid sequestrants
Constipation, drug-drug absorption interaction issues,
increased in triglycerides
Dopamine agonists
Cardiac valvular fibrosis, hypotension, significant
nausea, impulse control disorders
Injectable Agents for the Treatment of Type 2
Diabetes Mellitus
Drug Class
Special Precautions
Rapid acting insulin
Hypoglycemia, hypokalemia
Short acting insulin
Hypoglycemia, hypokalemia
Intermediate acting insulin
Hypoglycemia, hypokalemia
Long acting insulin
Hypoglycemia, hypokalemia
Glucagon-like peptide-1 (GLP-1) agonists
GI side effects, thyroid tumors (Bydureon),
pancreatitis; avoid use in impaired gastric motility;
use not recommended in severe renal impairment
Amylinomimetics
Avoid use in impaired gastric motility
Principles of Geriatric Palliative
Medicine
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Factors Affecting Pharmacokinetics of
Drugs in the Elderly
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Medications Considered to have a High Potential for Severe
Adverse Outcomes in Older Patients
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Pain Assessment Questions
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Types of Pain and Treatment
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Stepladder Approach to Pain
Management
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Opioid Side Effects and Treatment Options
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Geriatric Dosing and Adverse Effects for Commonly
Used Drugs in End-of-Life Care
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Remember:
“It is neither immoral nor unethical to think
about the cost of therapy!”
Methadone Mary 1998
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Questions ?
[email protected]
www.deltacarerx.com
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