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Advisor Live®
Optimizing Outcomes and Managing CostsIV Acetaminophen and Liposomal Bupivacaine
Performance Capsule Report Series #1:
Multi-modal Pain Control
March 23, 2016
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PROPRIETARY & CONFIDENTIAL – © 2016 PREMIER, INC.
Presenters
Nathan Ash, Pharm D, MBA, BCPS, Director
Pharmacy Clinical Services, Mercy Health
Rick Knudson, Pharm D, MS, MBA, BCPS, Senior
Director, Pharmacy Member Support, Premier, Inc.
Ray Perigard, Director, Data Optimization, Premier,
Inc.
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PROPRIETARY & CONFIDENTIAL – © 2016 PREMIER, INC.
Pe℞formance Capsule Report Series
Edition #1: Multi-Modal Pain Control
Ray Perigard
Director, Data Optimization
Rick Knudson, PharmD, MS, MBA, BCPS
Senior Director, Pharmacy Member Support Team
March 23, 2016
Integrated Service Center
Data Optimization Team
Ray Perigard
Anne Hauert
Deirdre
McGuinness
Shannon Teal
• Background
• Background
• Background
• Background
• Purchasing RD
• QA user at member
site
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• Informatics RD
• Performance
partner
• Periop Consulting
• Performance
partner
• QA
• Cost Accounting
PROPRIETARY & CONFIDENTIAL – © 2014 PREMIER, INC.
• Premier’s Data
Optimization team
produces analyses
for organizations that
subscribe to
QualityAdvisorTM and
have data sharing
agreements in place.
• This service is
provided on a valueadded basis.
• Contact your Premier
field team contact or
call the Solution
Center at
800.805.4608 to
learn more.
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PROPRIETARY & CONFIDENTIAL – © 2014 PREMIER, INC.
Pharmacy Team
Pharmacy Member Support Team
Marv Feldman, RPh, MS
Nina Shehan, RPh, MBA
Ed Smith, RPh, MBA
• New England
• South – Southwest (interim)
• Eastern Seaboard
• West - Southwest
Rick Knudson,PharmD,
MS, MBA, BCPS
• Central
• Great Lakes
Additional PMST Support Resources
•
•
•
•
•
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Anne Jernigan
Jerry Frazier
Bob Biagi
Mary Thompson
Cheryl Buswell
PROPRIETARY & CONFIDENTIAL – © 2014 PREMIER, INC.
Pharmacy Member Support Team
Establish working relationships with key pharmacy stake
holders at member organizations
Regionally deployed pharmacists
• Value-added service
• Assist member organizations identify Premier programs/offerings
that will enhance their pharmacy operations
» Contract portfolio optimization
» QualityAdvisor education and assistance
» TheraDoc integration
» Continuing education opportunities
» Resolution of membership issues (e.g. rostering, etc.)
» Retail, specialty and additional practice-related optimization
» On-going virtual engagement with RX members
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PROPRIETARY & CONFIDENTIAL – © 2016 PREMIER, INC.
The Pe℞formance Capsule Report Series
Typical Pharmacy Questions That Require Hospital-Specific
Data to Answer Appropriately
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Do we prescribe
this drug more
frequently than
peers?
Is there variance
in the way we
prescribe drugs
to treat the same
condition or
DRG?
Do we really
obtain the clinical
and financial
benefits claimed
by the supplier
for their drug?
Do our patients
get better faster
with one drug
versus another?
Can we identify
high quality peer
groups to
compare therapy
in conditions like
transplants?
Where should we
focus efforts to
reduce waste and
achieve cost
savings in drug
therapy?
PROPRIETARY & CONFIDENTIAL – © 2014 PREMIER, INC.
The Pe℞formance Capsule Report Series
Goals of the report series:
• Provide useful, relevant and contemporary analyses of drugcentric questions you face every day in a user-friendly format
• Provide “camera ready” QualityAdvisor reports for you to utilize
without extensive work/preparation on your part
• Highlight the power of the QualityAdvisor comparative database
relative to formulary/drug-management questions
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PROPRIETARY & CONFIDENTIAL – © 2016 PREMIER, INC.
The Pe℞formance Capsule Report Series
Report series logistics:
• Premier Pharmacy Member Support Team and Data Optimization
teams will work in tandem to produce the clinical content of each
report
» Overall templates will look similar
» Clinical content may vary slightly based on the clinical issues
surrounding a specific drug(s)
• QualityAdvisor subscribers who have given permission to Premier
to analyze their facility(ies) data “en mass” will have reports
generated
» If your facility is not a QualityAdvisor subscriber you will not have the
Pe℞formance Capsule reports available
» Similar data analytics can be extracted from other “source systems”
• Reports will be released approximately every 6-8 weeks over the
course of the 10 report series (through ~end of 2017)
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PROPRIETARY & CONFIDENTIAL – © 2016 PREMIER, INC.
The Pe℞formance Capsule Report Series
1. Multi-modal Pain Control
» A focus on - Liposomal Bupivacaine & IV Acetaminophen
2. MRSA Antimicrobial Agents
» A focus on – Daptomycin, Linezolid, Tigecycline, Vancomycin, Tedizolid,
Dalbavancin, Ceftaroline, Oritavancin, Telavancin
3. Inhaled Agents / MDI’s vs Nebulizers
4. Alvimopan
5. Insulin Agents
6. Anticoagulant Agents
7. Thrombolytics / Anti-Thrombolytics
8. IV Anti-Hypertensives
9. IV-to-PO Practices
» A focus on – Proton Pump Inhibitors / Levothyroxine
10. Parenteral Diuretic Agents
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PROPRIETARY & CONFIDENTIAL – © 2016 PREMIER, INC.
The Pe℞formance Capsule
Multi-Modal Pain Control
The Pe℞formance Capsule – Multi-Modal Pain Control
Multi-Modal Pain Control
• A focus on:
» Lipsomal Bupivacaine
» Intravenous Acetaminophen
Two separate reports
• One for each respective “drug”
• Identical content (data)
Reports available for each
hospital entity within
QualityAdvisor
• Reports are not generated at a
“health-system” view
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Note: “Drug” in this slide deck can represent either Liposomal Bupivacaine or IV Acetaminophen
PROPRIETARY & CONFIDENTIAL – © 2016 PREMIER, INC.
The Pe℞formance Capsule – Multi-Modal Pain Control
Basic components of each report
• Overall drug utilization vs. Premier aggregate (IP & OP)
• Top 10 principle procedures with “drug” use by volume (IP & OP)
• Cost Impact
» Total cost of analgesic treatment of those receiving vs those not receiving
“drug” (same procedure)
» Utilizes QualityAdvisor reported costs
 Finance department reported costs – directional in nature
 Not indicative of any supply chain purchase costs
• IP Opioid Utilization
» Top 5 principle procedures
» Two principle procedure patient arms – with and without “drug”
• Length of Stay Comparison
» Top 10 IP Procedures
» Two principle procedure patient arms – with and without “drug”
• Readmission Rate Comparison
» Top 10 IP Procedures
» Two principle procedure patient arms – with out without “drug”
• Additional available resources
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IP = inpatient, OP = outpatient
PROPRIETARY & CONFIDENTIAL – © 2016 PREMIER, INC.
The Pe℞formance Capsule – Multi-Modal Pain Control
Top 10 Principle Procedures With “Drug” Use
Opioid Utilization With & Without “Drug”
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LOS Comparison With & Without “Drug”
PROPRIETARY & CONFIDENTIAL – © 2014 PREMIER, INC.
The Pe℞formance Capsule Report Series
Reports must be distributed to the facility via a Premier
representative – they are not available for direct
download
How do you obtain your facility/health-system’s copy(ies)
of these reports?
• Contact your Premier Informatics Region Director to obtain your
report via e-mail
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PROPRIETARY & CONFIDENTIAL – © 2016 PREMIER, INC.
Our Journey with IV
Acetaminophen and Liposomal
Bupivacaine
Nathan Ash, PharmD, MBA, BCPS
A Catholic healthcare ministry serving Ohio and Kentucky
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Mercy Health
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Mercy Health
• One system-wide formulary
• One instance of EMR installed across
all hospitals
• Hospitals are divided into 7 different
markets based on geography
• System-wide clinical institutes that
standardize best practices
• Orthopedic Surgery
• Behavioral Health
• Cardiology
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Multimodal Pain Therapy
• 2012 American Society of
Anesthesiologists Task Force on Acute
Pain Management
• ASA strongly agree that whenever
possible, anesthesiologists should use
multimodal pain management therapy
• Multimodal techniques include
administration of two or more drugs that
act by different mechanisms
American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain
management in the perioperative setting: An updated report by the American Society of Anesthesiologists Task
Force on Acute Pain Management. Anesthesiology 2012; 116: 1573-81.
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Multimodal Pain Therapy – Key
Considerations
• Is there evidence that the medication or
medications in the regimen work?
• Is the regimen the most cost-effective
method to address pain?
• Impact on Bundle Payment Model
• Impact on Fee for Performance Contracts
• Impact on Length of Stay (LOS)
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Summarized Mercy Health Literature
Review: IV Acetaminophen
• No consistent benefit or improvement in
outcomes compared to oral or rectal
routes
• Some published data suggests that IV
acetaminophen may be associated with
a reduction in opioid usage
• No consistent improvement in pain
management
• No decrease in adverse events
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IV Acetaminophen Formulary
Review
• First Formulary Review: October 2012
•
After due consideration by the CarePATH
formulary committee it was not approved for
addition to the formulary
• Meeting with IV Acetaminophen Proponents:
July 2014
•
Comments and recommendations captured for
submission to the CarePATH Formulary
Committee
• Second Review: August 2014
•
After additional review and consideration by the
CarePATH formulary committee it was not
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Slide Updated: 4/15/2016
Summarized Mercy Health Literature
Review: Liposomal Bupivacaine
•
Dec. 14, 2015 – FDA rescinded marketing warning letter
previously posted regarding Exparel.
•
•
Letter clarifies that Exparel approved label indication is NOT only
for two surgical procedures
New package labeling (FDA-approved):
-
•
Exparel is a liposome injection of bupivacaine, an amide local anesthetic,
indicated for single-dose infiltration into the surgical site to produce postsurgical
analgesia
One Phase 2 and one Phase 3 trial in orthopedic surgery
•
•
Control group used “plain” bupivacaine
No statistical differences between the two groups in either trial
Bramlett K, Onel, E, Viscusi ER, Jones K. A randomized, double-blind, dose-ranging study comparing
wound infiltration of Depofoam bupivacaine, an extended-release liposomal bupivacaine, to bupivacaine
HCL for postsurgical analgesia in total knee arthroplasty. The Knee. 2012;19(5): 530-536.
Pacira Pharmaceuticals, Inc. A Phase 3, multicenter, randomized,double-blind, parallel group, active controlled
study to evaluate the safety and efficacy of a single intraoperative administration of SKY0402 for prolonged
postoperative analgesia in subjects undergoing total knee arthroplasty (TKA). Data on File.
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Summarized Mercy Health Literature
Review: Liposomal Bupivacaine
• Many small, single center trials have
been presented at medical conferences
• Some have later been published
• Results have been inconsistent
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Liposomal Bupivacaine
Formulary Review
• Formulary Review: August 2013
• After due consideration by the CarePATH
formulary committee it was not approved
for addition to the formulary
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Trends Since Initial Formulary
Decision Process
• In 2014 and 2015, a consistent increase
in spend on both products was noticed
primarily in two markets
• Pharmacy leadership across the system
began engaging local physicians to
determine the rational for use
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Trends Since Initial Formulary
Decision Process
• Requests from local physicians to
purchase the medication for a “trial”
• Perception that there is a large body of
supporting evidence
• Pressure to decrease LOS and increase
patient satisfaction scores
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2015 Mercy Health Spend
• IV Acetaminophen: $407,310
• 75% of spend was from 1 market
• Liposomal Bupivacaine: $990,884
• 82% of spend was from 2 markets
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Usage: IV Acetaminophen
• Top 3 Primary Procedures
• Total Knee Replacement
• Total Hip Replacement
• Reverse Total Shoulder Replacement
* Data from QualityAdvisorTM (Premier, Inc.)
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Usage: Liposomal Bupivacaine
• Top 3 Primary Procedures
• Total Knee Replacement
• Total Hip Replacement
• Reverse Total Shoulder Replacement
* Data from QualityAdvisorTM (Premier, Inc.)
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On-Going Discussions & Activities
• Mid-level practitioners and nurses report
that the patients have less pain and are
using less opioids
• Some reports that the LOS is trending
down as a result of these agents being
added to pain regimen(s)
• Continued discussions of anecdotal
experiences, literature evidence and
overall practice pathways
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On-Going Discussions & Activities
• Difficult to obtain an opportunity to
present information to surgeons and
anesthesiologists
• Busy schedules
• Literature alone not persuasive
• Must use local data
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Current and Future Directions
• Determine which institutions are using
IV acetaminophen and liposomal
bupivacaine
• Spend Data
• EMR Reports
• QualityAdvisorTM and Performance
Capsules
• Determine the top prescribers and
principal procedures
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Current and Futures Directions
• Compile local information on narcotic
usage and LOS
• Compare patients who received and did
not receive IV Acetaminophen
• Compare patients who received and did
not receive Liposomal Bupivacaine
• Only way to evaluate anecdotal evidence
• Utilize QualtiyAdvisorTM and Performance
Capsule Reports from Premier
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Current and Future Directions
• Develop list of current practices and
alternatives
•
•
•
•
•
•
Plain bupivacaine
Regional anesthesia
Oral acetaminophen
Rectal acetaminophen
Liposomal bupivacaine
IV acetaminophen
• Present literature and local data to
executives at the institutional level
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Current and Future Directions
• Present literature and local data to local
pharmacy leadership
• Present literature and local data to
target group of physicians
• Work with local pharmacy leadership to
develop an overall strategy
• Local pharmacy leadership presents data
to local physicians with system support
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Current and Future Directions
• Present literature and local data to
medical leadership of Orthopedic
Surgery Clinical Institute
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Current Local Data Analysis:
IV Acetaminophen
• LOS
• No significant difference between groups
at system level or local institution level
• Narcotic Usage
• No significant difference between groups
at system level or local institution level
*Data from QualityAdvisorTM and Performance Capsules (Premier)
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Current Local Data Analysis:
Liposomal Bupivacaine
• LOS
• No significant difference between groups
at system level or local institution level
• Narcotic Usage
• No significant difference between groups
at system level or local institution level
*Data from QualityAdvisorTM and Performance Capsules (Premier)
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Current Status
• Work on action plan began in January
2016
• Presented data and literature to local
physician leadership over two virtual
meetings
• Directors of Pharmacy
• Clinical Pharmacy Coordinators
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Current Status
• Presented data on both medications at
Orthopedic Surgery Clinical Institute
• Open to moving away from IV
acetaminophen
-
Recommended engaging anesthesiology
groups
• Continued discussion on the role of
liposomal bupivacaine
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Current Status
• Presented liposomal bupivacaine
literature and data to one high volume
market’s executive leadership
• Local pharmacy leadership presented
information to local orthopedic surgeon
group
• Spend on liposomal bupivacaine has
started to decline in this market
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Summary
• Important to understand and summarize
the literature
• Important to collect local institutional
data to review impact on outcomes
• Sharing both literature and local data
with key shareholders helps facilitate
productive discussions
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Your Questions
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PROPRIETARY & CONFIDENTIAL – © 2016 PREMIER, INC.
Thank you for joining us
For more information, contact:
Anna Vordermark
[email protected]
704-816-5599
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