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Medihoney for Pressure Ulcers in Hospice Patients

Esther Liu, PharmD, MSIA, CGP
Kristen Brodrick, RN, BSN, CHPN, CWCN

Recently, I have had several nurses inquiring about the application of Medihoney dressing for hospice patients with pressure ulcers. It has become more popular because there was a study suggesting medical honey can inhibit bacterial growth for pressure ulcers and it seems to be a more affordable option in comparison to the other protective products like DuoDerm gel. I want to share some of the findings I have on Medihoney with you.

Regarding to the antibacterial property of honey, it has yet to be confirmed. The referenced study done in 2012 was relatively small (20 patients).1  It was conducted on a group of patients that had participants as young as 30 years old,  so the skin integrity and healing power in this population may be stronger than our typical hospice patients at end of life. The study showed that it took approximately a week to get a clean swab study from the wound bed but there was no controlled group on placebo so we were unsure if that was the time it took the normal skin to eradicate the bacteria or it was eradicated by the honey. If the hospice patient has an infected or odorous pressure ulcer, topical antibiotics, such as topical metronidazole, are preferred over Medihoney to manage the infection due to the confirmed efficacy.

I have discussed this product with a wound care specialist in our northern California region, Kristen Lyn Brodrick, RN, BSN, CHPN,CWCN.   We are in agreement that Medihoney would still be an affordable protective gel option for those patients with dry wound beds.  However, Kristen pointed out that this product is made with honey so it can be very sticky and hard to handle sometimes.   Foam and clear dressings are more convenient, but may add some extra cost. Kristen also recommended Sensi-care (methylcellulose) protective cream for the shallower pressure wounds.  Barrier cream can keep wound bed moist and protected in an area often difficult to have dressing adhere. It comes in a much larger tube with a slightly higher price than Medihoney. Please see below for the AWP pricing on the products mentioned. You may be able to get a better pricing through your local medical equipment supplier.

Medihoney 15gram gel .....  $4.50 per tube
DuoDerm 15gram gel .....  $8.10 per tube
Sensi-Care 85gram Cream .....  $6.00 per tube

In summary, Medihoney is a more affordable option for those with a less complicated pressure ulcer that is dry, but not for those with more shallow or heavily draining wound beds.  It may not be clinically appropriate to use it for the purpose of disinfecting a wound due to the unconfirmed efficacy. Please be cautious when selecting the wound care product for your hospice patients.

1. Biglari B, Linden P, Simon A, et al. Use of Medihoney as a non-surgical therapy for chronic pressure ulcers in patients with spinal cord injury. International Spinal Cord Society. 2012, 50, 165-169.

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Hydrocodone Combination Products Will Become Schedule II Controlled Substances

Dr. Jim Joyner, PharmD, CGP

The Drug Enforcement Agency (DEA) has issued a directive that reschedules ALL hydrocodone combination products from schedule III to the more restrictive schedule II category of the Controlled Substances Act.  DEA has indicated that it took this action based upon evidence and expert advice demonstrating that these products are associated with a significant degree of abuse, misuse, and diversion that presents a hazard to those using the products and the public in general.  Products affected will include numerous brand-name and generic analgesics and cough suppressants. Some common brand-names are provided here:

Norco, Lortab, Vicodin, Vicoprofen

Cough suppressants :
Hycodan, Tussionex

As a result of this action these products will no longer be re-fillable.  A new prescription will be required for each fill.  This may result in the need for increased provider visits.  Some states, such as California and Texas, require triplicate prescription forms for all schedule II drugs which will represent a significant departure from the way these drugs were prescribed in the past.  

This new action will become effective on October 6, 2014,  forty-five days after the directive was published in the Federal Register. 


Nationwide Advance Care Planning Consulting Service Now Available

We would like to let our hospice partners and friends know about an exciting new opportunity. The Coalition for Compassionate Care of California now offers a nationwide Advance Care Planning Consulting Service for healthcare providers.

With healthcare reform, we’re all more aware of the need to provide more effective care for less money. One of the best tools out there for achieving the goals of healthcare reform is advance care planning. 

The Coalition has been working in advance care planning for more than 15 years and is a wealth of information and experience on advance care planning. The Coalition has just started a consulting service as way to bring to you this knowledge and best practices. They can provide you with customized hands-on training, carefully crafted materials, and the support you need to make an impact with your patient population. Whether your organization is large or small, urban or rural, for-profit or non-profit, The Coalition will tailor the program to meet the cultural needs of your organization and the population you serve.

Our CEO, Dr. Martin McDonough, serves on the Coalition Board of Directors and can vouch for the quality of their work. To find out more, Vist the Coalition ACP Integration Systems Site today.

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Outcome Resources Pharmacists Mentor Future Healthcare Leaders

Dr. Esther Liu, PharmD, CGP, MSIA

Through the recent collaboration with the student chapters associated with Academy of Managed Care Pharmacy, Outcome Resources organized a shadowing opportunity to two inspirational pharmacist candidates, Sora Yoon and Jennifer Vu, from Western University. We shared our experiences about pharmacists’ involvement in a managed care and hospice care setting. The students found this experience to be “incredibly educational and inspiring.”  The pharmacists from our clinical team at Outcome Resources are excited and proud of our preceptorships to future pharmacy leaders. We are committed to participate in many more of these similar events in order to share our knowledge in hospice as well as to provide a unique training opportunity in a managed care setting to our future healthcare leaders.

Inspiring future pharmacists to develop expertise in the specialized focus of hospice and palliative care will benefit future patients, and at Outcome Resources, patient care is our #1 priority.


New Evidence to Support Routine Discontinuation of Statin Therapy in Hospice

Esther Liu, PharmD, MSIA, CGP

It is often difficult for hospice providers to make a recommendation to patients and their family caregivers regarding discontinuation of medications. Most of the patients have been told that they need to take their chronic medications, such as a statin, for the rest of their life to prevent strokes. In fact, the benefits of statin therapy in the past research studies are all estimated on a patient population with a life expectancy of more than 10 years. In theory, the benefit of statin therapy in terminal patients is not significant enough to outweigh the risk of adverse effects, but we did not have much evidence to back up this theory in the past. Finally, there is some solid evidence published by the Journal of Clinical Oncology in June of this year to support our recommendation regarding discontinuation of statin for terminally-ill patients.

This study is a multisite randomized controlled trial of continuing versus discontinuing statins in the setting of life-limiting illness. It included patients with advanced life-limiting illness on a statin for more than 3 months for primary or secondary prevention, a life expectancy of greater than one month, and evidence of recent deterioration in performance status. The study found that the group discontinuing statins lived longer (Time-To-Death: 229 days vs. 190 days), had a better quality of life (McGill QOL scale: 7:11 vs 6.85) and exhibited less symptoms (Edmonton Symptom Assessment Scale: 25.2 vs. 27.4). In addition, there were only a few participants in either group that experienced cardiovascular events and the event rate was similar in both groups of patients. The researchers concluded base on the result of this study that it is unlikely that harm will accrue when statins are discontinued and these patients may even benefit from discontinuation of this medication at a palliative care setting.

This new evidence reinforced our previous recommendations to discontinue statins routinely for patients enrolling into hospice programs with a life expectancy of 6 months or less. It provides solid evidence for us and your hospice staff to share with patients, caregivers, and primary physicians who have difficulty with the decision on statin discontinuation. For more details regarding the study please follow the link in the reference session to view the study abstract published at the 2014 American Society of Clinical Oncology annual meeting. Here is a list of the statins available on the market:

• Lipitor (atorvastatin)
• Zocor (simvastatin)
• Pravachol (pravastatin)
• Lescol (fluvastatin)
• Mevacor (lovastatin)
• Altoprey (lovastatin ER) – Brand only
• Livalo (pitavastatin) – Brand only
• Crestor (rosuvastatin) – Brand only

A Abernethy, J Kutner, P Blatchford, et al. Managing comorbidities in oncology: A multisite randomized controlled trial of continuing versus discontinuing statins in the setting of life-limiting illness. 2014 ASCO Annual Meeting. Accessed July 23rd 2014: http://abstracts.asco.org/144/AbstView_144_135132.html

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Update on Hospice & Medicare Part D: Revised Guidance thanks to Hospice Advocacy

At Outcome Resources, “Helping Hospices Succeed” is more than just a tagline, it is our mission and our primary focus every day. As we consult with our hospice partners, patient care is our number one priority. With patient care impacted by Medicare Part D guidance issued by CMS, Outcome Resources has provided our hospice partners with education via live webinars and consultations and supporting documentation via our Medication Reviews, and then we worked with NHPCO and the Hospice Action Network to change the rules.

As the sole hospice pharmacy partner to sponsor the Hospice Action Network Advocacy Intensive last month in Washington D.C., we are proud that our commitment to hospice advocacy has helped to result in revised guidance being issued by CMS. In addition to our team traveling to D.C. to meet with Congress, we also provided scholarships to 22 attendees of this year’s Advocacy Intensive from around the nation, to ensure that as many legislators as possible were reached with this very important message regarding hospice and Medicare Part D. Thanks to all of us in the hospice community, including those of you who participated by calling in to speak with your congressmen and senators, our voices have been heard!

Revised guidance has been issued as of July 18th. This revised guidance does provide substantial relief of the burden for hospice providers since prior authorizations will only be required on the four categories identified as typically used in hospice: analgesics, antinauseants (antiemetics), laxatives, and antianxiety drugs (anxiolytics). Other drugs will not have to go through the PA process. You may read the full CMS Memo for more information.
We urge you to make special note that the guidance emphasizes the need for hospices to include a comprehensive written drug profile as part of the hospice plan of care. While this Medication Review meets the need for Conditions of Participation, it now also may be provided to a Part D sponsor during the PA process. Outcome Resources has provided the most comprehensive, best in industry Medication Reviews well before these requirements were put in place. We invite you to compare our Medication Reviews to what you are currently receiving. While these are the #4 reason for being cited in survey, no Outcome Resources partner has ever been cited for Medication Reviews.

To learn more about hospice advocacy and the hospice regulatory environment, join us at the Annual Pathways to Success Hospice Conference this November in Berkeley, California. Jon Keyserling of NHPCO will address Hospice Advocacy and Policy in 2015, and Susan Balfour will discuss Hospice and the Letter People, and how to keep up with regulatory changes. Drs. Glen Komatsu and Stephen Leedy will keynote the two day Conference, and you may earn up to ten contact hours of continuing education. View the Full Agenda and Register Today!

Photo: Outcome Resources CEO Dr. Martin McDonough Addresses Attendees at the Hospice Action Network Advocacy Intensive, June 2014


Hospice Item Set (HIS) - CMS Quality Data Collection Starts on July 1st 2014

Esther Liu, PharmD, MSIA, CGP

HIS is a patient-level data collection tool developed as part of the Hospice Quality Reporting Program (HQRP), which can be used to collect data to calculate 6 National Quality Forum-endorsed (NQF) Measures and 1 modified NQF Measure. See below for a list of measures required:

1. NQF #1617 Patients Treated with an Opioid who are Given a Bowel Regimen
2. NQF #1634 Pain Screening
3. NQF #1637 Pain Assessment
4. NQF #1638 Dyspnea Treatment
5. NQF #1639 Dyspnea Screening
6. NQF #1641 Treatment Preferences
7. Modified NQF #1647 Beliefs/Values Addressed (if desired by the patient)

HIS is implemented as part of the FY 2014 Hospice Wage Index Final Rule issued last year in July 2013. To refresh your mind regarding HIS submission, you may visit the CMS website to view the training materials. CMS requires ALL Medicare-certified hospices to submit HIS data on ALL patients. Please be aware of the completion and submission deadlines. Data collection of HIS for each admission must be completed within 14 days and submitted to CMS within 30 days after admission. Data collection for HIS for discharged patients must be completed within 7 days and submitted to CMS within 30 days after discharge.  If the hospice failed to be compliant in reporting patient admission/discharge data, this would impact its payment rate in fiscal year of 2016.

As a Pharmacy Benefit Manager, we help our hospice partners to collect data to fulfil HIS requirements related to medications. To learn about the different reporting tools we offer to our partners, please contact the clinical department at clinical AT outcomeresources DOT com or Submit Your Information and we will contact you directly.


Hospice Medication Alert: New PPI Available OTC - Nexium 24HR

Jennifer Chen, PharmD

On March 28th, FDA approved the over-the-counter Nexium 24HR (esomeprazole magnesium) 20mg delayed-release capsules. Nexium is part of a class of drugs called proton pump inhibitors (PPIs), which is commonly used for gastroesophageal reflux disease (GERD), erosive esophagitis and prevention of NSAID-induced gastric ulcers. This purple pill, previously available by prescription only, is now available over-the-counter providing patients who suffer from frequent heartburn an easier access.

However, Nexium 40mg delayed-release capsules still remains available by prescription only as well as other formulations of Nexium including Nexium I.V. and Nexium oral suspension. For patients with difficulty swallowing, the Nexium 24HR capsule can be opened and mixed in applesauce.

The status change to OTC does not take away its potential harms. Its side effects include headache, diarrhea, increased infection and bone fractures. In general, short-term use of PPI is safe. The approved OTC labeling is a 14-day treatment and may be repeated every 4 months.

As mentioned in a previous article, Nexium was the number 2 drug in “Top 100 Drugs by Sales” over the past year. The cost for Nexium 24HR is significantly lower than the prescription version (about 1/10th the cost of prescription Nexium). The OTC availability of Nexium 24HR provides another cost-effective alternative for hospice patients. Other PPIs available in OTC formulations are Prevacid (lansoprazole) and Prilosec (omeprazole).


Medication Errors: The Problem of Look-Alike, Sound-Alike Drug Names

Jim Joyner, PharmD, CGP

One of the most common sources of medication errors is the problem of “look-alike” and/or “sound alike” drug names.  The risk for serious errors can arise when medication orders or prescriptions are not written clearly and the reader misinterprets the intended drug for a different drug with a very similar spelling.  Another variation on this error theme is when a drug name is transmitted verbally (either directly or more likely, over the phone) which sounds very similar to a different drug.  The listener may hear a different drug name than that which was intended.  There are very many drugs that fit into these categories of look-alike and sound alike drugs, providing the clinician with a great many opportunities for misinterpretation. This table provides just a few examples. (You may wish to share this with your staff.)

There are a number of ways to reduce the risk for this type of error through increased clinician awareness of the problem, coupled with a variety of safe practices.  Here are a few safe practices that are worth consideration:
• Put the drug name that you heard or read into the context of the overall medication order; does the strength, frequency for use, and reason for use make sense for the drug name? 

• Know what the medication is intended to be used for.  Is the drug name that you heard indicated or commonly used for managing that type of condition or symptom?

• If the person transmitting the order verbally is not clear or has an accent that you are not familiar with, ask them to spell it out. 

• When initiating an order in writing or verbally, consider using both the brand name AND generic name.

• When initiating an order, consider including the “reason for use” in the medication order.    Such as “for depression” or “for arthritis”.

• When selecting drug line items from a computer data-base, keep in mind that look-alike drug names may appear consecutively in the list, making the incorrect selection a high probability.  Double – check all selections for accuracy against the intended drug name.  

• Some computerized drug data bases can be configured to change the appearance of look-alike drug names to draw attention to their dissimilarities.  This is done with the use of “tall man” (mixed case) lettering. 

• Develop a working knowledge of actual look-alike and sound-alike drug names.  The Institute for Safe Medication Practices (ISMP) has a very extensive list of drug name pairs that have been reported as error related events of this type.  The ISMP list is updated every few months.  Refer to http://ismp.org for more information on this topic and other medication error issues.  

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Hospice Legislative Update: The 2014 HAN Advocacy Intensive

Outcome Resources considered it an honor to recently sponsor the 2014 Hospice Action Network Advocacy Intensive in Washington, D.C. Together with over 200 hospice professionals we had the opportunity to share our hospice stories with nearly all of the nation’s Senators and State Representatives. In addition, this year, twenty advocates whose hospice programs would otherwise be unable to afford it were able to attend the Hospice Action Network’s Advocacy Intensive thanks to Outcome Resources scholarships. It is vital to bring these stories to Congress and have our voices heard on Capitol Hill.

The support of our elected officials is crucial to protect and preserve the hospice Medicare Benefit and to support legislation that positively affects those patients and families facing end of life. We are grateful to the Hospice Action Network for providing all of us involved in hospice the forum and opportunity to speak with a unified message in support of our daily efforts. During the meetings on the Hill with Representatives, Senators, and Legislative Assistants, this year advocates focused on requesting support with the issue of Hospice and Medicare Part D. (Learn more in our previous blog post about the issue.) As you may be aware, CMS issued guidance to the Part D provider and hospice communities introducing a “prior authorization” process for how the two groups should determine who pays for which drugs once a patient elects hospice. Since there is no uniform process in place, hospices are dealing with multiple Part D prior authorization processes and paperwork that in many cases requires the addition of staff, and patients are trapped in the middle of this confusing process – sometimes even deciding to disenroll from hospice or being left without medications.

To learn more about these issues or how you can help, please visit Hospice Action Network. You can also participate by calling your members of Congress. Outcome Resources has been involved as hospice advocates for many years and will continue to support these efforts at every opportunity. We are honored to have Jonathan Keyserling, Senior Vice President, Office of Health Policy and Counsel at the National Hospice and Palliative Care Organization presenting a session on Hospice Advocacy at the Outcome Resources Pathways to Success Conference by the Bay this November. To learn more about the Conference, visit the Conference Website or Download the Information Sheet.

View our photos of the HAN Advocacy Intensive on Facebook at http://on.fb.me/1m4GXvz.

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