Posted by Dr. Jim Joyner
The July issue of The Clinician, our quarterly clinical newsletter, will feature the final article in our three-part series on pediatric palliative care. In the upcoming article, Julia Harder, PharmD, will discuss the management of some of the most common non-pain symptoms encountered in pediatric palliative care. Specific symptom complexes that will be addressed include: anxiety & depression, agitation, insomnia, anorexia-cachexia, nausea-vomiting, constipation, and dyspnea. Specific medication strategies will be presented for managing each of these troubling symptoms in pediatric hospice patients. All clients of Outcome Resources receive complimentary copies of The Clinician each quarter. Previous issues of The Clinician can be obtained by contacting Jim Joyner, PharmD, at jjoyner@outcomeresources.com Be sure to check the Blog for the upcoming Part 3 in the series.
Dowload Part 1 of Pediatric Palliative Care Series: Current Concepts in Drug Therapy
Dowload Part 2 of Pediatric Palliative Care Series: Pain Management
Posted by Autumn Spence
Next week is NHPCO's Annual Management & Leadership Conference in Washington DC and the Outcome Resources team looks forward to seeing you there! If you have the chance to attend this year, stop by Booth #202 in the Exhibit Hall. We will have a special treat for the first 100 attendees that come by at the Opening Reception on April 22nd from 5:15pm - 7:00pm. Also, be sure to enter to win our contests and pick up information to share with your team. If you are not attending, request your Free Information Kit or a Free Consultation to learn more.
Outcome Resources is a Pharmacy Benefit Manager for hospices. Take a look at some of the benefits available to your hospice by partnering with OR:
- With one contract, your hospice receives one low discounted rate on ALL medications.
- Your patients have their choice of pharmacies (including mail order options) while your hospice receives one clear and concise invoice.
- Easier management of hospice patients in skilled facilities since all closed-door pharmacies are included on your invoice.
- With custom-tailored plan design and formulary control, you are in control of the medications that are dispensed and paid for by hospice.
- Your pharmacies are paid electronically every 15 days and processing claims through our program means fast and easy dispensing along with reduced chance for error.
- Unlimited Access to a team of experienced PharmDs for patient consults, drug information, and education programs.
- Online access to reports and patient medication information means you always have management tools at your fingertips.
- Dedicated lines of communication with your Account Claims Manager and Pharmacists to eliminate time-wasting transfers and phone trees.
- Partnership with a company dedicated solely to hospices - we understand your specific complex requirements.
- You can keep your hospice's medication dollars in the local economy, supporting the community that in turn supports your hospice.
Posted by Dr. Jim Joyner
Can opioids be administered by nebulizer for shortness of breath (dyspnea)?
Opioids are the mainstay of treatment for management of severe dyspnea in hospice patients with late stage CHF and COPD. The use of opioids in dyspnea is supported by extensive experience as well as clinical studies with the use of both oral and parenteral opioids, specifically morphine. The mechanism of action is unclear and it is interesting that opioids can alleviate dyspnea in many patients without changing the respiratory rate or producing any measurable changes in blood gas parameters. The rationale for considering nebulized opioids centers on the belief that dyspnea can be relieved while avoiding potential systemic side effects associated with oral or parenteral routes. The current medical literature does not support this belief. A review article by Foral (1) and colleagues in 2004 evaluated a number of clinical studies in patients being treated for dyspnea with inhaled nebulized opioids. The authors concluded that the evidence did not support the use of nebulized morphine for the relief of dyspnea. They also reported that in all cases opioid side effects were present from mild to moderate degree. There are several other options available for conventional opioid administration routes for hospice patients, including: oral, subcutaneous, intramuscular, intravenous, rectal, transmucosal, and sublingual.
(1) Nebulized Opioids use in COPD. Chest 2004;125:363-365
Posted by Dr. Jim Joyner
Extensive federal Hospice Conditions of Participation (CoP's) were published in the Federal Register June 5, 2008. These regulations became effective on December 2, 2008. A documented comprehensive assessment of each patient is required which must identify patient needs across the entire spectrum of hospice related care. Part of this assessment entails a review of each patient's drugs both prescription and OTC drugs, including herbal remedies. The review should address at least the following:
1) Effectiveness of drug therapy
2) Drug side effects
3) Actual or potential drug interactions
4) Duplicate drug therapy
5) Drug therapy currently associated with lab monitoring
With regard to the drug regimen review, the hospice is required to ensure that the interdisciplinary group confers with an individual with education and training in drug therapy management . This individual may be an employee of the hospice or under contract with the hospice to ensure that drugs and biologicals meet the patient's individual needs. In most cases this individual would be a clinical pharmacist.
Outcome Resources offers a service to provide Comprehensive Medication Reviews. Our team of PharmD's can provide these for all patients, just complex patients, or as needed if the qualified person the hospice employs is unavailable. Turnaround time is 24-48 hours, well within the 5 day timeframe established by the CoP's. If you are interested in learning more about the services we can offer to your hospice, Contact Us for more information.
Posted by Autumn Spence
Pharmacy Benefit Manager: Abbreviated PBM. A company under contract with heath care sponsors such as managed care organizations, self-insured companies, and hospice programs to administer and manage pharmacy networks and contracts, provide drug utilization review, outcomes management, and disease management. A pharmacy benefit manager will fill drug prescriptions by a network of pharmacies and/or mail order pharmacy. The aim of Outcome Resources, as a PBM exclusively for hospices, is to save money through specialized focus on palliative symptom management and patient driven outcomes for hospice organizations.
PBM is a term which refers to any prescription drug program administrator. PBMs technically are private companies that contract with health care sponsors (such as hospices) and specialize in claims processing and administrative functions. With increased attention focused on prescription drug programs, expenditures, and coverage, interest also has increased in drug program cost control measures, in particular those of Pharmacy Benefit Managers (PBMs). (The University of Wisconsin School of Pharmacy report in 2000.) PBMs have had a central functional role in prescription drug coverage plans built around claims processing and program administration activities. A number of strategies and techniques to control costs in drug programs have been used by PBMs. Some of the strategies utilized by PBMs include the combination between a discounted Average Wholesale Price (AWP) rate, generic substitutions, formularies, Drug Utilization Reviews and symptom relief management.
The standard approach for pharmacy reimbursement for dispensed prescriptions is to pay an ingredient cost for the drug dispensed plus a dispensing fee. Ingredient cost payment for drugs is typically determined by deducting a percentage from the drug's average wholesale price (AWP). Though this is changing, AWP has been a common contractual rate. Due to a PBMs volume of claims and network relationships, contracts with a PBM generally provide a deeper discount than an organization can negotiate on their own. Hospices can benefit from the ease of one contract and one rate with access to multiple pharmacies. Working with a PBM can streamline administration by providing one consolidated invoice.
The goal of generic substitution is to increase the use of generic drugs and decrease costs. At the time of dispensing the pharmacist will be notified about the generic substitutions. Only if specified by the Doctor will a brand product be filled. In addition, Outcome Resources also provides consultation services with clinical pharmacists trained in end-of-life medication management, enabling hospice staff to consult regarding drug substitution, interactions, and the best medication based on individual patient circumstances.
Online real-time adjudication is another one of the benefits to a hospice of using a PBM, since many errors are caught at the time of dispensing thereby reducing the need to resubmit claims. Outcome Resources also offers detailed oversight of a clinical pharmacist team in analyzing each hospice's drug utilization, providing monthly reports and using the information to increase the quality of patient care, decrease costs, and customize formularies and education programs for the hospice.
A formulary is another way PBMs manage drug utilization. A list of covered or reimbursable drugs is approved based on the formulary. The underlying intent of a formulary is to improve prescribing and drug use quality. Formularies can be established by PBMs, hospices, or other health care sponsors. Formularies can be labeled in various ways to reflect the drugs included and ease access to drugs not on the formulary or not covered. An open formulary includes all drugs. Any drug transmitted will be approved and dispensed. A closed formulary includes only covered drugs such as those on a specific formulary. A closed formulary varies from including only one select drug within a therapeutic category to including multiple drugs within a therapeutic category. A preferred or partially closed (restricted) formulary specifies the drugs covered, but allows exceptions to the list. Each PBM handles the development and monitoring of formularies differently. For example, Outcome Resources allows hospices to custom-tailor their formulary as part of their individualized plan design. Some other PBMs insist on a strict formulary that must be adhered to.
Palliative management has evolved with some PBMs through the Disease Management model. This generally refers to the practice of identifying patients with specific conditions and providing intensive care and monitoring of drug utilization and effects. The goal is to minimize treatment costs and maximize patient care. Pharmacists may be paid separate professional service fees for their efforts in disease management or it may be included as part of your overall service contract with a PBM. The target of disease management programs is the consumer, through the efforts of pharmacists providing educational and therapeutic interventions for patients, caregivers, and prescribers.
Cost control strategies of PBMs do work and some successes have been supported empirically. Prescription expenditures and pharmacy costs have been the most rapidly growing component of health care expenditures in recent years and health care sponsors such as hospices are demanding the services of a PBM to help control these complex costs. Hospices are finding that a partnership with a Pharmacy Benefit Manager (PBM) can result in maximizing palliative symptom management and minimizing drug therapy costs. Also the competitive industries for PBMs provide a large spectrum of programs and services offered to hospices. If your hospice is considering a partnership with a Pharmacy Benefit Manager (PBM), please contact us for information and a free consultation.
Outcome Resources is a PBM that has partnered exclusively with hospices nationwide for a decade, and we would be honored to discuss the value of a partnership with your hospice organization.
Posted by Dr. Jim Joyner
Continued from Part 1 of Discontinuing Drugs in Hospice
There is no hard and fast rule regarding drug discontinuation. The plan for each hospice patient will depend upon their individual condition, prognosis, and goals of care. In many cases, the doses being used will not be great enough to result in any significant withdrawal or rebound effects upon abrupt discontinuation of the drug. It is important for the clinician to be aware of the potential for these types of drugs to cause adverse effects if withdrawn abruptly. Decisions regarding tapering of medications can then be addressed in light of the hospice patient's current condition, the dosage of medication, and the duration of therapy with the medication. Some strategies for gradual discontinuation have been provided here and should be considered as starting points in a patient's plan for gradual dose reduction. Once the process of gradual dose reduction is initiated, it should be individualized and modified depending upon the patient's response. In dying hospice patients who are no longer able to swallow medication, it is generally acceptable to discontinue many of these medications abruptly.
Beta-blockers (metoprolol, atenolol) are one of the more widely known examples of drugs that usually requires tapering. In general, if beta-blockers are stopped abruptly the patient will be at risk for rebound hypertension, angina, and tachycardia. Patients on higher doses will be at greater risk for those problems. Patients on the lower entry-level doses such as metoprolol 25mg bid probably will not be adversely affected by an abrupt discontinuation. Beta blockers may need to be tapered over 7 to 10 days depending upon the dosage.
Antidepressants may need to be tapered over 3 to 4 weeks (reduced by 25% a week) to avoid withdrawal symptoms. This is true of SSRI type and Tricyclic type of antidepressants. SSRI withdrawal symptoms include: flu-like symptoms (muscle aches, nausea-vomiting, diarrhea), insomnia, irritability, depression, flushing, sweating, dizziness, and "electric-shock" sensations in various parts of the body. Tricyclic withdrawal symptoms are similar to that of the SSRI drugs, but without the dizziness or the "electric shock" sensations. The withdrawal syndrome has been reported most commonly with Paxil and Effexor, but may occur with any antidepressant. Patients on lower doses may have doses reduced by 50% per week over 1 to 2 weeks.
Antipsychotic drugs may need to be tapered over 1 to 2 weeks to avoid withdrawal symptoms that may include: sweating, salivation, runny nose, flu-like symptoms, parathesia, increased urination, vertigo, agitation, anorexia, and psychosis. Antipsychotics may be stopped abruptly if severe adverse effects are present (dystonia, agranulocytosis). If abrupt discontinuation is necessary, withdrawal symptoms may be managed with benzodiazepines or valproic acid.
Anticonvulsants may need to be tapered by 25% a week to reduce the risk of seizures. More rapid tapering may be initiated if there are serious adverse effects present, however, smaller dose reductions may be necessary if seizure control has been poor. Ideally, taper should start after a new agent has been titrated to an effective dose. Gabapentin & Pregabalin withdrawal symptoms may include anxiety, insomnia, nausea, pain, & sweating in addition to seizure activity.
Benzodiazepines when stopped abruptly from moderate to high doses may result in a true physiological withdrawal and may also cause a relapse in the original anxiety symptoms that the patient was being treated for. Symptoms of benzodiazepine withdrawal include: sweating, tremor, agitation, nausea, and tachycardia. At very high doses, abrupt stoppage of the drug may result in seizures. Patients on high doses may need to be tapered over 4 weeks. Those at the low end of the dosage range may not require a taper.
Muscle relaxants, including Baclofen, Carisoprodal, and Tizanidine may need to be tapered over 1 week to avoid symptoms ranging from mild reactions of body aches, anxiety, sweating, and insomnia to severe reactions including hallucinations, hypertension, tachycardia, and seizures. Doses in the lower range are generally associated with only mild reactions upon abrupt discontinuation.
Corticosteroids may need to be tapered to avoid a rebound of symptoms of the underlying condition being treated (flares of rheumatoid arthritis, lupus, dermatitis) as well as to avoid steroid withdrawal symptoms. Steroid withdrawal symptoms include: flu-like symptoms (muscle aches, nausea/vomiting, diarrhea), hypotension, abdominal pain, weakness, and weight loss. Steroid withdrawal symptoms are due to the unmasking of adrenocortical suppression seen with the abrupt stoppage of corticosteroids in patients on long-term therapy. Generally significant adrenocortical suppression is not a concern in patients who have received corticosteroids for 3 weeks or less and have not received a dosage of > 20mg/day of Prednisone or Prednisone equivalent (dexamethasone > 3mg/day). Abrupt cessation in these patients is unlikely to trigger significant steroid withdrawal symptoms. For patients who have been on higher dose steroids or receive courses of therapy longer than 3 weeks, a gradual taper is recommended. Steroid doses may initially be reduced rapidly (by halving the dose every 2 days) until physiological doses are reached (prednisone 7.5mg daily or equivalent), then more slowly (1-2 mg/week) to allow the adrenals to recover.
Clonidine, the antihypertensive medication, may need to be tapered over 2 to 4 days to reduce the risk of a discontinuation syndrome. The discontinuation syndrome with Clonidine consists of rebound hypertension, headache, anxiety, insomnia, sweating, tachycardia, tremor, muscle cramps, hiccups,nausea, and salivation. Rarely, in extreme cases of abrupt withdrawal off of very high doses, encephalopathy, stroke, and death have been reported. The risk of the discontinuation syndrome is greater with oral Clonidine than with the Transdermal patch, however, it is recommended that the patch be tapered or the patient switched to oral and then tapered.
Opioid withdrawal symptoms consist of runny nose, tearing, chills, muscle aches, vomiting, diarrhea, cramps, anxiety, insomnia, and agitation. Rebound pain from the underlying condition being treated may also present. Initial dosage reduction should be at an increments of 25% every 3 days.
Posted by Dr. Jim Joyner
Coughing
is beneficial to help clear the airways of secretions and foreign matter. It should generally be encouraged. Coughing is considered problematic when the cough is:
♦ Ineffective
♦ Interfering with sleep, rest, eating, or social activity
♦ Causing other adverse symptoms such as vomiting, muscle strain, rib fracture, headache, syncope
There are two primary categories of drugs that may be employed to treat inappropriate coughing: protussives and antitussives.
Protussives, also known as expectorants, work by making the sputum less thick and tenacious so that the patient can more effectively expectorate it. Protussives do not impair the cough reflex. As the name suggests, antitussives interfere with the normal cough reflex. The decision-tree for drug treatment selection starts with the question of whether the patient's cough is "wet" or "dry".
In a hospice patient with a wet cough (sputum, secretions are present) a protussive may help the patient expectorate material that may be irritating the throat and reduce the frequency of coughing. A protussive agent, such as guaifenesin, is the appropriate initial therapy for wet cough and response will be enhanced if the level of hydration can be increased as well. An antitussive may be added later if there is a lack of desired response. For dry cough the initial treatment step is an antitussive.
Antitussives can be divided into peripherally acting agents and centrally acting ones. Peripherally active agents include the demulcents, which are (non-drug) syrup or glycerol containing products such as the various OTC lozenges that work by stimulating the production of saliva and soothing the oropharynx, thus interfering with the cough reflex. The therapeutic response to these products is relatively short-lived.
Local anesthetic solutions such as lidocaine and bupivicaine are other examples of peripherally active antitussives. They act by inhibiting the sensory nerves in the airways involved in the cough reflex. The use of these products is very limited due to bitter taste, oropharyngeal numbness, and a short duration of action (approx. 30min).
Benzonatate (Tessalon) is chemically related to the local anesthetics and is believed to act by peripherally inhibiting the stretch receptors along the airways. It has a longer duration than the local anesthetics, in the range of 6 to 8 hours. It also has the advantage of being available in a capsule form for added convenience and this dosage-form also eliminates the possibility of non-compliance due to bad-taste.
The centrally acting antitussives are primarily opioids or opioid derivatives such as dextromethorphan. These drugs act by suppressing the cough reflex center in the brain stem. Codeine and hydrocodone are the most common opioid drugs found in cough preparations, however, all opioids have significant antitussive activity.
In hospice and palliative care, patients are often already receiving strong opioids. If a PRN dose of the regular opioid relieves the cough it may continue to be used as a PRN or the hospice patient's routine opioid dose may be increased accordingly. If no improvement is seen with the current opioid PRN dose, there is generally no advantage to adding another opioid such as codeine for cough suppression.
Benzonatate or dextromethorphan are often the initial antitussives of choice due to good efficacy and low incidence of side effects. Opioids are more effective but present a potential for more significant side effects. For patients with persistent cough, unresponsive to opioids, the antidepressant, paroxetine (Paxil) 10-20mg daily, has been demonstrated to be very effective in series of patients.(1)
Ideally, the primary cause of the hospice patient's cough should be identified and specifically addressed, e.g. drug discontinuation in the case of ACE-inhibitor induced cough or antibiotics for infection-related cough. However, when the cause of the cough is unknown or not amenable to treatment, it is appropriate to institute measures to suppress the cough.
(1) Zylicz, Krajnik J Pain Symptom Manage.2004;27(2):180-184
PROTUSSIVES |
ANTITUSSIVES |
|
Guaifenesin (Mucinex, Robitussin Plain) |
Benzonatate (Tessalon) |
|
Nebulized Saline solution 0.9% |
Lidocaine (Xylocaine) 2% solution |
|
Nebulized Acetylcysteine (Mucomyst) |
Dextromethorphan (Robitussin DM, various others) |
| |
Codeine (Robitussin AC, various) |
| |
Morphine (Roxanol) |
| |
Oxycodone (Oxyfast) |
| |
Methadone (various) |
| |
Hydrocodone (Hycodan, Hycomine) |
| |
Hydromorphone (Dilaudid) |
| |
|
| |
|
Posted by Autumn Spence
The Pharmacies
The pharmacy is one of the primary relationships when dealing with a Pharmacy Benefit Manager (PBM). Ask for pharmacy references and call them. The pharmacy will have a lot of insight to the level of service the hospice can expect from the PBM. Most likely, if a pharmacy has had problems so will the hospice.
The Mail
Work with a PBM that offers mail order, if needed, but also one that has relationships with local pharmacies. Every hospice that works with a PBM will need to utilize local pharmacies, whether as common practice or in emergency situations. You want to be sure that pharmacy is expecting you and can service you. Many pharmacies will not regularly stock all hospice medications if they are not regularly servicing them or not expecting the hospice patient.
The Specialist
Though PBM's have been around for over 25 years, most are not equipped to handle hospice business. PBM's traditionally set up strict formularies without any changes; they enter the information into the computer system and do very little after the initial enrollment. Most PBM's do not have the capabilities to manipulate the data on an individual basis that is needed for hospice. This can mean unnecessary denials from the pharmacy, multiple phone calls to get a patients medications filled and non-hospice approved medications being billed to the hospice.
The Decision
Whether choosing a PBM for the first time or considering a new provider, the choice is important. Hospices need to partner with a PBM for a variety of different reasons. Pharmacy services and costs are too much for most hospices to handle internally. New hospices, small rural hospices, and established nationwide hospices alike are seeking the expertise of a PBM. Choose a PBM that will sustain a long and valuable relationship. Find a PBM that meets your hospice clinical needs, provides you a competitive price and excellent customer service with a commitment to a lengthy partnership.
PBM for past, present and future
Choose a PBM that will meet your needs today and tomorrow. With new legislation, pharmaceutical costs on the rise and changes happening on a daily basis, be sure to choose a PBM that is able to make the changes that the future demands. Ask questions about their company, employees, pharmacy networks, continuing education and their vision for the future - you will be a part of it!
Contact Us for a Free Consultation for your Hospice
Posted by Autumn Spence
The Choice
The primary reasons hospices are choosing to partner with a PBM are rising pharmacy costs, complex patients, a growing census and strain on resources. Even hospices that own their own pharmacy are partnering with a PBM for some of their patients. It can be very costly for an organization to put off an evaluation of their pharmacy services and PBM relationship. If you are not working with a PBM, now is the time to consider. Choose a PBM that is more focused on client services and building relationships rather than one focused on sales and procurement of new business. If a PBM is running correctly, they will have slow, steady growth with a strong base and solid reputation.
Your Needs
Communicate what you are looking for in a relationship with a PBM. There are many options so you want to be sure to pick the best one for your hospice. Be clear about what your needs are and demand they are met.
The Beginning
Trust and confide in the sales representative you are working with. If you cannot, get another one. Contact the company directly and request a new representative. This person is pivotal in the decision making process and you will need to be confident in their ability to define their scope of business. Be sure they are "selling" a program that they can deliver. The biggest mistake made by sales associates is "over selling".
The Relationship
Look at the other layers of the organization you will be working with. Once the "sales" job is over, you will primarily be in contact with someone who did not "sell" you the program. Inquire about who will be handling your account once a contract is signed. Inquire about the enrollment and set-up process. Meet with the clini-cians and others you will be in a daily contact with. Communicate with other members of the organization you will be working with to make the best choice.
The Value
Get the best value for your hospice. Share your contracted rate or what you are being offered; use this as leverage to get the best value. Request a specific price comparison. Consider carefully the services you will be getting for the price offered. Cheaper is not always better.
The Patients
Patient care is the primary factor in any decision a hospice makes. Choose a PBM that will increase hospice patient care and services. Pharmacy choices are just the beginning. Good clinical assistance, palliative symptom protocols, educational services and strong relationships with local pharmacies are some of the differ-ences between a good PBM and a great PBM.
The Clinicians
Patient care is affected by the skill, experience and knowledge of the caregivers. Partner with a PBM that has experts in palliative care, symptom management, certified in geriatric care and experience with hospice patients. Also, a great PBM will have specialists in the field that can also provide formulary recommendations, consultation for patients in skilled facilities and other areas specific to hospice.
TO BE CONTINUED, SEE PART TWO OF TIPS FOR CHOOSING A PBM