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American Society of Consultant Pharmacists (ASCP) 2011 Spring Conference and Exhibition
May 17-19, 2011 Las Vegas, NV
Enlisting Pharmacy Consultants to Reduce Nursing Home Medication Costs
Nursing home administrators and consultant pharmacists evaluate medication costs at long-term care facilities from different perspectives, according to Frank Grosso, RPh, vice president of pharmacy services at Genesis Healthcare Corp, who gave a lecture at the ASCP Spring Conference. He explained that pharmacists are primarily concerned with average prescription prices, the use of expensive drugs, and whether medications are being overprescribed for some patients. Nursing home administrators, however, are more concerned with drug units per patient day (PPD), occupancy rates, and the quality mix (ratio of Medicare patients to patients with non-public coverage). Grosso said because the census and payor mix can significantly affect a facility’s costs, administrators must monitor them closely.
At times, an administrator might approach the pharmacist for help in evaluating and controlling the facility’s medication costs. Grosso described this as an opportunity for consultant pharmacists to work with the administrator to improve patient outcomes, decrease costs, and maximize revenues. He recommended looking at the problem from the nursing home operator’s point of view and suggested trending pharmacy invoices over time, assessing invoices according to the facility’s quality mix, and managing the PPD drug costs.
“The [biggest] opportunity is in managing the PPD,” Grosso said. He advised pharmacists to make “high value therapeutic interchanges,” and avoid recommending therapeutic substitutions unless the replacement drug offers a reasonable return on investment. The replacement drug should improve the patient’s quality of life, and any indirect costs (eg, supplemental labor, wasted medication) for making the interchange should not outweigh anticipated savings in direct costs.
Grosso said consultant pharmacists should manage polypharmacy to improve patient satisfaction and reduce medication errors, review prescriptions that are not covered under Medicare Part D, and assist in processing prior authorizations. To promote cost savings, he also recommended they emphasize managed care payor strategies and look for opportunities to improve admission and discharge patterns.
“We can work together to have better patient outcomes and control costs,” Grosso said. “We need cooperation. We need to work collaboratively to meet the needs of the elderly.”
Long-Term Care Residents at Risk for VTE
Venous thromboembolism (VTE) is a serious concern for hospitalized patients and residents of long-term care (LTC) facilities, who together account for approximately 60% of VTE cases. In a lecture at the ASCP Spring Conference, Barbara J. Zarowitz, PharmD, chief clinical officer and vice president of professional services for Omnicare Inc, and Allen L. Lefkovitz, RPh, PharmD, consultant pharmacist for Beeber Pharmacy, noted the uncertainties surrounding treatment of VTE in the LTC setting, which stem partly from the underrepresentation of this patient population in related clinical trials. The speakers said although a PubMed literature search revealed ~1200 studies on VTE, only four were relevant to the LTC population. “We really have a paucity of information to draw upon, which can lead to poor decisions,” Ms. Zarowitz said.
VTE events include deep vein thrombosis (DVT), which occurs when a blood clot forms in a deep vein of an extremity or the pelvis; and pulmonary embolism (PE), an often fatal condition that arises when a blood clot lodges in an artery of the lung. Risk factors include age ≥60 years, cancer, cigarette smoking, heart failure, immobilization, obesity, hypercoagulability disorders, use of indwelling venous catheters, recent surgery, limb trauma, and a previous VTE event.
According to a 2005 report in the Journal of Thrombosis and Haemostasis, the incidence of VTE in LTC residents was estimated at 13 per 1000 nursing home years (www.ncbi.nlm.nih.gov/pubmed/16102026). Ms. Zarowitz said patients who need help with mobility or who have suffered a hip, leg, or pelvic fracture have an even greater risk.
Clinical signs of VTE include dilated collateral superficial veins and tenderness, warmth, swelling, or pitting edema in the calf, thigh, or entire leg. Ultrasonography is highly effective for diagnosing VTE. Venograpy and D-dimer testing are other useful modalities for detecting VTE.
Several medications are available to treat VTE, including warfarin, unfractionated heparin, low-molecular-weight heparin, and fondaparinux. For some patients, guidelines recommend pharmacological prophylaxis, such as for hospitalized patients with cancer. Nonpharmacologic prophylactic options are also available. Some medical therapies are associated with an increased risk of bleeding. The speakers said healthcare professionals must carefully weigh the risks and rewards of available therapies.
ASCP Product Theater
Uloric Overview: Managing Hyperuricemia in Patients with Gout
On February 17, 2009, Uloric (febuxostat) became the first new gout drug to be approved by the FDA in more than 40 years. Febuxostat, a xanthine oxidase inhibitor, reduces the production of uric acid in patients with gout and symptomatic hyperuricemia. Persons with serum uric acid levels (sUA) >6 mg/dL are at risk of monosodium urate crystals forming in their soft tissues and joints, which can lead to tophi (a deposit of crystalline uric acid and other substances at the surface of the joints or in skin or cartilage) and persistent low-grade inflammation around the joints.
“We need to start thinking of gout as a chronic, progressive disease,” said speaker Malin Prupas, MD, Arthritis Center of Reno, NV, during the Uloric product theater. Gout affects approximately 6.1 million individuals in the United States annually, and these individuals are at risk of gout flares, which may occur without warning and can be debilitating, he noted.
Studies have indicated that maintaining sUA levels <6 mg/dL may reduce the risk of gout flares. A 2004 retrospective study by Shoji and colleagues that reviewed data on 267 patients with gout over 3 years found that 86% of patients (n = 81) who achieved a serum uric acid level of <6 mg/dL had no gout flares during the observation period (www.ncbi.nlm.nih.gov/pubmed/15188314). These patients had been treated with allopurinol and benzbromarone.
Prupas proceeded to discuss the pharmacological approach to managing gout. He noted that expert consensus generally recommends resolving the acute flare by initiating treatment with an anti-inflammatory agent. Thereafter, a urate-lowering therapy to achieve an sUA level <6 mg/dL should be started, preferably in combination with a nonsteroidal anti-inflammatory agent or colchicine to prevent mobilization flares. Urate-lowering therapy should be continued to maintain sUA levels, and anti-inflammatory prophylaxis can be given for up to 6 months as sUA levels normalize. Once the flare resolves, periodic monitoring of patients’ sUA levels should be undertaken to ensure that target sUA levels are achieved and maintained.
Appropriate candidates for febuxostat are patients with mild-to-moderate renal impairment (creatinine clearance [Clcr] ≥30 mL/min and <90 mL/min) and gout that is poorly controlled on allopurinol, as demonstrated by sUA levels of >6 mg/dL. There are currently insufficient data on the use of febuxostat to treat gout in patients with severe renal dysfunction (Clcr <30 mL/min); thus, it should be used cautiously in these patients.
When initiating febuxostat, 40 mg once daily is the recommended starting dose, said Prupas. If an sUA level <6 mg/dL is not achieved after 2 weeks of treatment, the dose can be increased to 80 mg once daily, he noted. Special dose adjustments are not needed in patients with mild-to-moderate renal or hepatic impairment. Febuxostat can be used in patients on warfarin, but is contraindicated in those taking theophylline or immunosuppressants, such as azathioprine and mercaptopurine.
