Journal of Pain & Palliative Care Pharmacotherapy ISSN: 1536-0288 (Print) 1536-0539 (Online) Journal homepage: http://www.tandfonline.com/loi/ippc20 A Cost and Quality Analysis of Utilizing a Rectal Catheter for Medication Administration in End-of- Life Symptom Management Natalie M. Latuga, Mary Gordon, Paula Farwell & Megan O. Farrell To cite this article: Natalie M. Latuga, Mary Gordon, Paula Farwell & Megan O. Farrell (2018): A Cost and Quality Analysis of Utilizing a Rectal Catheter for Medication Administration in End-of-Life Symptom Management, Journal of Pain & Palliative Care Pharmacotherapy, DOI: 10.1080/15360288.2018.1500509 To link to this article: https://doi.org/10.1080/15360288.2018.1500509 © 2018 Natalie M. Latuga, Mary Gordon, Paula Farwell, and Megan O. Farrell Published online: 31 Dec 2018. Submit your article to this journal Article views: 41 View Crossmark data Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ippc20 JOURNAL OF PAIN & PALLIATIVE CARE PHARMACOTHERAPY https://doi.org/10.1080/15360288.2018.1500509 ARTICLE A Cost and Quality Analysis of Utilizing a Rectal Catheter for Medication Administration in End-of-Life Symptom Management Natalie M. Latuga, Mary Gordon, Paula Farwell and Megan O. Farrell ABSTRACT ARTICLE HISTORY Technology that can improve the ability to provide quick symptom control while decreasing Received 14 December 2017 the cost and burden of care could help hospice agencies deal with current hospice industry Revised 8 June 2018 challenges. This paper describes how the use of a new rectal medication delivery technol- Accepted 9 July 2018 ogy at a large hospice in western New York has improved patient care and nursing effi- KEYWORDS ciency while at the same time decreasing the cost of care. Cost savings; end of life; hospice; Macy catheter; palliative care; symptom management Introduction care needs and visit intensity during those last The ability to provide excellent end-of-life care in days of life. Lastly, the increased requirements for a cost-effective manner is the goal of every hos- quality metrics and the rapidly changing regula- pice agency. Unfortunately, the business of hos- tory landscape have put a large burden on hospi- pice is becoming more challenging each year. ces, which have had to add quality oversight staff Hospices are questioning their long-term survival to keep up with regulatory burdens. with the continued decreases in reimbursement Symptom management can be costly to agen- and increased costs of care. The phaseout of the cies in clinician time and medication and other budget neutrality factor, sequestration, and the pharmacy-related costs. Although patients with productivity adjustments by Medicare continue to difficult symptom management represent a decrease hospice reimbursement and are slated to minority of hospice cases in our experience, they continue through 2022 (1). can be very costly, raising the overall direct cost In addition to decreased revenue, operational of care. Oral and sublingual routes of medication costs continue to rise. According to the most delivery facilitate effective symptom control in recent March 2018 MedPAC (Medicare Payment most hospice patients, but there is still a signifi- Advisory Commission) report, (2) the 2015 aver- cant subset of patients for whom these routes age hospice cost of care was $150 per day, an either are not functional or fail to control symp- “ ” increase of 0.5% from 2014. MedPAC reports an toms. Chasing symptoms with sublingual medi- increased profit margin between 2014 and 2015 cation by raising the dosage can lead to from 8.2% to 10% for all combined hospices but aspiration, stressed caregivers, patient suffering, predicts the 2018 margins to be about 8.7%. and nonpeaceful deaths that lead to poor-quality MedPAC reports that the median length of hos- outcomes and increase the cost of care. The sub- pice stay was 18 days for 2016, with more than lingual route of delivery is in most cases not an 25% of patients enrolling within the last week of effective route for patients with severe agitation, life, while acknowledging an increase in patient pain, seizures, nausea and vomiting, and other severe symptoms. These patients usually need an Natalie M. Latuga, PharmD, BCPS, Mary Gordon, RN, Paula Farwell, RN, and Megan O. Farrell, BSN, MHA, CHPN are with The Center for Hospice and Palliative Care, Cheektowaga, New York, USA. CONTACT Natalie M. Latuga [email protected] The Center for Hospice and Palliative Care, 225 Como Park Boulevard, Cheektowaga, NY 14227, USA. ß 2018 Natalie M. Latuga, Mary Gordon, Paula Farwell, and Megan O. Farrell This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 2 N. M. LATUGA ET AL. alternative route, which traditionally has been piloted in the last quarter of 2015 in the 22-bed limited to intravenous (IV), subcutaneous (SQ), HIU, followed by a rollout to the home care or rectal suppository. All these options mandate teams in the first quarter of 2016. Pharmacy costs ordering, preparing, and delivering new forms of continued to rise through 2016, particularly par- medication with additional cost and lag time to enteral medication costs in the HIU, despite the therapy implementation. Faced with these chal- introduction of the catheter as a possible option lenges, in 2015, Hospice Buffalo began using a for symptom management. specialized rectal administration catheter that solved these problems by enabling the use of oral Methods medications that were already on hand at the bedside. In February 2017, Hospice Buffalo initiated a set This rectal administration catheter (Macy cath- of guidelines to curb pharmacy expenses by fur- eter; Hospi Corporation, Eureka, CA) is Food ther encouraging and directing the use of the rec- and Drug Administration (FDA)-cleared to pro- tal catheter in both home care and the HIU. The vide rectal access to deliver medications and flu- guidelines included instructing clinicians to try ids. The catheter comes in a kit that has a pill the rectal administration catheter as the first-line pulverizing system included. Use of the catheter alternative when a patient was unable to swallow and pulverizing system enables medications to be and sublingual was ineffective. The agency con- easily pulverized, suspended in a small amount of tinued to ask patient families to bring the water, and given rectally. The catheter consists of patient’s oral medications to the HIU to reduce a 14-Fr tube with a soft balloon on one end and waste and costs, as had been done all along. a valved medication port and balloon inflation A more detailed post hoc analysis of cost and port on the other. It facilitates ongoing adminis- clinical outcomes was conducted following the tration of medication or fluids for up to 28 days guideline implementation when pharmacy invoi- and can be reinserted during this time period if ces were noted to be significantly lower. Actual expelled with (or removed for) a bowel move- cost savings and modeled cost savings were cal- ment. The end of the catheter rests on the leg, culated from the monthly pharmacy billing invoi- allowing access to deliver medication or fluid ces and census data. The clinicians (physicians, without having to expose or move the patient. nurse practitioners, and registered nurses) were Medications in solid form are ground with the informally surveyed regarding the catheter’s pill pulverizer, a small amount of water is added, effectiveness, benefits, and challenges. and the resulting microenema suspension is injected into the distal one third of the rectum. Results Hospice Buffalo provides hospice care in both private homes and long-term care facilities and In 2016, Hospice Buffalo utilized 160 catheters in provides inpatient care in a 22-bed hospice the HIU (approximately 25% of patients) and 139 inpatient unit (HIU) in Erie County, New York. catheters in home care (approximately 9% of In 2016, the agency cared for approximately 4134 patients). This did not include the routine home hospice beneficiaries, including 1609 home care hospice patients in skilled nursing facilities, as patients, 1062 long-term care/assisted-living the agency had not yet trained facilities in use of patients, 815 hospital patients, and 648 the catheter. The direct supply cost of the cath- HIU patients. eter in 2016 was $0.15 per patient day ($25,415 Hospice Buffalo decided to implement use of in total cost for the catheters divided by 168,054 the catheter as an additional symptom manage- total days of care). ment tool with the goal of improving patient care and having an additional option to administer HIU costs medications when the patient could not swallow, while hoping to simultaneously decrease the bur- The first month the guidelines were in effect, den and cost of care. Use of the catheter was first medication costs in the HIU dropped $12.76 per JOURNAL OF PAIN & PALLIATIVE CARE PHARMACOTHERAPY 3 $50.00 $45.80 $40.00 )srallod(DPPtsoC Pre-change average = $35.52 $38.81 $36.24 $33.83 $15.85 (45%) decrease in PPD $30.00 $32.52 $31.46 $32.11 $30.04 Post-change average= $19.67 $23.92 $20.00 $19.35 $18.25 $17.15 $10.00 May-16 Jun-16 Aug-16 Oct-16 Nov-16 Jan-17 Mar-17 Apr-17 Jun-17 Monthly PBM Medication Cost PPD Average Cost PPD Pre-change Average Cost PPD Post-change PPD= per patient day; PBM = pharmacy benefits manager Figure 1. Hospice inpatient unit (HIU) medication PPD cost, June 2016 to May 2017. $2.40 cost in PPD and the average cost before and after $2.20 guideline changes throughout the time period in $2.00 $1.85 $1.75 the HIU.