explain this please
Joined: 06 Aug 2003
Posts: 1
Posted: Wed Aug 06, 2003 4:17 am Post subject: AMIGEN IE; EPO
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> Implementation of Pharmaceutical Care Services in a Renal<
> Dialysis Unit<
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> Cynthia A. Naughton, Pharm.D., M.S.<
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> Heartland Health System<
> North Dakota State University College of Pharmacy<
> Fargo, North Dakota<
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> Managing patients with chronic kidney disease (CKD) is<
> frequently complex due to the presence of multiple medical<
> conditions along with renal impairment. Dialysis patients<
> generally exhibit numerous concurrent problems, either due to<
> or as a consequence of their renal failure. Associated medical<
> problems include diabetes mellitus, hypertension, anemia,<
> hyper or hypocalcemia, hyperphosphatemia, secondary<
> hyperparathyroidism, infectious processes, and cardiovascular<
> morbidity.<
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> Pharmacotherapy management of CKD patients has been<
> optimized through the addition of pharmaceutical care to the<
> already existing medical, nursing, dietary, and social work care<
> plans. The pharmaceutical care service began in 1998 and<
> initially consisted of erythropoietin dosing. The service has now<
> grown to include the following:<
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> Medication history upon admission <
> Quarterly drug regimen review <
> Maintenance of a computerized patient database <
> Renal dosing service <
> Erythropoietin dosing protocol management <
> Iron dosing protocol management <
> Vitamin D dosing protocol management <
> Patient and family education <
> Participation in monthly care conferences with attending<
> nephrologists, and <
> Collaboration with the transplant team <
><
> The Heartland Health Systems Kidney Dialysis Unit is a<
> regional, ambulatory dialysis facilities servicing approximately<
> 110 hemodialysis and 30 peritoneal dialysis patients. The<
> average daily census is 55 patients. Prior to implementing a<
> pharmaceutical care service, pharmacy services were purely<
> distributive functions. The pharmacy supplied the<
> erythropoietin, heparin, iron dextran, and calcitriol injection<
> without looking at appropriateness of therapy or monitoring.<
><
> In 1997 the National Kidney Foundation released their Dialysis<
> Outcomes Quality Initiative (DOQI) Clinical Practice Guidelines<
> on Anemia Management. The consensus document targeted a<
> hematocrit range of 33-36% to improve patient outcomes and<
> survival. The Health Care Finance Administrations (HCFA) also<
> announced changes to Medicare reimbursement.<
> Reimbursement for erythropoietin would be denied if a<
> patient?s average hematocrit exceeded 36.5%. At the time<
> erythropoietin was the number one pharmaceutical in dollars<
> spent at Heartland. The cost was $10 per 1000 units, the<
> typical patient dose was 10-12,000 units/week (range<
> 1000-30,000 units), and approximately $50,000 worth of<
> erythropoietin was used per month in the kidney dialysis unit.<
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> The clinical and financial impact was great and an<
> erythropoietin use evaluation was conducted. Criteria included<
> the percent of patient in DOQI target hematocrit range<
> (33-36%) and the percent of patients with a hematocrit<
> exceeding 36.5%. The results were 40% of patients were<
> below target range, 30% were within the target hematocrit<
> range of 33-36%, and 30% were above the 36.5% hematocrit.<
> With 30% of the patients exceeding a hematocrit of 36.5%, it<
> was projected that $16,000 per month would be lost revenue<
> in denied Medicare claims with the current dosing practice.<
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> A performance improvement team consisting of physicians,<
> nursing, pharmacy, and finance were convened to study the<
> problem and identify alternatives to the current practice of<
> physician directed erythropoietin dosing and monitoring. From<
> this group a pharmacy managed EPO dosing protocol was<
> developed, approved, and implemented in January 1998.<
> Pharmacy also supplied erythropoietin in unit dose syringes to<
> minimize waste and coordination with finance department for<
> reimbursement was established. <
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> The new EPO protocol was evaluated for medical and finance<
> outcomes after 12 months. The percentage of patients within<
> the DOQI target hematocrit range of 33-36% with the new<
> protocol consistently exceeded the baseline value of 30%. Also<
> the percent of patients exceeding an average hematocrit<
> greater than 36.5% declined from 30% to an average of 8.0%<
> and there were no Medicare denials for erythropoietin.<
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> Due to the success of the EPO project, other opportunities<
> were explored to expand services in the kidney unit. A<
> telephone survey of renal units was conducted in the<
> surrounding states. About 25% of the pharmacy?s provided<
> some pharmaceutical services which turned out to be<
> predominately antibiotic dosing. <
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> Service opportunities were identified for pharmaceutical care at<
> Heartland including:<
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> Anemia management <
> Medication management <
> Identification and resolution of drug related problems <
> Calcium and phosphorous balance management <
> Hyperparathyroidism management <
> Patient and Family Education <
> Transplant therapeutics <
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> Hospital administration supported the idea of adding<
> pharmaceutical care services to the kidney unit as long as no<
> additional staff needed to be hired. An application for a grant<
> was written and awarded by the Dakota Medical Foundation to<
> fund a pharmacy resident. Pharmaceutical care services were<
> implemented when the pharmacy resident started at the<
> facility. Pharmaceutical care services were provided initially to<
> hemodialysis patients only and have now been expanded to<
> the peritoneal dialysis population also.<
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> The pharmacy resident position was instrumental in<
> implementing the program. The resident helped design the<
> computerized database capable of generating current<
> medication profiles which were then placed in the medical<
> record. A rotating calendar of patient appointments was<
> generated so that all patients would meet with a pharmacist<
> upon admission and then quarterly for drug regimen review. In<
> the first year alone, 131 drug related problems were identified<
> during the patient appointments.<
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> Drug related problems identified in dialysis patients <
> (from July 2000-June 2001.)<
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> Problem <
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> Frequency (%)<
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> Untreated Indication<
> 45 (34.3%)<
> Indication with an Incorrect Drug <
> 21 (16%)<
> Adverse Drug Reaction <
> 14 (10.7%)<
> Failure to Receive or Take a Drug<
> 10 (7.6%)<
> Incorrect Timing<
> 10 (7.6%)<
> Drug without an Indication<
> 8 (6.1%)<
> Sub-therapeutic Drug Dose<
> 8 (6.1%)<
> Therapeutic Duplication<
> 8 (6.1%)<
> Drug Overdose<
> 7 (5.3%)<
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> Services were expanded in the first year of pharmaceutical<
> care services to include the development and implementation<
> of a pharmacist managed iron dosing protocol and a<
> pharmacist managed Vitamin D dosing protocol. <
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leadsag
Joined: 31 Oct 2002
Posts: 263
Posted: Wed Aug 06, 2003 4:29 am Post subject: Lets get this right
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So they are proud of the fact
that they have reduced the percentage of patients with hemocrit over 36.5% from 30% of the patients to 8%?<
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>And they are happy about this!!!<
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>
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RedheadedReptile
Joined: 09 Mar 2003
Posts: 69
Posted: Wed Aug 06, 2003 4:38 am Post subject: Sure they are happy
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Medicare doesn't pay for EPO if your crit is over 36.5... so in effect, every patient with a high crit is costing them money.<
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>So much for 'rehabilitation' being part of the program-- anybody with a low crit obviously won't be able to go back to work.
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leadsag
Joined: 31 Oct 2002
Posts: 263
Posted: Wed Aug 06, 2003 4:41 am Post subject: write to your senator
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So lets get some ETHICAL senator to introduce a bill raising the level at which Medicare will pay for EPO from 36.5% . Is there someone involved here who can write a good letter that we can send to all the senators?
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Lin
Joined: 28 Oct 2002
Posts: 337
Posted: Wed Aug 06, 2003 6:57 am Post subject: *&%^@!!!!
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All I know is that when my hgb. falls below 11 I feel like crap, and when it's at 11 or above I feel super. They figure the majority of dialysis pts. are retired and even if they felt better wouldn't go back to work, but what about the rest of us. Sure, I could go back to work but I wouldn't have the energy to cook, clean, do laundry, yard work, ect ect; who would do those things? Right now I keep house and go to dialysis, and do without things I can't afford now. I would love to have the energy to work outside of the house, and yes even pay taxes. My retirement nest egg is the size of a marble!<
>My hemglobin shot up to 12.5 so they cut back the epo; trust me, I knew when it dropped to 10 like now. All I know is that younger pts. on dialysis are getting shafted epo wise, and it stinks! Lin.
