Saturday, February 16, 2008

GAO Report on end-of-Life Care; Oxycodone review; problems with Duragesic and Oxycontin

End-of-Life Care: Key Components Provided by Programs in Four States is a report commission by Sen. Ron Wyden. Using descriptions from last decade’s IOM Report and a 2004 AHRQ study, as well as interviews with NHPCO and NAHC, and interviews with 10 EOL researchers, GAO identified 6 “key components” of end-of-life care.

  • Care management to coordinate and facilitate service delivery
  • Supportive services for individuals residing in noninstitutional setting
  • Pain and symptom management
  • Family & caregiver support
  • Communication among individuals, families, and program staff
  • Assistance with advance care planning

They then visited 4 states (Arizona, Florida, Oregon & Wisconsin) to determine how these key components are addressed in practice. They interviewed practitioners and administrators in PACE programs (state-administered care programs for elders supported by Medicare); similar but state-specific programs in Wisconsin & Arizona; and 12 palliative care programs of varying designs (at least 2 in each state).

Examples of the key components in practice:

  • Care management: case managers; interdisciplinary teams
  • Supportive services for patients: adult care programs; meal delivery; housekeeping services; transportation for medical care
  • Pain and symptom management: either integral part of the care model, or established referral patterns with low threshold for referral
  • Family & caregiver support: respite care; bereavement support; assistance with decision-making; in-home support
  • Communication: team meetings; integrated electronic medical records; early and/or continuous conversations with patients to ensure their wishes for care and advance planning are current; use of standard tools to assess patient condition
  • Advance care planning: an integral part of each program, usually beginning early in the relationship with patient; includes family; assist patients with completing advance directive documentation; Physician Orders for Life-Sustaining Treatment (POLST)

The two barriers (“challenges”) to delivering the services described that are highlighted in the report are trying to deliver any services in rural areas, and physician training and practices. The rural issues range from distance and poor roads to lack of pharmacies and other collaborating services, as well as lack of qualified nursing and other personnel. “Physician training and practices” will have a familiar ring: lack of training in pain & symptom management & communication skills, especially those related to EOL discussions & decisions; lack of training regarding EOL services such as hospice and palliative care [here they cite the NEJM article that Christian blogged on last year].

This is not like reading a study in a medical or nursing journal. It is intended for a lay audience (specifically, Sen. Wyden & his office), does not belabor demographics or other statistics, has no tables or charts, is quite repetitious, and is simply descriptive with no attempt at analysis or recommendations. Nonetheless, the services and issues described across these diverse states and programs are quite comparable. This makes it useful information for policy makers and legislators (as was its intent), as well as folks like newspaper editorialists, health columnists, and teachers in public health and clinical programs, especially at the undergraduate level. For those looking for something a little more meaty, the IOM and AHRQ reports cited by the GAO may be helpful. While looking for the AHRQ report, I found a more recent one by the same authors. I'm also reminded of a more recent IOM report on palliative care for cancer, and the very recent report on psychosocial care for cancer patients.

There is an extensive review of oxycodone in Current Medical Research & Opinion . This is not a meta-analysis, but a pretty thorough literature review. At first I was concerned that the authors were not taking a particularly critical look at the studies they looked at, but they do indicate weaknesses in individual studies and as well as the general lack of head to head studies with other opioids. After the umpteenth clinical trial of oxycodone in one form or another (including parenteral in Europe) vs placebo, I begin to wonder why there isn’t more solid research basis for what is obviously a very effective analgesic. The article mostly focused on clinical uses; I would have liked a bit more pharmacology. Maybe not one for the teaching file, but it probably has a place in the oxycodone folder because of its very long reference list.

Problems with fentanyl patches and Oxycontin

All Duragesic 25 mcg patches have been recalled, due to a leakage problem.

This one is a little less clear to me, but it seems all the generic extended release oxycodone products are no longer available. This is because Purdue Pharma won a patent infringement lawsuit. This is apparently not news to the legal crowd or the pharmaceutical industry watchers, but it has caught many clinicians unawares. There are reports of shortages of Oxycontin because of the increase in demand for the branded product. I don’t know whether 3rd party payers who mandate generics have caught up with this.

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