title: Drug utilization review on a tertiary palliative care unit.
abstract: Drugs are indispensable for the management of symptoms in palliative care patients, and account for a significant proportion of expenditures on a Tertiary Palliative Care Unit (TPCU). Drug expenditures for Edmonton's TPCU increased by 40% in 2002 compared to 2001. Fifty-five percent of the increase was attributable to injectable fentanyl, oral and injectable ondansetron, and total parenteral nutrition (TPN). As there was no increase in the unit cost of these drugs between 2001 and 2002, the increased expenditures reflected increased utilization. The hypothesis of this study was that the increased utilization of these drugs reflected appropriate prescribing. The objective was to compare the indications for prescribing these drugs in 2002 against evidence- and consensus-based criteria. Patients who received these drugs while admitted to the TPCU from January 1 to December 31, 2002 were identified through the pharmacy database. Evidence- and consensus-based criteria for drug utilization were developed. Prescribing indications were retrospectively compared against the criteria. Drug prescriptions were categorized as follows: (1) meeting criteria, (2) not meeting criteria, or (3) uncertain. The drugs under study were prescribed during 48 out of 234 admissions to the TPCU in 2002. Prescriptions for fentanyl met criteria in 26 of 29 cases. Indications were unsuccessful therapy with morphine, hydromorphone, and oxycodone (20), requirement for rapid titration from fentanyl patch (5), renal failure (2), and sublingual administration for breakthrough pain (1). Prescriptions for ondansetron met criteria in 19 of 21 cases. Indications were nausea refractory to metoclopramide and dexamethasone (13), and nausea related to radiotherapy or chemotherapy (6). Prescriptions for TPN met criteria for initiation in only one of five cases. However, in all cases, TPN had been started prior to admission. In cases where death was considered imminent, TPN was continued pending consultation with the patient and family regarding discontinuation. These data indicate that the increased prescribing of fentanyl and ondansetron on the TPCU satisfied evidence- and consensus-based criteria in most cases, apparently justifying the associated increase in drug expenditures. This type of analysis may be useful whenever increased drug utilization requires review. A cost effectiveness analysis would be the next step in evaluating the costs vs. the benefits. The issue of discontinuing TPN in palliative care patients requires further investigation.
authors.affiliation: Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Alberta, Canada.
authors.forename: Lea Renina
authors.initials: LR
authors.lastname: Llanes
authors.forename: Konrad
authors.initials: K
authors.lastname: Fassbender
authors.forename: Vickie E
authors.initials: VE
authors.lastname: Baracos
authors.forename: Sharon
authors.initials: S
authors.lastname: Watanabe
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000701:Analgesics, Opioid / Q000191:economics / Q000627:therapeutic use*; D014151:Anti-Anxiety Agents / Q000191:economics / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D017723:Drug Utilization Review; D005260:Female; D005283:Fentanyl / Q000191:economics / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000178:diet therapy / Q000191:economics; D017294:Ondansetron / Q000191:economics / Q000627:therapeutic use; D010146:Pain / Q000188:drug therapy*; D010166:Palliative Care / Q000191:economics / Q000706:statistics & numerical data*; D010289:Parenteral Nutrition, Total / Q000191:economics
chemical_list: D000701:Analgesics, Opioid; D014151:Anti-Anxiety Agents; D017294:Ondansetron; D005283:Fentanyl