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Potpourri from Clinical Work V

The following observations and questions came up during my recent work as palliative care attending.  Thoughts and responses are welcome:

  • How well do so-called "bridge" programs work?  These are the home-care programs for patients who qualify but whose goals do not align with hospice, or who have serious illness but a prognosis outside of the hospice criteria (e.g. 1 year rather than 6 months).  I have heard rumors that bridge programs may drop patients who do not "cross the bridge" to hospice, or who do not have profitable insurance.  Does anyone know of any studies desribing these programs, and critically evaluating the quality of their services?  This seems to be a potentially important avenue of research.
  • Problems with VA hospice contracts for residential hospice.  A number of area SNF/nursing homes are not accepting the VA hospice contract, or prioritizing it so low as to effectively not accept it.  The fact that the VA will pay for residential hospice care (including room and board) for veterans has always struck me as a very important benefit for this population.  So many veterans lack informal caregivers to provide for their daily needs, and lack the financial resources to hire private help.  Hospice alone - generally a few visits a week - is not nearly enough.  They need the custodial care that the residential benefit provides.  I hope our area issue is not a sign of a national trend toward making placement of veterans in a residential hospice difficult, or (worse) impossible.
  • Opioid analgesia in patients with liver failure.  Does anyone have a good reference?  I read this one and this one, but wasn't particularly impressed.  There doesn't seem to be a fast fact on the topic.

by: Alex Smith

Comments

David Klos, NP said…
Alex, I was the Palliative Care Coordinator for the Providence RI VAMC and we often had to use the Community Nursing Home Program to provide this care to our Veterans. What we found is that, yes, there is a directive that states that Veterans are entitled to it but most CNH programs are not budgeted for it and each hospital can run the program the way they want. SNFs will often low prioritize VA Contract patients for a couple of reasons: 1) The CNH Coordinator has contracted with pricing that is so low that it is not financially worth providing care to the Veteran. or 2) The CNH or Fee Basis Program does not pay their bills appropriately and the SNFs will often have to wait for an extended period of time to get paid for the patient's stay. We had to work very close with the CNH Coordinator and GEC Service Line Manager/Chief to ensure the benefit was there and we had access to it appropriately. We also spoke with the SNFs to see what the problems were. We had to address them and provide support to the SNFs to repair the relationship. It is a very complex relationship within the VA much like the rest of the VA system. Thanks, David Klos, NP
TIM COUSOUNIS said…
"Bridge" programs have become an important part of a palliative care network, and are deserving of greater evaluation than what they've received to date. I haven't found any articles describing and evaluating these programs, so I too would be interested in learning about such publications.

As with all palliative services, patient admission/discharge decisions are regularly made using many criteria, including insurance coverage.
We have a short, practical, and free paper at Pain-Topics.org on safe opioid prescribing in patients with hepatic or renal dysfunction that has been extremely popular. See here:
http://pain-topics.org/opioid_rx/safety.php#RenalHepatic
. Hope this helps. -- Stew Leavitt
Alex Smith said…
Thanks to David, Tim, and Stew for the fast responses!

David-appreciate your story. It sounds like we have more work to do to understand the reasons for the problems with the SNFs and VA hospice contracts, and work to repair those relationships.

Tim-completely agree we need more information about the quality and services offered by bridge programs. They fill an important niche, but what exactly are they? What do they do? What is the impact on patient outcomes? How are patients enrolled and disenrolled?

Stew - the pain topics paper is a great reference! Very practical. One issue - the pain topics paper recommends against the use of methadone in patients with hepatic dysfunction (citation is a package insert). The article in Mayo Clinic Proceedings by Chandok I linked to above actually touts methadone (along with fentanyl) as one of the safest drugs to use in hepatic dysfunction. For support, they note the many patients who use methadone without problems for opioid replacement therapy (history of substance abuse). Anecdotally, we've used methadone in patients with hepatic dysfunction without issue. Methadone is metabolized in the liver, however, so I understand there are reasons for caution, and we've generally dose-reduced when used for analgesia.
Brad S said…
Alex -- Shameless plug: our Advanced Illness Management (AIM) Program started as "bridge program" in 2002, although it's since grown into a care-coordination intervention linking hospital, office/clinic, and home/community. We published AIM hospice enrollment rate increases in JPM back in Dec. 2006, but have not yet published data from "AIM 2.0." A brief profile of the new program including cost savings, however, is in Health Affairs 2011;30(3):390-393. Similar programs of "Advanced Care" such as Aetna's Compassionate Care and Gundersen's Respecting Choices have also provided new (unreimbursed) services to provide care driven by patient choice, and have also achieved significant reductions in utilization and cost. Founders of all 3 of these programs, along with many others, have banded together to form the DC-based Coalition to Transform Advanced Care (C-TAC -- go to advancedcarecoalition.org) in order to develop a national model. May be coming soon to a health system near you!
Alex... our Pain-Topic.org paper needs some updating (we still list propoxyphene, aargh!). We advise against methadone in "severe" liver failure due to the potential for accumulation over time to hazardous serum levels. I suppose at very low analgesic doses, with only moderate liver dysfunction, this might not be as significant a problem -- but there are other effective opioids to choose among (eg, we do say oxycodone and fentanyl are okay).

Considering methadone as "safe" with any degree of hepatic dysfunction seems like a 'stretch.' And, using MMT (Methadone Maintenance Treatment) settings as a support of this might not be appropriate. There are many challenges in adequately dosing MMT patients with methadone if they have HCV, cirrhosis, or other liver ailments; the potential for overdose is significant, but they need the methadone to maintain addiction recovery (it's not an analgesic application of the drug).

Anyway, that was the opinion of our authors and peer reviewers when the paper was originally developed. I hope the above doesn't sound defensive.
James B. Ray, PharmD said…
Alex,
I believe Howard Smith has updated his article from the Mayo Clinic Proceedings in 2009. Smith HS. The Metabolism of Opioid Agents and the Clinical Impact of their Active Metabolites. Clin J. Pain 2011; 27(9): 824-838.
James
Alex Smith said…
Brad, thanks for the ref and the website. I checked out advancedcarecoalition.org. It's good to hear there is some effort to standardize and develop a national model. It still seems like there is a need for independent researchers to critically evaluate the existing programs to identify opportunities for improvement.

Stew - not at all defensive, thank you for the explanation! You're right, 'safe' is not the right word for using methadone in the setting of liver failure. Extreme caution is probably better. My take away from this is that for dose finding and breakthrough, oxycodone at a reduced dose and spaced out interval is probably best. For patients with a stable requirement, the fentanyl patch is safest. Or in settings where IV administration is feasible, IV fentanyl may be used.

James - thanks for the reference, just flipped through it. Nice summary - not as practical for the practicing clinician, as it doesn't say what to do and not do, but great background about the metabolism of each opioid.
Alex Smith said…
Stew - one more piece to the puzzle of methadone, from up-to-date on management of pain in patients with cirrhosis: "Methadone is a long acting opioid that is frequently used to treat heroin addiction. In a study of patients with mild to moderate cirrhosis, the pharmacokinetic profiles of methadone were unchanged compared to healthy individuals [17]. Although the half life of methadone in patients with severe cirrhosis can be mildly prolonged, drug disposition is not significantly altered [17]. Thus, methadone appears to be safe in patients with cirrhosis at least for short-term administration."

The reference 17 is: http://www.uptodate.com/contents/management-of-pain-in-patients-with-cirrhosis/abstract/17

Maybe safe isn't such a stretch of a word after all?
Thanks Alex.

For many patients, sometimes the most ill patients, methadone seems to work when all other analgesics have failed. Yet, I've been a "student" of methadone for almost 20 years and it still has me mystified at times. Research regarding its actions, and interactions, really needs to be examined critically, as so much of it is of low quality, of questionable validity, and hasn't been adequately replicated. I suppose the old advice is still most suitable for any clinical situation with methadone: start low and go very slow.
J Simon, MB ChB, FRCPC said…
I like this ref too for opioid and other meds guidance:
http://www.ncbi.nlm.nih.gov/pubmed?term=rhee%20palliation%20and%20liver%20failure

Rhee & Broadbent Palliation of liver failure: palliative medication dosage guidelines 2007 J Palliat Med
Anonymous said…
I find the Bridging programs quite helpful. We call it (with respect to Saturday Night Live) the Not Quite Ready for Hospice program. It may be the patient (or doc!!) is not ready to hear hospice. It may be there is still aggressive care being undertaken but still significant symptoms present. We find slighlty more that half our palliative care patients "flip" to hospice. Over all we find the program it good bridge.

Greg Phelps MD
UT Hospice

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