Innovative approaches to care may be necessary to provide the most effective symptom management to hospice patients. One approach is prescribing newer
pharmacotherapy options with the potential to improve symptom management in hospice. Such
therapies are sometimes prescribed outside of Food and Drug Administration indications and are typically more costly than older agents used for the same symptoms. Another approach is the collaborative practice (CP) care model, whereby clinical pharmacists are given prescriptive authority according to evidence-based protocols and algorithms within boundaries approved by a physician. The agents typically included in CP protocols are those with wide therapeutic indices and with substantial evidence to support their use. The purpose of this study was to examine both approaches to management of
pain,
insomnia, and
nausea, comparing symptom scores for those patients who received noncollaborative
drug therapies (transdermal
fentanyl,
zolpidem, and
ondansetron) to those who received agents under CP (oral sustained-release
opioids,
temazepam, and
prochlorperazine). The object of the study was to investigate outcomes associated with newer
drug therapy options as compared to older agents for the management of
pain,
insomnia, and
nausea. A secondary goal is to compare symptom outcomes for patients receiving pharmaceutical care under CP and non-CP models. The study design was retrospective with a cohort. A total of 50 patients were randomly selected for each cohort of the
pain and
insomnia study arms. Only 45 patients prescribed oral
ondansetron met inclusion criteria for the
nausea group; 45 patients prescribed
prochlorperazine were randomly selected as the comparator group. Patients were compared on their degree of response to the prescribed
therapy. Response was classified as complete, partial, no improvement from baseline, worsened, or unknown. A complete response was defined as the symptom score improving to a 0 of 10, regardless of the previous value documented. A partial response was defined as any improvement in score that did not result in a 0 of 10. No improvement from baseline reflected a lack of overall change in score throughout the series of data points collected. A worsened response was any score found to be higher than the score documented at the time of dispense. The unknown category reflects any set of scores that had an "N/A " documented at the time of medication dispense or when documented for both attempts subsequent to dispensing the medication. A complete response was present in 14 of 50 (28 [corrected] percent) of the patients prescribed oral
therapy [corrected] as compared with 12 of 50 (24 [corrected] percent) of those prescribed
fentanyl [corrected] (p = .82). Responses defined as partial, no improvement over baseline, worsened, and unknown were also comparable between the two cohorts. A complete response was seen in 26 patients prescribed
temazepam (52 percent), whereas only 11 (22 percent) of patients initially prescribed
zolpidem achieved the same response (p = .0037). Both groups had a similar distribution of partial, no improvement over baseline, and worsened responses. For the
nausea arm of the study, a difference was found in the number of complete responses, favoring
prochlorperazine (22 of 45, 48.9 percent for
prochlorperazine, 12 of 45, 26.7 percent for
ondansetron, p = .0504), as well as an increased number of worse responses seen with
ondansetron patients (p = .0513); however, neither difference was statistically significant. Newer
pharmacotherapy options for the management of
pain,
insomnia, and
nausea were not found to be superior when compared to older agents prescribed under CP.