Rachi Parekh

Defense Date


Graduation Date

Spring 2013


Immediate Access

Submission Type


Degree Name



Pharmacy Administration


School of Pharmacy

Committee Chair

Khalid Kamal

Committee Member

Autumn Stewart

Committee Member

Mary Mihalyo

Committee Member

James Drennen


Hospice Pharmacy Benefit Managers, Medication cost, Hospice



1. Describe patient-related and hospice-related characteristics such as gender, average length of hospice stay, primary diagnoses, average daily census, number of admissions per year, net operating revenues, inpatient unit (IPU) operating costs, and medication expenditures of hospices in Ohio and compare it with NHPCO data.

2. Identify and analyze therapeutic drug classes and medications with the most frequent utilization rates and largest percentage of expenditures in hospice care.


Hospice Pharmacy Benefit Managers (PBM) employ pharmacists to provide comprehensive pharmaceutical care services for patients under hospice care and one component of pharmacist provided services include comprehensive medication review. To study the impact of pharmacist-led medication review on hospice costs and medication utilization, PBM claims data for year 2007 were obtained from five hospices in Ohio. The data included information on utilization and costs of medications, patient-related (gender, average length of hospice service, and primary diagnoses) and hospice-related (number of admissions per year, average daily census, net operating revenues, inpatient unit [IPU] operating costs and pharmacy costs) characteristics. Claims data were analyzed to identify the most frequently used therapeutic drug classes and those classes which contributed to the largest percentage of pharmacy expenditures. Prescription drug count and total cost for medications under the identified therapeutic drug classes were also obtained. For benchmarking purposes, analysis was conducted to compare patient and hospice-related data obtained from the five hospices to the 2007 NHPCO data.


The average number of admissions per hospice for the year 2007 was 627 patients. Average daily census (136 patients) and total patient days (51,350 days) in these five hospices were 1.5 times higher as compared to that of NHPCO data (90 patients and 31,300 days, respectively.). Annual drug expenditures per hospice ranged from $67,580 to $763,413 while average hospice medication cost per patient per day (PPPD) was $11.12 ($12.43 PPPD for home care and $8.5 PPPD for nursing care). Average PPPD excluding outliers such as enoxaparin was $10.72 ($12.05 PPPD for home care and $8.25 PPPD for nursing care).

Approximately 1,020 different drugs under 246 therapeutic classes were utilized in the five hospices. The most frequently utilized therapeutic class of drugs, based on prescription drug volume included analgesic-narcotics (15.6%) followed by laxatives-cathartics (7.5%), and anti-anxiety drugs (7%). Therapeutic classes contributing to the majority of drug expenditures, included analgesics-narcotics (16.5%), SSRIs (4.7%), and anti-anxiety drugs (4.5%). Medications whose frequency of use accounted for high expense included morphine sulfate (5.3% - utilization, 4.4% - expenditure), lorazepam (4.4%, 3.1%), furosemide (4%, 0.6%), methadone (3%, 0.9%), and prednisone (3.1%, 0.5%). Medications such as enoxaparin injections whose frequency of utilization was low (0.01%), contributed to 3.1% of total medication expenditure. Likewise, fentanyl and oxycodone contributed to 3.5% and 3.7%, respectively to the total medication expenditure, but their frequency of utilization was only 0.9% and 1.9%, respectively.


The five hospices in Ohio utilized preferred drugs recommended by pharmacists following a medication review to identify potential drug related problems (DRPs) and encourage cost-effective drug utilization. As a result of these interventions, the utilization of expensive medications is low. Pharmacists specializing in hospice and palliative care are able to recommend preferred medications in end-of-life care thus producing cost-savings. More importantly, hospice pharmacists frequently identify DRP's which can improve patient outcomes. Hospices should consider interventions made by pharmacists and place emphasis on the utilization of cost effective drugs that can be used among terminally ill patients to provide a high level of quality care with fiscal responsibility.