Defense Date


Graduation Date

Summer 5-18-2021


Immediate Access

Submission Type


Degree Name



Pharmacy Administration


School of Pharmacy

Committee Chair

Dr. Jordan R Covvey

Committee Member

Dr. Khalid M Kamal

Committee Member

Dr. Vincent Giannetti

Committee Member

Mary Mihalyo

Committee Member

Dr. Carl Anderson

Committee Member

Dr. James Drennen


Hospice and palliative care, methadone, cost effectiveness, primary research, secondary research


Background: As discussed within the guidelines from the American Society of Health-System Pharmacists (ASHP), pharmacists are an integral part of the hospice multidisciplinary team involved in optimizing the treatments. Methadone, a long-active opioid, is particularly useful in this population but may be clinically underutilized. Additionally, the cost share of medication utilization in hospice and palliative care is shifting towards hospice providers. The assessment of medication utilization and methadone use in this setting can help develop overall cost/clinical optimization strategies. Thus, there is a need to understand the use and expenditure of various medications and pharmacists' role in providing methadone use recommendations in hospice and palliative care settings that would facilitate the cost containment.

Objectives: The purpose of the study was to (1) identify the prevalence and acceptance of clinical pharmacists’ methadone recommendation before and after admission to hospice/palliative care, and (2) identify the frequency, expenditure, and monthly mean cost of therapeutic medication classes belonging pain, pulmonary and anticoagulant medications categories.

Methods: The study was conducted in two phases. The phase I was conducted in two parts of data collection at DeltaCareRx hospice and palliative care site. A systematic literature review formed the basis of clinical pharmacist's role and significance in the multidisciplinary team of hospice and palliative care. The instruments for data collection were developed for the clinical pharmacists and student pharmacist researcher. Descriptive and inferential statistics of the collected data identified the prevalence of clinical pharmacist recommendations for methadone upon admission to hospice/palliative care and the acceptance of the pharmacists’ recommendations for methadone after admission to hospice/palliative care. Phase II studied medication utilization at the hospice/palliative sites served by the pharmacy benefit manager (PBM) DeltaCareRx. Pharmacy claims data for six months of the year 2019 was obtained from DeltaCareRx. The data included information on the utilization of individual medications and their associated therapeutic classes, patient characteristics, and dispensing cost charged to the patients. Claims data were analyzed to identify the frequency in use, total expenditure, and the monthly average cost of each therapeutic class and the pattern in the utilization of therapeutic class based on the sex of the patients. The consumption of individual medications was calculated using defined daily doses (DDD), a methodology that analyses medication consumption and enables comparison across different months in a standardized manner.

Results: In total, the data collected on both instruments included 158 (99.3%) patients. The prevalence of pharmacist methadone recommendation was 37 (23.4%). The majority (26; 16.5%) of methadone recommendation were for switching to methadone as the maintenance treatment. Out of the 37 pharmacist recommendations, 5 (13.5%) were accepted by the physicians, and the physicians themselves implemented 3 (8.1%) recommendations. In phase II, the pharmacy claims data were obtained for six months (January, June, July, September, October, and November) of 2019. The data consisted of 487 unique therapeutic classes and 3,189 unique medications. Sympathomimetics, opioid agonists, and coumarin anticoagulants were the most frequently used therapeutic classes. The average cost per male/female patients was the highest ($64.82 and $67.70) for pulmonary medications. Medications such as albuterol, enoxaparin, and morphine had higher consumption levels.

Conclusion: The study provided valuable insights regarding clinical pharmacists' significant role in hospice and palliative care. A pharmacist's role in providing recommendations on medication use to the patients can improve clinical/cost optimization in the setting. The data collection on pharmacists’ recommendations on methadone demonstrates minimum medication use in the hospice and palliative care setting. There should be an increase in the use of this cost-effective medicine for pain management among the patients. The pharmacy claims data analysis implements that the rise in use of cost-effective medications from the individual therapeutic classes will help in higher cost savings at DeltaCareRx’s client sites and reduce the provider’s overall cost burden.