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Cagle JG, McPherson ML, Frey JJ, et al. Estimates of Medication Diversion in Hospice. JAMA. 2020;323(6):566–568. doi:10.1001/jama.2019.20388
Given the challenges of symptom management during hospice care, patients require responsive opioid prescribing. Within the context of the national opioid crisis, medication diversion in hospice is an increasing concern.1
We conducted a national survey of hospices (June-September 2018). Using 2015 data on US hospices,2 we randomly selected 600 agencies, proportionately stratified by state and profit status. We surveyed agency representatives by phone or online about practices, policies, and experiences regarding medication diversion. Procedures were deemed exempt by the University of Maryland, Baltimore, institutional review board. Survey participation implied informed consent.
Dichotomous items asked about screening patients or family members for substance use disorder, medication monitoring, participation in prescription drug monitoring programs, screening the patient care environment for medication safety concerns, formal policies for dealing with patients or family members with substance use disorder, and staff drug testing. Data on confirmed diversion were gathered using the question “In the past 90 days, approximately how many separate cases of confirmed [not just suspected] drug diversion have you had at your agency?” Cases of suspected diversion were assessed using a similar item. Rates of confirmed and confirmed plus suspected diversion were adjusted for current patient census.
A weighting class adjustment approach3 was used to account for disproportionate response. Using SPSS version 24 (IBM) and a 2-tailed α = .05, negative binomial regression analyses estimated prevalence rate ratios for 2 outcomes: (1) confirmed diversion and (2) total combined confirmed plus suspected diversion. Examined variables included agency characteristics, statewide opioid death rate (using public data4), and agency practices or policies designed to prevent or identify diversion.
Surveys were completed by representatives from 371 hospices (response rate, 62%), of which 63% were by phone (Table 1). All provided at least some home care. Respondents had 7.5 mean years (SD, 7.7 years) of agency experience.
Among the 31% of hospices reporting at least 1 case of confirmed diversion in the past quarter, the individuals most frequently involved in diverting medications were primary family caregivers (39%), other family (38%), and patients (34%). There were 282 confirmed diversion cases within the past 90 days (mean, 0.8 cases per agency; rate, 7.3 cases per 1000 current patients). Fifty-eight percent of hospices reported 1 or more cases of confirmed plus suspected diversion within the past quarter (807 total cases; mean, 2.2 cases of confirmed plus suspected diversion per agency; rate, 20.9 cases per 1000 current patients).
Smaller agencies reported fewer total cases of diversion (25 confirmed; 67 confirmed plus suspected) relative to medium-sized hospices (61 confirmed; 206 confirmed plus suspected) and large hospices (194 confirmed; 529 confirmed plus suspected). However, small hospices reported higher diversion rates per 1000 current patients (17.6 for confirmed; 47.1 for confirmed plus suspected) compared with medium-sized agencies (6.1 for confirmed; 20.6 for confirmed plus suspected) and large agencies (7.2 for confirmed; 19.6 for confirmed plus suspected). The adjusted prevalence rate ratio for confirmed diversion in small vs large hospices was 2.33 (95% CI, 1.70-3.20) per 1000 (Table 2). In adjusted models, confirmed diversion also was significantly associated with providing the majority of care at home and having a policy for responding to patients or family with substance use disorder. Confirmed plus suspected diversion was significantly associated with small size, providing the majority of care at home, and using a prescription drug monitoring program.
This study found that 31% of hospices reported at least 1 confirmed instance of medication diversion in the past 90 days; smaller agencies reported much higher rates of diversion per patient compared with medium and large hospices. Diversion rates were also associated with agencies that provide the majority of care at home. Although home is often a preferred setting for end-of-life care,6 private residences pose challenges for hospices in providing and monitoring treatment. Reported diversion was also associated with policies dealing with patients or family members with substance use disorder. Formal policies may help hospices identify diversion, or agencies with frequent diversion may be more likely to adopt these policies. A limitation was the use of self-reported data, which is subject to recall bias.
More research is needed to understand how agency-level characteristics affect clinical practice and risk mitigation—and to identify optimal ways to provide adequate pain management while simultaneously minimizing diversion risks.
Accepted for Publication: November 20, 2019.
Corresponding Author: John G. Cagle, PhD, MSW, School of Social Work, University of Maryland, Baltimore, 525 W Redwood St, 3W13, Baltimore, MD 21201 (firstname.lastname@example.org).
Author Contributions: Dr Cagle had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: Cagle, Frey, Ware, Guralnik.
Drafting of the manuscript: Cagle, Frey, Ware.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Cagle, Wiegand, Guralnik.
Obtained funding: Cagle.
Administrative, technical, or material support: Frey, Ware.
Supervision: Cagle, Guralnik.
Conflict of Interest Disclosures: Dr Ware reported having held stock in Amgen, AstraZeneca, and GlaxoSmithKline. No other disclosures were reported.
Funding/Support: This study was funded by the University of Maryland CARES Science-to-Systems Pilot Grant Program, the University of Maryland School of Social Work, and the Hospice Foundation of America.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: We thank Laura Stapleton, PhD, and Gregory R. Hancock, PhD, from the Measurement, Statistics, and Evaluation Program at the University of Maryland, College Park, who provided consultations on survey design and sampling and were compensated for their efforts.
Additional Information: We dedicate this work to the legacy of our friend and colleague, Debra L. Wiegand, PhD, who died in November 2018.
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