AIDS-related home infusions plummet, but is it temporary?
Oral medications may provide a false sense of security
The strides made recently in AIDS research, such as the various drug cocktails and protease inhibitors available to AIDS patients, have helped extend the lives of those afflicted with the disease. But where do these promising developments leave home infusion agencies, particularly those that rely heavily on AIDS patients? As these oral medications become more widespread, some agencies report sharp drops in AIDS-related home infusions as much as 60% or more in some cases.
Home infusion providers that have seen their infusion revenues shrink are not convinced the end is near for AIDS infusion therapies.
A permanent fix or reprieve?
Nations Healthcare in San Francisco has seen its home infusion referrals for AIDS patients take a huge hit over the past several months.
"We’ve had a 60% decrease in home AIDS-related infusions since June," says Frank Keillor, general manager. "Protease inhibitors are the reason. Where we would get 25 to 30 AIDS referrals a month, we’re down to about two or three."
Scenarios are similar elsewhere.
In Albuquerque, NM, NMC Homecare has watched its AIDS-related home infusions drop, as well.
"For many years, we supplied a lot of the [antibiotic] IV drugs for ancillary types of infections they would get," Jackie Woods, general manager of NMC, tells Home Infusion Therapy Management. "But over the past four months, with the use of protease inhibitors and triple therapies, the use of IV-type medications has almost stopped completely."
Even though AIDS patients are living longer and more comfortably, the disease is still fatal.
"What it’s done and what the physicians talk about is that it’s a little holiday everyone is on because of the different cocktails’ that are out there," says Marion Ratkewotch, executive director of Target Management Services in New York City. "However, there are a couple of things to remember. This is a progressive chronic disease, and it is terminal. We may have a holiday here, but it’s still going to cost the payer more in the long run or shift the cost."
For example, while money spent on home infusion may have decreased, oral drugs can run as much as $14,000 to $18,000 a year per patient, says Ratkewotch.
It’s clear AIDS patients are benefitting from pharmaceutical advances. Here and now, that’s good news for those with AIDS. But some worry that the success of such treatments has given many a false sense of security.
In commemoration of World AIDS Day, which was Dec. 1, U.S. Department of Human Health Services Secretary Donna E. Shalala issued a statement that warned of the continued struggle against the virus.
"Another 8,500 people will be infected tomorrow and the next day, and the next day. . . . These statistics send a sobering message: The AIDS pandemic is not over."
Similarly, home infusion agencies shouldn’t overlook continual needs of AIDS patients.
"A lot of these patients are going to be living longer because of all these drugs, but eventually they will go on IVs," says Jessica Neumann, RPh, director of pharmacy for NMC Homecare in Albuquerque, NM.
Just how long the new oral drug therapies will keep patients free of IVs is unclear at this time.
"I think it’s too early to tell what this means down the road," says Keillor. "Our medical advisor feels that the life of protease inhibitors is probably about 15 months."
However, with new generations of the protease inhibitors coming out, Keillor notes that there is the possibility of two or three years of successful oral drug therapy. "And by that time there will be seven or eight generations of the drug," he adds.
Yet despite the good news about these new oral drugs, the fact remains they are a temporary solution. Moreover, the latest oral drugs don’t work for all patients. Keillor notes there’s a failure rate of about 20% with protease inhibitors.
"There are some patients that just don’t fit that protease inhibitor realm, and for them nothing has changed," he says.
Keeping up on the numerous drugs, both oral and intravenous, available for treating AIDS patients can be a daunting task. Neumann relies heavily on the United States Pharmacopoeia and Drug Information. Published once every five years, it provides monthly supplements on the latest drugs and their preparations and what the drug is approved for.
Clinical concerns just the tip of the iceberg
With the numerous new drugs available and various therapies required by AIDS patients, they may be as clinically complex as any other type of patient you’ll deal with.
"They’re not going to be just one-therapy patients," notes Cheryl LaChance, PharmD, clinical pharmacist at Apria Healthcare in Minneapolis. "They’re going to be multi-therapy patients; they’re going to have multiple needs that go beyond just infusion. They’re such a complex group of patients. You have to follow them on a nutrition basis; you have to follow them on an infectious disease basis; and you have to follow them on a psycho-social basis." So look for ways to treat AIDS patients other than straightforward antibiotic infusions.
The psycho-social aspect may be the most difficult and unique concern to this patient type. Most terminally ill patients have support networks of friends and families. That’s not always the case with AIDS patients. Although the Centers for Disease Control and Prevention in Atlanta notes that heterosexual women and teenagers are the two fastest-growing groups of newly infected people, those numbers still have not caught up with the gay male and IV-drug users groups in total figures. Because of the demographics of the latter two groups in particular, the gay population such patients may be distant from, or no longer in contact with, their families.
"The most unique thing about the AIDS patient or HIV patient is they don’t have a good support network in the home, so that’s sometimes tough," says Woods. "Either their significant other has already passed away, or their family hasn’t necessarily accepted them."
But the gay population isn’t the only high-risk group that lacks a support network. Keillor notes that intravenous drug users have a high incidence of AIDS and similarly may not have much support. In fact, the gay community has some advantages over drug users.
For the most part, Keillor says that people from the gay community are sophisticated health care recipients. They’re likely to have insurance and be well-educated about the disease because of the resources available through the gay community.
"They know a lot," says Keillor. "If you bring in a nurse who doesn’t know what’s going on, that person is going to be found out real quickly. They’re aware of the full disease process."
It’s not just your staff’s knowledge you must watch after, though.
"If you’ve got caregivers that are homophobic, you’ve got problems," says Neumann. "These people deserve to be treated with the same respect as any other patients, and if your employees can’t give them that respect, you’ve got problems."
NMC provides inservices on Occupational Safety and Health Administration regulations as they apply to HIV techniques and patients. The organization also goes out of its way to treat all patients the same. For example, all drivers wear gloves when picking up equipment, not just for HIV or AIDS patients. The agency also tells all prospective employees upfront that they will be dealing with such patients.
"If they have a problem dealing with these types of patients, they need to know they should not be working here," says Neumann.
Dealing with the trend
The key to surviving the downward spiral if your agency previously relied on AIDS patients is simple, according to Keillor.
"Diversify, diversify, diversify," he says. As pointed out earlier, it’s too early to tell how long oral therapies will keep patients off home infusions. But that doesn’t mean there is no care a well-rounded agency can provide.
For example, Keillor’s agency continues to provide other care to its AIDS patients.
"We provide value-added services, such as a social worker who specializes in working with AIDS patients," he says.
Diversification has proven critical to NMC’s success as well.
"The patients get the protease inhibitors directly from the manufacturer, but we still do some of their nursing, such as oxygen and DME," notes Woods.
It’s important to realize that the oral drugs, even with their success, are not a cure. It’s therefore important to stay in touch with the AIDS population.
"A lot of these patients are going to live longer because of all these drugs," says Neumann, "but eventually they will go on IVs. They’re going to live longer, but eventually they’ll come back."
(Editor’s note: Next month, HITM will look at what payer sources and physicians look for in a home infusion agency when referring AIDS patients. )
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