impact of a drugs & therapeutics backgrounder on docusate ... · impact of a drugs &...
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Darren Pasay, B.Sc.Pharm
Drug Stewardship Pharmacist (Central Zone)
Impact of a Drugs &
Therapeutics Backgrounder on
Docusate Utilization
I have no actual or potential conflict of interest in relation to
this topic or presentation.
Disclosure
• Drug Stewardship (DS) Team established in
2012
• “The shared responsibility of Drugs &
Therapeutics Committee (DTC), prescribers,
pharmacy and care units to ensure
medications are used in a manner that
maximizes the effectiveness, safety and
sustainability of care for our patients”
• Research and project support
Drug Stewardship in Alberta Health Services
Effectiveness
Safety
Sustainability
• Frontline staff wanted background and support on DTC/formulary
issues1
• One page document, meant to enhance conversations with
prescribers
• Supported by content experts, based upon DTC directions
• Published 6 times/year
• Followed by 2 interactive webinars for each edition
Drugs & Therapeutics Backgrounders
(DTBs)
1. Pasay Darren K, Chow Sheldon JS, Bresee Lauren C, Guirguis Micheal, Slobodan Jeremy. Assessment of current antimicrobial stewardship policies and
resources: a focus group project. Healthcare Infection 2015; 20: 7–15.
• Over-the-counter stool softener
• It is clear, based on published peer-reviewed
literature, that docusate is ineffective for the
prevention or treatment of constipation
• Open listed on AHS Provincial Drug
Formulary
• Limited coverage on Alberta Drug Benefit
List (palliative care only)
Docusate
• Influences o Engrained in practice
• Part of pharmacy, medicine,
nursing curriculums
• Order sets, Pre-printed care
orders (PPCO)
o Seen as innocuous, safe
• Preliminary work o ~ 2 million doses/year dispensed
o Some LTC sites have eliminated use already
• What are the costs of? o Procurement
o Processing, dispensing
o Medication administration
o Medication burden
Docusate DTB
BOTTOM LINE: Docusate is no more effective
than placebo for the prevention and treatment
of constipation.
CALL TO ACTION: Docusate may be stopped
with tapering or additional monitoring.
Patients already using docusate could have it
withdrawn without the need to replace it with
another laxative.
Synopsis of
evidence
Impact of use
HYPERLINK: Stool Softeners: WHY are they still used?
Meanwhile………….
• Order set revisions o Call to action in initial and follow up presentations to review/revise order
sets/PPCOs to remove docusate
o CPOE system in Calgary Zone
• Targeted communication to order set authors to remove docusate
• Therapeutic Interchanges o Removed docusate from Senekot-S interchange
Other interventions
• P – For sites in Alberta with measurable drug utilization data
• I – Did a multifaceted educational intervention to decrease docusate use
• C – Compared to other laxatives over time
• O – Result in fewer docusate DDD/1000 patient days dispensed
• Primary – Interrupted Time Series (ITS) analysis1,2
• Secondary – Proportional changes over time
Evaluation
1.Ramsay CR, Matowe L, Grilli R, Grimshaw JM, Thomas RE. “Interrupted time series designs in health technology assessment: lessons from two systematic reviews of behaviour change
strategies.” International Journal of Health technology Assessment in Health Care 2003; 19: 613-23
2.Use of Interrupted Time Series Analysis in Evaluating Health Care Quality Improvements Penfold, Robert B. et al. Academic Pediatrics , Volume 13 , Issue 6 , S38 - S44
• Dispended data obtained from each of 5 Zones
• Converted to defined daily doses (DDD) per 1000 patient days
• Utilization rates for the 6 months pre to and 3, 6, and 12 months post DTB
publication
• ITS o IBM SPSS 19 – ARIMA analysis
o Cochrane EPOC, ITS analysis
(https://epoc.cochrane.org/sites/epoc.cochrane.org/files/uploads/21%20Interrupted%20time%20series%20anal
yses%202013%2008%2012_1.pdf)
• Proportional o Microsoft Excel
Methods
Drug Defined Daily Dose (DDD)
Docusate (capsule, liquid, syrup) sodium = 150 mg; calcium = 360 mg
PEG 3350 (powder) 17 grams
Lactulose (oral liquid) 6.7 grams (10 ml)
Magnesium hydroxide (MOM) 3 grams (30 ml)
Psyllium (capsule, powder) 7 grams
Study Medications
http://www.whocc.no/atc_ddd_index/
Results
* Statistically significant
Relative Change Confidence Interval
% p Low (%) High (%)
6 Months
Pre
Docusate -2.9 0.479 -12.5 6.6
Other Laxatives 2.4 0.554 -17.8 10.5
3 Months
Post
Docusate -19.6 0.025* -28.7 -1.2
Other Laxatives -5.0 0.339 -15.9 8.4
6 Months
Post
Docusate -25.9 0.027* -37.8 -1.2
Other Laxatives -6.2 0.376 -20.0 12.4
12 Months
Post
Docusate -33.0 0.091 -50.7 15.7
Other Laxatives -8.8 0.43 -28.2 23.7
Interrupted Time Series
Proportional
• Uncontrolled before/after design
• Multiple data sources/pharmacy systems
• Did not account for wastage or expired
• Non-constipation use included
• Did not include all known laxatives and cathartics
Limitations
• This project demonstrates that a multifaceted educational campaign with
clear messaging and a call to action can have significant impact on
medication use, while not inappropriately increasing the use of other agents.
• Two year data analysis (18 months post)
• Continued communication with order set/PPCO authors
• Intra-zone analysis
• Re-opening the delisting discussion
Conclusion & Future Directions
• DTB Review o AHS Drug Use Advisory Panel
• Interim report review o Gabrielle Zimmerman
• Co-authors: o Dr. Lauren Bresee
o Dr. Micheal Guirguis
o Jeremy Slobodan
• Project contributors o Caroline Ibrahim
o AHS Drug Use Evaluation
Acknowledgments
QUESTIONS
Contact Information:
Darren Pasay, B.Sc.Pharm.
Drug Stewardship Pharmacist, Alberta Health Services (Central Zone)
Email: [email protected]
Twitter: @RxDarrenP
Phone: 587-280-2307