Impact of a Drugs & Therapeutics Backgrounder on Docusate Utilization Darren Pasay, B.Sc.Pharm Drug Stewardship Pharmacist (Central Zone) [email protected] Disclosure I have no actual or potential conflict of interest in relation to this topic or presentation. Drug Stewardship in Alberta Health Services • Drug Stewardship (DS) Team established in 2012 • “The shared responsibility of Drugs & Safety Therapeutics Committee (DTC), prescribers, pharmacy and care units to ensure Sustainability medications are used in a manner that maximizes the effectiveness, safety and sustainability of care for our patients” Effectiveness • Research and project support Drugs & Therapeutics Backgrounders (DTBs) • 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 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. Docusate • 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 DTB • Preliminary work o ~ 2 million doses/year dispensed • Influences o Some LTC sites have eliminated o Engrained in practice use already • Part of pharmacy, medicine, nursing curriculums • Order sets, Pre-printed care • What are the costs of? orders (PPCO) o Procurement o Seen as innocuous, safe o Processing, dispensing o Medication administration o Medication burden BOTTOM LINE: Docusate is no more effective than placebo for the prevention and treatment of constipation. Impact of use Synopsis of evidence 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 Patients already using docusate could have it withdrawn without the need to replace it with another laxative. HYPERLINK: Stool Softeners: WHY are they still used? Meanwhile…………. Other interventions • 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 Evaluation • 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 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 Methods • 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 Study Medications http://www.whocc.no/atc_ddd_index/ 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 Results Relative Change Confidence Interval % p Low (%) High (%) 6 Months Docusate -2.9 0.479 -12.5 6.6 Pre Other Laxatives 2.4 0.554 -17.8 10.5 3 Months Docusate -19.6 0.025* -28.7 -1.2 Post Other Laxatives -5.0 0.339 -15.9 8.4 6 Months Docusate -25.9 0.027* -37.8 -1.2 Post Other Laxatives -6.2 0.376 -20.0 12.4 12 Months Docusate -33.0 0.091 -50.7 15.7 Post Other Laxatives -8.8 0.43 -28.2 23.7 * Statistically significant Interrupted Time Series Proportional Limitations • 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 Conclusion & Future Directions • 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 Acknowledgments • Co-authors: • DTB Review o Dr. Lauren Bresee o AHS Drug Use Advisory Panel o Dr. Micheal Guirguis • Interim report review o Jeremy Slobodan o Gabrielle Zimmerman • Project contributors o Caroline Ibrahim o AHS Drug Use Evaluation 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 .