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 &
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
Safety
Sustainability
Effectiveness
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
o Some LTC sites have eliminated
use already
• What are the costs of?
o
o
o
o
Procurement
Processing, dispensing
Medication administration
Medication burden
• Influences
o Engrained in practice
• Part of pharmacy, medicine,
nursing curriculums
• Order sets, Pre-printed care
orders (PPCO)
o Seen as innocuous, safe
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withdrawn without the need to replace it with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
Docusate (capsule, liquid, syrup)
Defined Daily Dose (DDD)
sodium = 150 mg; calcium = 360 mg
PEG 3350 (powder)
Lactulose (oral liquid)
Magnesium hydroxide (MOM)
Psyllium (capsule, powder)
17 grams
6.7 grams (10 ml)
3 grams (30 ml)
7 grams
Results
6 Months
Pre
3 Months
Post
6 Months
Post
12 Months
Post
Docusate
Other Laxatives
Docusate
Other Laxatives
Docusate
Other Laxatives
Docusate
Other Laxatives
* Statistically significant
Relative Change
%
p
-2.9
0.479
2.4
0.554
-19.6
0.025*
-5.0
0.339
-25.9
0.027*
-6.2
0.376
-33.0
0.091
-8.8
0.43
Confidence Interval
Low (%) High (%)
-12.5
6.6
-17.8
10.5
-28.7
-1.2
-15.9
8.4
-37.8
-1.2
-20.0
12.4
-50.7
15.7
-28.2
23.7
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:
o Dr. Lauren Bresee
o Dr. Micheal Guirguis
o Jeremy Slobodan
• Project contributors
o Caroline Ibrahim
o AHS Drug Use Evaluation
• DTB Review
o AHS Drug Use Advisory Panel
• Interim report review
o Gabrielle Zimmerman
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