Impact of a Drugs Therapeutics Backgrounder on Docusate

Impact of a Drugs & Therapeutics Backgrounder on Docusate Utilization Darren Pasay, B. Sc. Pharm Drug Stewardship Pharmacist (Central Zone) darren. pasay@ahs. ca

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 issues 1 • 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 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 Patients already using docusate could have it withdrawn without the need to replace it with another laxative.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) analysis 1, 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 , S 38 - S 44

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%20 Interrupted%20 time%20 series%20 anal 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) 17 grams Lactulose (oral liquid) Magnesium hydroxide (MOM) Psyllium (capsule, powder) 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 * 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: darren. pasay@ahs. ca Twitter: @Rx. Darren. P Phone: 587 -280 -2307