Prescription Of Laxatives Research Articles

A Decision Support Alert for Promoting Prophylactic Laxative Use with Clozapine.

We investigated the effectiveness of a decision support alert to improve prophylactic laxative use with clozapine in hospital. Prescribing data for first clozapine and laxative prescriptions were extracted and linked. Proportions of first clozapine prescriptions for which a laxative was co-prescribed within 24 hours was compared before and after alert implementation. The alert was associated with increased and earlier laxative co-prescribing.

Laxative use in adults with intellectual disabilities: development of prescribing guidelines.

Constipation is overrepresented in people with intellectual disabilities. Around 40% of people with intellectual disabilities who died prematurely were prescribed laxatives. A quarter of people with intellectual disabilities are said to be on laxatives. There are concerns that prescribing is not always effective and appropriate. There are currently no prescribing guidelines specific to this population. To develop guidelines to support clinicians with their decision-making when prescribing laxatives to people with intellectual disabilities. A modified Delphi methodology, the RAND/UCLA Appropriateness Method, was used. Step 1 comprised development of a bespoke six-item, open-ended questionnaire from background literature and its external validation. Relevant stakeholders, including a range of clinical experts and experts by experience covering the full range of intellectual disability and constipation, were invited to participate in an expert panel. Panel members completed the questionnaire. Responses were divided into 'negative consensus' and 'positive consensus'. Members were then invited to two panel meetings, 2 weeks apart, held virtually over Microsoft Teams, to build consensus. The expert-by-experience group were included in a separate face-to-face meeting. A total of 20 people (ten professional experts and ten experts by experience, of whom seven had intellectual disability) took part. There were five main areas of discussion to reach a consensus i.e. importance of diagnosis, the role of prescribing, practicalities of medication administration, importance of reviewing and monitoring, and communication. Laxative prescribing guidelines were developed by synthesising the knowledge of an expert panel including people with intellectual disabilities with the existing evidence base, to improve patient care.

Real-world evidence of constipation and laxative use in the Korean population with chronic kidney disease from a common data model

Constipation is a highly prevalent gastrointestinal disorder in patients with chronic kidney disease (CKD). However, our understanding of its epidemiology and management in CKD is limited. We aimed to explore real-world data on constipation and laxative use in patients with CKD in a nationwide population-based cohort from the Korean Health Insurance Review and Assessment-National Patient Sample database. This study analyzed retrospective health claims data in Korea from 2012 to 2017 that were transformed into the Observational Medical Outcomes Partnership Common Data Model. The pooled proportion of constipation diagnoses was 30.5% in all patients with CKD and 15.9%, 16.5%, 17.4%, 29.9%, and 43.3% in patients with CKD stages 1–5, respectively, suggesting a higher prevalence in advanced CKD. Patients receiving peritoneal dialysis or hemodialysis had the highest prevalence of constipation, while transplant recipients showed a prevalence comparable to that of patients with early CKD. Patients with CKD had a significantly higher risk of constipation than age- and sex-matched non-CKD individuals (range of odds ratio [OR]:1.66–1.90). Laxative prescribing patterns differed by CKD severity. Osmotic agents were prescribed in more than half of patients with advanced CKD, while magnesium salts and bulking agents were prescribed less frequently. The CKD patients with constipation were more likely to be prescribed constipation-inducing medications, including antipsychotic and neurological medications. Our findings provide real-world constipation and laxative prescription status in the Korean CKD population, revealing a significantly higher risk of constipation and different laxative prescribing patterns in patients with CKD.

Naldemedine and Magnesium Oxide as First-Line Medications for Opioid-Induced Constipation: A Comparative Database Study in Japanese Patients With Cancer Pain.

Introduction Naldemedine and magnesium oxide are common first-line early laxative medications used in the real-world scenario in Japan, for patients with cancer pain who receive opioid prescriptions, as per a nationwide hospital claims database study. However, the real-world prescription patterns and associated outcomes are unknown. Methods In this retrospective, cohort study using the Medical Data Vision (MDV) database (January 2018 to December 2020), data were collected from eligible patients (who had a long-term prescription of strong opioids, for >30 days) in Japan with naldemedine or magnesium oxide as the first-line laxative prescription, for a long-term opioid prescription for cancer pain with ≥6 months post-opioid observation period. A laxative prescription within three days after the opioid prescription date was termed an "early" prescription. The composite incidence of dose increase or addition/change of laxatives at three months after the start of the opioid prescription was the primary endpoint after adjusting baseline characteristics between the treatment arms by propensity score matching. Results After propensity score matching, 1717 and 544 patients who were prescribed naldemedine and magnesium oxide each were included in the early prescription and non-early prescription groups, respectively. Even after matching, the incidence of death was not adjusted enough and was significantly higher in the naldemedine arm than in the magnesium oxide arm in the non-early group but comparable in the early group. The incidence of addition, change, or dose increase was significantly higher in the naldemedine arm than in the magnesium oxide arm of the early prescription group (hazard ratio (95% confidence interval), 1.08 (1.00, 1.17); p=0.0402); the incidence was comparable between the arms of the non-early group. Conclusion These findings may provide valuable insights into real-world clinical treatment patterns and preliminary evidence for the selection of first-line medications to mitigate opioid-induced constipation in Japanese patients with cancer pain.

Opioid Prescribing for Noncancer Patients—Issues of Drug Therapy Safety: Results from a German Study Based on Routine Data

Opioids are highly effective drugs but need close monitoring to avoid harm to patients. The aim of this study was to analyze how guideline recommendations are met for (i) the avoidance of the concomitant use of anxiolytics, hypnotics, or sedatives; (ii) the prescribing of laxatives in long-term opioid treatment; (iii) the co-prescribing of drugs to control the emetic effect of opioids; (iv) pretreatment with non-opioids; and (v) screening for depression when initiating opioids. The results are based on a routine data analysis of a large German health insurance fund. Different study populations of noncancer patients (18+ years old) treated with opioids were analyzed: 10.4% of the opioid recipients in 2021 received at least one concomitant prescription with anxiolytics, hypnotics, or sedatives; 69.3% of those with long-term opioid treatment received at least one laxative prescription. Of those with first-time opioid prescriptions, 4.8% received an antiemetic drug; 47.3% of those with a newly initiated opioid therapy received a non-opioid prescription within three months before the start of the opioid therapy; and 22.0% of patients with incident opioid prescription had at least one documentation of a depression diagnosis within three months of the first prescription. There is an urgent need to improve opioid prescribing to avoid risky combinations and adverse effects.

Development of prescribing indicators related to opioid-related harm in patients with chronic pain in primary care—a modified e-Delphi study

BackgroundLong-term opioid use is associated with dependency, addiction, and serious adverse events. Although a framework to reduce inappropriate opioid prescribing exists, there is no consensus on prescribing indicators for preventable opioid-related problems in patients with chronic pain in primary care in the UK. This study aimed to identify opioid prescription scenarios for developing indicators for prescribing opioids to patients with chronic pain in primary care.MethodsScenarios of opioid prescribing indicators were identified from a literature review, guidelines, and government reports. Twenty-one indicators were identified and presented in various opioid scenarios concerning opioid-related harm and adverse effects, drug-drug interactions, and drug-disease interactions in certain disease conditions. After receiving ethics approval, two rounds of electronic Delphi panel technique surveys were conducted with 24 expert panellists from the UK (clinicians, pharmacists, and independent prescribers) from August 2020 to February 2021. Each indicator was rated on a 1–9 scale from inappropriate to appropriate. The score’s median, 30th and 70th percentiles, and disagreement index were calculated.ResultsThe panel unanimously agreed that 15 out of the 21 opioid prescribing scenarios were inappropriate, primarily due to their potential for causing harm to patients. This consensus was reflected in the low appropriateness scores (median ranging from 1 to 3). There were no scenarios with a high consensus that prescribing was appropriate. The indicators were considered inappropriate due to drug-disease interactions (n = 8), drug-drug interactions (n = 2), adverse effects (n = 3), and prescribed dose and duration (n = 2). Examples included prescribing opioids during pregnancy, concurrently with benzodiazepines, long-term without a laxative prescription and prescribing > 120-mg morphine milligram equivalent per day or long-term duration over 3 months after surgery.ConclusionsThe high agreement on opioid prescribing indicators indicates that these potentially hazardous consequences are relevant and concerning to healthcare practitioners. Future research is needed to evaluate the feasibility and implementation of these indicators within primary care settings. This research will provide valuable insights and evidence to support opioid prescribing and deprescribing strategies. Moreover, the findings will be crucial in informing primary care practitioners and shaping quality outcome frameworks and other initiatives to enhance the safety and quality of care in primary care settings.

Association of maternal constipation and risk of atopic dermatitis in offspring.

Objectives: Atopic dermatitis (AD) is a chronic and relapsing dermatologic disease that can affect individuals of all ages, including children and adults. The prevalence of AD has increased dramatically over the past few decades. AD may affect children's daily activities, increase their parents' stress, and increase health expenditure. Constipation is a worldwide issue and may affect the gut microbiome. Some research has indicated that constipation might be associated with risk of atopic disease. The primary objective of this retrospective cohort study was to extend and to explore the link between maternal constipation and risk of atopic dermatitis in offspring. Methods: Using the Longitudinal Health Insurance Database, a subset of Taiwan's National Health Insurance Research Database, we identified 138,553 mothers with constipation and 138,553 matched controls between 2005 and 2016. Propensity score analysis was used matching birth year, child's sex, birth weight, gestational weeks, mode of delivery, maternal comorbidities, and antibiotics usage, with a ratio of 1:1. Multiple Cox regression and subgroup analyses were used to estimate the adjusted hazard ratio of child AD. Results: The incidence of childhood AD was 66.17 per 1,000 person-years in constipated mothers. By adjusting child's sex, birth weight, gestational weeks, mode of delivery, maternal comorbidities, and received antibiotics, it was found that in children whose mother had constipation, there was a 1.26-fold risk of AD compared to the children of mothers without constipation (adjusted hazard ratio [aHR]: 1.26; 95% CI, 1.25-1.28). According to subgroup analyses, children in the maternal constipation group had a higher likelihood of AD irrespective of child's sex, birth weight, gestational weeks, mode of delivery, and with or without comorbidities, as well as usage of antibiotics during pregnancy. Compared to the non-constipated mothers, the aHR for the constipated mothers with laxative prescriptions <12 and ≥12 times within one year before the index date were 1.26; 95% CI, 1.24 -1.28 and 1.40; 95% CI, 1.29-1.52, respectively. Conclusion: Maternal constipation was associated with an elevated risk of AD in offspring. Clinicians should be aware of the potential link to atopic dermatitis in the children of constipation in pregnant women and should treat gut patency issues during pregnancy. More study is needed to investigate the mechanisms of maternal constipation and atopic diseases in offspring.

Laxative-prescribing habits: a summative impact evaluation of a constipation programme implemented in two hospitals in New Zealand.

To evaluate the impact of a multifaceted intervention aimed at improving adherence to a list of preferred laxatives in two hospitals in New Zealand. A constipation programme was developed at Capital & Coast District Health Board to improve adherence to safe and effective (preferred) laxatives over potentially dangerous and less effective (non-preferred) agents. The intervention included a new constipation guideline, a poster of preferred laxatives, a patient information leaflet, hospital formulary adjustments and staff education. The evaluation compared the number of dispensations of each laxative during two periods: a 12-month period prior to programme implementation and a 12-month period following programme implementation. Data were retrospectively gathered from multiple sources on all laxatives dispensed on 14 adult wards across two New Zealand hospitals. Prior to the programme, there were 111,771 laxatives dispensed, the majority of which (62%) were non-preferred agents. Following the programme, there were 91,005 laxatives dispensed, the majority of which (82%) were from the preferred list, indicating a large shift in prescribing habits. Inpatient laxative prescribing habits require attention and are amenable to quality improvement initiatives. This may reduce waste, prevent harm and improve patient outcomes.

279 A Quality Improvement Project Is Associated With Increased Prescribing of Laxatives With Opioid Analgesics to Patients Discharged From the Emergency Department

279 A Quality Improvement Project Is Associated With Increased Prescribing of Laxatives With Opioid Analgesics to Patients Discharged From the Emergency Department

Association of early childhood constipation with the risk of autism spectrum disorder in Taiwan: Real-world evidence from a nationwide population-based cohort study.

Autism spectrum disorder (ASD) is a neurodevelopmental problem that presents with limited interests, repetitive behaviors, and deficits in reciprocal communication and social interactions. Mounting evidence indicates that an imbalanced gut microbiota contributes to autism via the gut-brain axis. Constipation may result in alteration of the gut microbiota. The clinical influence of constipation on ASD has not been fully researched. Thus, in this study we aimed to evaluate whether early childhood constipation influenced the risk of developing ASD using a nationwide population-based cohort study. We identified 12,935 constipated children aged 3 years or younger from the National Health Insurance Research Database (NHIRD) in Taiwan from 1997 to 2013. Non-constipated children were also selected from the database and propensity score matching of age, gender, and underlying comorbidities was conducted with a ratio of 1:1. Kaplan-Meier analysis was applied to determine different levels of constipation severity and cumulative incidence of autism. Subgroup analysis was also applied in this study. The incidence rate of ASD was 12.36 per 100,000 person-months in the constipation group, which was higher than the rate of 7.84 per 100,000 person-months noted in the non-constipation controls. Constipated children had a significantly higher risk of autism when compared to the non-constipation group (crude relative risk = 1.458, 95% CI = 1.116-1.904; adjusted hazard ratio = 1.445, 95% CI = 1.095-1.907).Moreover, among constipated children, a higher number of laxative prescriptions, male gender, constipation during infancy, and atopic dermatitis were significantly associated with higher risks of ASD when compared to the non-constipation group. Constipation in early childhood was correlated with a significantly increased risk of ASD. Clinicians should pay attention to the possibility of ASD in constipated children. Further research is necessary to study the possible pathophysiological mechanisms of this association.

1304 LAXATIVES PRESCRIPTION MONITORING FOR AN OVERLOOKED PROBLEM

Abstract Introduction Constipation is a common diagnosis among hospitalized patients. It results in considerable morbidity in elderly patients, healthcare utilization and economic burden. Laxatives are commonly prescribed but poorly monitored due to benign side effect perception. Aim We undertook a review of the quality of laxative prescribing and subsequent monitoring amongst an inpatient cohort. We propose new standards: - Medication review at least once weekly; - Documented rationale for choice of medication - Specified timeframe review and outcome documentation We reviewed current hospital trust policy of laxative prescribing and produced a new constipation management guideline in response to early audit data. Method Data collected across medical wards in Trafford General Hospital, Manchester. Data was collected on types of laxatives, reason for prescription, date of review, length of course, compliance and effect of laxatives. Two rounds of audit were performed 6 months apart, with an interim intervention of staff education and local introduction of a new constipation management guideline. The guideline consisted of decision algorithm and suggested treatment. Results 47 individual prescriptions were audited in round 1 and 72 prescriptions in round 2, this represented 23 and 32 patients respectively. Review of medications within first week of prescription improved from 17% to 83.7% across the two cycles. Documentation of constipation diagnosis improved from 52.2% to 97.2%. There were large percentage improvements in documentation of specified treatment outcomes across all audited fields, despite overall poorer medication compliance among patients in round 2 (56.9% versus 66% in round 1). The average length of laxative use decreased from 18.6 days to 15.3 with overall percentage of patient with constipation resolved increased from 65% in round 1 to 73% in Round 2 Conclusion Staff education and implementation of treatment guidelines made a substantial improvement to the medical management of constipation in hospitalized patients.

Adherence to coprescribing of laxatives with opioids and associated characteristics in general practices in the Netherlands

BackgroundGuidelines recommend to prescribe a laxative with an opioid to prevent constipation. We aimed to determine the adherence by general practitioners (GPs) to this recommendation and to explore which GP- and patient related factors were associated with it from the perspective of the GP. MethodsWe conducted an observational study using GPs’ prescription data from the Nivel Primary Care Database combined with a questionnaire asking for reasons of non-adherence. The proportion of first opioid prescriptions prescribed together with a laxative was determined as primary outcome. Possible explanatory factors such as the quality of registration, the level of collaboration with the pharmacy, familiarity with the recommendation and use of a clinical decision support system were explored, as were the self-reported reasons for non-adherence (classified as either GP-related or patient-related). We assessed the association of factors with the primary outcome using univariable multilevel logistic regression analysis.ResultsThe recommendation was measured in 195 general practices. The median proportion of first opioid prescriptions prescribed together with a laxative in these practices was 54% (practice range 18–88%). None of the determinants was consistently associated with the primary outcome. GPs from 211 practices filled out the questionnaire and the most frequently mentioned reason not to prescribe a laxative was that the patient has laxatives in stock, followed by that the patient doesn’t want a laxative; both were patient-related factors.ConclusionThere was room for improvement in following the guideline on laxative prescribing in opioid use. A main reason seemed to be that the patient refuses a laxative. Improvement measures should therefore focus on communication between GPs and patients on the relevance of co-using a laxative with opioids. Future studies need to establish the effect of such improvement measures, and determine whether reasons for non-adherence to the guideline changed over time.

498 Junior Doctor Checklist for the Management of Neck of Femur Fracture: A Quality Improvement Project

Abstract Aim Patients admitted with Neck of Femur (NOF) fracture are often complex and frail. Junior doctors in our institution are first on call and have minimal orthopaedic experience. Anecdotal experience has shown that patients are often inadequately optimised. For example, fluids not prescribed, and anticoagulants not reversed which could lead to further complications and delay to surgery, affecting patient outcomes. Therefore, we developed a junior doctor checklist to improve the quality of care for patients with NOF fracture. Method A plan-do-study-act (PDSA) methodology was utilized in designing this project. Data was collected prospectively from 50 patients presented with NOF fracture pre and post intervention. Clerking proforma, drug chart and electronic systems were reviewed. Outcome measures were prescription of analgesia, fluids, anti-emetics and laxatives, completion of venous thromboembolism (VTE) prophylaxis, abbreviated mental test (AMT), group and save and reversal of anticoagulation, if available. Intervention included production of a checklist outlining the management plan which was distributed to junior doctors. Results Areas for improvement identified from pre intervention cycle were prescription of fluids, anti-emetics, laxatives, and anticoagulant reversal, with a compliance of 56%, 44%, 42% and 50%. Other parameters had a compliance of &amp;gt;90% pre and post intervention. Post intervention compliance was 90% for fluids, 66% for anti-emetics, 74% for laxatives and 80% for anticoagulant reversal. Conclusion Introduction of a checklist is effective in improving the quality of care for patients with neck of femur fracture. More interventions incorporating the PDSA methodology will be carried out to strive for further quality improvement.

1026 Good Prescribing Laxatives Practice for Trauma Admissions in Orthopaedic Wards at Altnagelvin Hospital

Abstract Aim The aim of this QIP is to firstly increase percentage of T&amp;O admissions to Orthopaedic Wards 23+25 prescribed laxatives by 25% by 1st of December over 1 month and to increase awareness among healthcare staff. Background Constipation in elderly during inpatient stay is common, 50% of pts&amp;gt;65years will develop this due to multifactorial reasons. Correct laxatives are very important to curb this predicament. Method These data were assessed over the following criteria, laxatives prescribed on admission, administered following prescription, monitoring bowel output, suppositories prescribed after admission. Following each week QI cycles, appropriate interventions were made to improve the adherence and data was re-measured again. Results From Baseline data, only 45% of patient were prescribed laxatives and only 20% patients received the medication initially. Of this group, only 20% pts had suppositories prescribed following admission. Lastly, 40% of patients had Bowel Opened (BO)&amp;gt;3days ago. First intervention was educating all SHOs to ensure patients received prescription on admission. Following this, mainly laxative prescription increased by 40%, and patient received their laxatives by 2% respectively in PDSA 1. In PDSA 2, we actively ensured educating nursing staff to encourage laxative prescriptions and to inform doctors for patients with Last BO&amp;gt;3days ago for suppositories prescribing. Following this, laxative prescription increased to 80% while 65% pts received their prescription. Only 15% pts had BO&amp;gt;3days too. Conclusion Regular laxatives are superior to PRN &amp; Recommended regime is Senna+Lactulose for patient adherence. Additionally, suppositories should be given as STAT rather than Prn as well.

Tapentadol versus klassische WHO-III-Opioide bei chronischen Rückenschmerzen

In clinical trials, tapentadol prolonged release (PR) showed a more favourable gastrointestinal tolerability profile compared to other strong opioids in the treatment of pain. The present analysis compared tapentadol PR and classical WHO-III PR opioids in routine clinical practice. Retrospective cohort study (matched pair approach) using anonymised health insurance data of patients with chronic low back pain who were prescribed strong opioids following pretreatment with WHO-I/II analgesics. Data were analysed from the date of first prescription in 2015 over a maximum period of two years. The primary analysis parameter was the prescription of laxatives. Data of 227 patients per cohort could be included in the analysis. Significantly fewer tapentadol PR than WHO-III PR patients were prescribed laxatives (20.3% vs. 37%; p < 0.0001). In addition, laxative dosages were significantly lower in the tapentadol PR cohort (26.4 vs. 82.5 defined daily doses; p < 0.0001). A significant difference in laxative prescription was also observed under long-term treatment (tapentadol PR patients 27.7% vs. WHO-III PR patients 50%; p = 0.0029). Routine clinical practice indirectly confirmed the more favourable gastrointestinal tolerability of tapentadol PR in the treatment of chronic pain which had previously been demonstrated in clinical trials and non-interventional studies.

Emergency department diagnosis and management of constipation in the United States, 2006-2017.

Constipation is a common diagnosis in adults and children. Emergency department (ED) visits for constipation increased from 1980 to 2010. Since then, efforts have aimed to reduce resource utilization for constipation in the ED setting. Our objective is to examine contemporary ED practice patterns in the context of updated care guidelines. We conducted a cross-sectional study using the National Hospital Ambulatory Medical Care Survey from 2006 to 2017. Encounters with a constipation diagnosis were included. We examined rates of ED visits, diagnostic testing, and medication use. We also compared general and pediatric ED practice patterns for children. Approximately 1.3 million ED visits with a diagnosis of constipation occurred annually, with pediatric encounters comprising one-third of all visits. There was a 114% increase in ED visits for constipation over the study period. Urinalysis and imaging increased by 17% and 15%, respectively. Older patients were more likely to undergo diagnostic testing. No significant changes in laboratory testing, radiographs, or osmotic laxative prescriptions were observed among children. Compared to pediatric EDs, general EDs were more likely to perform CBC (29% vs. 15%) and urinalysis testing (42% vs 31%). General EDs were less likely to prescribe osmotic laxatives for children compared to pediatric EDs (26% vs. 37%). ED visits for constipation have increased significantly since 2006. Rates of diagnostic tests and prescriptions have not changed despite published evidence and guidelines that the diagnosis of constipation does not require imaging, and that the management of constipation requires consistent outpatient treatment. Opportunities exist to reduce ED resource utilization through knowledge dissemination and implementation.

737 STOOLS FOR STOOLS - COMBINING MEDICAL AND CONSERVATIVE TREATMENTS TO REDUCE CONSTIPATION IN THE ELDERLY INPATIENT POPULATION

Abstract Introduction Constipation is a common cause of morbidity in the elderly. Its management is particularly challenging in the inpatient population, where many factors exacerbate constipation. We describe a Quality Improvement Project to reduce the rates of constipation on a female Medicine for the Elderly ward. Aims Our aim was to increase bowel chart documentation (nursing and doctor entries) and increase patient frequency of bowel motions to at least once every two days. In particular we focused on conservative measures such as the use of footstools to optimise posture when using commodes and toilets [R Hari Krishnan, Proc Inst Mech Eng H, 2019, 233(4):464–475]. Method • Weekly monitoring of ward inpatients. • Measurements taken were: days since last bowel motion, laxatives prescribed, bowel chart and ward round documentation, and episodes of diarrhoea over the past week. • One episode of diarrhoea was defined as 3 motions of type 6 or type 7 stool in 24 hours. • A new intervention was introduced every two weeks, over a total of 2 months. Interventions: 1. Recording bowel motions at the daily ‘Board Round’ Multi-Disciplinary Meeting. 2. Ward staff education sessions. 3. Footstools for use with commodes and toilets. 4. High-fibre foods to patients with constipation. Results Level of constipation was successfully reduced, with 100% patients moving bowels every 2 days from a baseline of 68%. Ward round and bowel chart documentation improved to 100% and 93.3% respectively (from 41.3% and 33.3%). However, incidence of diarrhoea increased from 0 episodes/week to 8 episodes/week, with laxative prescriptions similarly increased from 50% to 86%. Conclusion Constipation improved with our interventions, but at the unintended cost of laxative-associated diarrhoea. Our next steps will be to reduce laxative prescriptions in favour of conservative measures, in order to reduce episodes of loose stool while maintaining our improved constipation rates.

756 ORTHOPAEDIC SURGEONS CAN PRESCRIBE LAXATIVES &amp; ANALGESICS TOO - A QUALITY IMPROVEMENT PROJECT SPANNING 7 YEARS

Abstract Background Patients admitted with age 60 years and over with a hip fracture admitted to a District General Hospital. Introduction The aim was to improve the prescribing of regular laxatives and analgesia at the time of admission to hospital. Methods There were repeated PDSA cycles. Data was collected on consecutive patients (by admission date) identified from the National Hip Fracture Database. Data was collected at baseline (10 patients in November 2013) and after Phase 1 intervention (20 patients, December 2013—January 2014), after Phase 2 (20 patients, February 2014), after Phase 3 (39 patients, April—June 2017) and after Phase 4 (September—October 2020). The interventions were as follows: Phase 1: Prompts at new doctor induction (‘Induction’) + prompts in hip fracture admission document. Phase2: Phase 1 intervention + flow diagram in fracture admission document. Phase 3: Prompts at Induction + electronic prescribing protocol (including laxatives and analgesics) + removal of flow diagram from admission document. Phase 4: Phase 3 intervention + more effort to explain to new locum doctors. Results Laxative prescribing: Baseline = 40%, Phase 1 = 80%, Phase 2 = 80%, Phase 3 = 56%, Phase 4 = 74% (24 hours post-admission = 90%). Paracetamol prescribing: Baseline 100%, Phase 1,100%, Phase 2,100%, Phase 3 64%, Phase 4 82% (24 h post-admission = 90%). Regular strong opioid prescribing: Admission: Baseline 60%, Phase 1 90%, Phase 2,100%, Phase 3 44%, Phase 4 80% (24 h post-admission = 90%). Conclusion 1. Orthopaedic Surgeons can prescribe laxatives and analgesia well—given sufficient prompts 2. The electronic solution is not always sufficient—locum doctors may not be aware of it. 3. Do not assume continued success Future Plans Re-introduce flow diagram to admission document. Acknowledgements Many people have helped with previous phases &amp; will be acknowledged.

Laxative use and mortality in patients on haemodialysis: a prospective cohort study

BackgroundPatients on haemodialysis (HD) are often constipated. This study aimed to assess the relationship between constipation and mortality in such patients. In this study, constipation was defined as receiving prescription laxatives, based on the investigation results of “a need to take laxatives is the most common conception of constipation” reported by the World Gastroenterology Organization Global Guidelines.MethodsThis cohort study included 12,217 adult patients on HD enrolled in the Japan-Dialysis Outcomes and Practice Patterns study phases 1 to 5 (1998 to 2015). The participants were grouped into two based on whether they were prescribed laxatives during enrolment at baseline. The primary endpoint was all-cause mortality in 3 years, and the secondary endpoint was cause-specific death. Missing values were imputed using multiple imputation methods. All estimations were calculated using a Cox proportional hazards model with an inverse probability of treatment weighting using the propensity score.ResultsLaxatives were prescribed in 30.5% of the patients, and there were 1240 all-cause deaths. There was a significant association between laxative prescription and all-cause mortality [adjusted hazard ratio (AHR), 1.12; 95% confidence interval (CI): 1.03 to 1.21]. Because the Kaplan-Meier curves of the two groups crossed over, we examined 8345 patients observed for more than 1.5 years. Laxative prescription was significantly associated with all-cause mortality (AHR, 1.35; 95% CI: 1.17 to 1.55). The AHR of infectious death was 1.62 (95% CI: 1.14 to 2.29), and that of cancerous death was 1.60 (95% CI: 1.08 to 2.36). However, cardiovascular death did not show a significant inter-group difference.ConclusionsConstipation requiring use of laxatives was associated with an increased risk of death in patients on HD. It is important to prevent patients receiving HD from developing constipation and to reduce the number of patients requiring laxatives.

Chronic Constipation as a Risk Factor for Colorectal Cancer: Results From a Nationwide, Case-Control Study

Prolonged colon transit times may increase the contact time between potential carcinogens in the stool and the colonic mucosa. Nonetheless, previous studies have yielded conflicting results connecting chronic constipation with the risk of colorectal cancer (CRC). We examined the association between chronic constipation and later CRC. In this nationwide case-control study, we identified 41,299 CRC cases by colorectal biopsy in Sweden between July 2007 and December 2016 and matched them to 203,181 age- and sex-matched controls from the general population. We compared odds of earlier chronic constipation (defined as ≥2 laxative prescriptions in the Prescribed Drug Register with ≥6 months between the first and last prescription) between CRC cases and controls using logistic regression. In separate analyses, we compared odds of earlier constipation between CRC cases and sibling comparators, but also examined earlier risk of having an inpatient/outpatient specialty diagnosis of chronic constipation before CRC. Overall, 3943 patients with CRC met our criteria for chronic constipation before CRC. The crude proportion of chronic constipation in CRC patients was 9.5% compared with 8.8% in controls. After multivariable adjustment, there was a modest association between chronic constipation and later CRC (odds ratio [OR], 1.10; 95% CI, 1.06-1.14) that vanished using sibling comparators to control for residual confounding (OR, 1.04; 95% CI, 0.97-1.13). In a sensitivity analysis of 126,650 CRC patients diagnosed from 1989 to 2016, we found no association with earlier chronic constipation diagnosed in inpatient/outpatient specialty clinics (OR, 0.88; 95% CI, 0.75-1.04). In a nationwide case-control study, chronic constipation was not associated with later CRC.