Understanding medication recycling practices in Canadian hospitals.

BACKGROUND: Medication recycling within hospitals has proven financial and possible environmental benefits according to local evaluations done in British Columbia. Despite this, the extent of medication recycling in Canadian hospitals remains unclear in the literature. OBJECTIVE(S): To determine if Canadian hospitals recycle medications, provide an estimate of how much medication is recycled by dosage form, and identify medication recycling barriers through the distribution of a cross-sectional survey. METHODS: A nine-question survey was distributed to 171 hospital pharmacy departments across Canada that consented to complete the survey. The survey identified whether sites recycled unused medications, an estimate of how much is recycled based on dosage form, and barriers to recycling. KEY FINDINGS: Of 62 respondents, the majority indicated they do have medication recycling procedures; however, the frequency of recycling is suboptimal (30-50% of medications are not recycled), and not all medication types are always recycled. Individually packaged oral tablets were most often recycled, and oral liquid medications were least often recycled. Many multi-dose medications were not tamper-proofed. Most respondents selected "sanitization/infection control" and "resource constraint" as reasons for not recycling all medications. CONCLUSIONS: Among respondents, the proportion and type of unused medicines that are recycled varied. For sites that did not respond, this might suggest that medication recycling is not a priority. This could represent a missed opportunity to standardize practices and increase medication recycling in hospitals, both of which could represent a meaningful step towards responsible use of medications and reduction of negative impacts on human health and the environment.

How Patient-Centred Are Inhaler Device Choices? A Survey of Canadian Prescribers.

Background: The choice of inhaler device type can play a crucial role in managing asthma and chronic obstructive pulmonary disease (COPD). With various devices available, differences in choice and application may lead to confusion for both prescribers and patients. Furthermore, improper use of a device may lead to suboptimal or inadequate treatment. Objectives: The primary objective was to identify factors that prescribers consider when selecting an inhaler device for a patient. The secondary objective was to evaluate the rankings of these factors, including identification of which factors had greater importance and frequency for prescribers' choice of inhaler device for patients. Methods: A 10-question online survey was developed and distributed in late 2021 to prescribers (physicians, nurse practitioners, and pharmacists) in western Canada in an outpatient setting. Prescribers were asked to use their own words to describe the factors they considered important and were then asked to rank the stated factors in order of importance for 2 scenarios: an 83-year-old woman with COPD and a 21-year-old man with asthma. The results were examined qualitatively and quantitatively. Recurring themes were identified, and each response was categorized on the basis of its corresponding theme. Results: In all, 82 respondents completed the survey (yielding a total of 164 responses across the 2 scenarios). Overall, prescriber experience (84/164, 51%), cost (84/164, 51%), patient ease of use (59/164, 36%), and other patient considerations (49/164, 30%) were the factors most frequently mentioned. The prescriber's experience was most often mentioned as a factor for scenario 1 (COPD), whereas cost was most often mentioned for scenario 2 (asthma). In both scenarios, prescriber experience was the highest-ranked factor. Conclusions: When determining the appropriate type of inhaler device, respondents frequently prioritized their own experience, as well as cost and ease of use. However, many respondents ranked prescriber experience higher than all other factors.

Contexte: Le choix du type d'inhalateur peut jouer un rôle crucial dans la gestion de l'asthme et de la maladie pulmonaire obstructive chronique (MPOC). Étant donné la diversité des dispositifs disponibles, les différences de choix et d'application peuvent prêter à confusion tant pour les prescripteurs que pour les patients. De plus, la mauvaise utilisation d'un appareil peut conduire à un traitement sous-optimal ou inadéquat. Objectifs: L'objectif principal consistait à identifier les facteurs pris en compte par les prescripteurs lors de la sélection de l'inhalateur pour un patient. L'objectif secondaire consistait à évaluer le classement de ces facteurs, notamment l'identification des facteurs les plus importants et des inhalateurs les plus fréquemment choisis par les prescripteurs. Méthodes: Un sondage en ligne de 10 questions a été préparé et distribué fin 2021 aux prescripteurs (médecins, infirmières praticiennes et pharmaciens) de l'ouest du Canada en milieu ambulatoire. Les prescripteurs devaient, dans leurs propres mots, décrire les facteurs qui leur semblaient importants avant de les classer par ordre d'importance dans le cadre de deux scénarios : une femme de 83 ans atteinte de MPOC et un homme de 21 ans avec de l'asthme. Les résultats ont fait l'objet d'un examen qualitatif et quantitatif. Des thèmes récurrents ont été identifiés et chaque réponse a été catégorisée en fonction du thème correspondant. Résultats: Au total, 82 répondants ont répondu au sondage (total de 164 réponses dans les 2 scénarios). Dans l'ensemble, l'expérience du prescripteur (84/164, 51 %), le coût (84/164, 51 %), la facilité d'utilisation pour le patient (59/164, 36 %) et d'autres considérations en rapport avec le patient (49/164, 30 %) étaient les facteurs déterminants les plus fréquemment mentionnés. Pour le scénario 1 (MPOC), l'expérience du prescripteur était le facteur le plus souvent mentionné, alors que le coût l'était pour le scénario 2 (asthme). Dans les deux scénarios, l'expérience du prescripteur était le facteur le plus important. Conclusions: Lors de la détermination du type d'inhalateur approprié, les répondants ont souvent donné la priorité à leur expérience personnelle, ainsi qu'au coût et à la facilité d'utilisation. Cependant, de nombreux répondants ont accordé une note plus élevée à l'expérience du prescripteur qu'à d'autres facteurs.

Prescribing Portraits to Optimize Prescribing of Proton Pump Inhibitors in Long-Term Care: PPI-T STOP Study.

Background: Proton pump inhibitors (PPIs) are among the most commonly prescribed medications in Canada, particularly for older adults (at least 65 years of age). Overprescribing of long-term PPIs leads to health care system waste and is associated with adverse effects, including infections and fractures. The high prevalence of PPI prescribing in long-term care (LTC) facilities prompted an evaluation of systematic approaches to PPI deprescribing. Objective: To assess the impact of individualized prescribing portraits, a type of audit-and-feedback quality improvement intervention, on PPI deprescribing in the LTC setting. Methods: This prospective, nonblinded, uncontrolled, pre-post quality improvement study was conducted from December 2021 to April 2022 at a 126-bed LTC facility in Vancouver, British Columbia. A PPI prescribing portrait was developed for each prescriber (n = 5) at the LTC facility, containing the prescriber's personal PPI prescribing metrics as compared with those of their peers across all LTC facilities within the same health authority; an evidence summary for PPI deprescribing; and a personalized list of the prescriber's PPI-treated residents, along with their respective PPI indications and strategies for PPI deprescribing. Three months after the prescribers received their PPI prescribing portraits, the number and types of PPI deprescribing orders were recorded. Results: The implementation of prescribing portraits resulted in 17 (61%) of 28 PPI-treated residents receiving a deprescribing order by the end of the study period. Of the 28 PPI-treated residents, 20 were determined to be eligible for PPI deprescribing according to the evidence summary presented in the prescribing portrait; of these 20 residents, 16 (80%) appropriately received PPI deprescribing. Conclusions: Individualized prescribing portraits had the potential to increase evidence-based PPI deprescribing among LTC residents, beyond the extent of deprescribing previously achieved through standard of care.

Contexte: Les inhibiteurs de la pompe à protons (IPP) comptent parmi les médicaments les plus couramment prescrits au Canada, particulièrement chez les personnes âgées (au moins 65 ans). La prescription excessive d'IPP à long terme entraîne un gaspillage pour le système de santé et est associée à des effets indésirables, notamment des infections et des fractures. La prévalence élevée de la prescription d'IPP dans les établissements de soins de longue durée (SLD) a entraîné une évaluation des approches systématiques de déprescription des IPP. Objectif: Évaluer l'incidence des schémas de prescription individualisés, un type d'intervention d'amélioration de la qualité basée sur l'audit et la rétroaction, sur la déprescription des IPP dans les établissements de SLD. Méthodes: Cette étude prospective, sans insu et non contrôlée sur l'amélioration de la qualité pré-post a été menée entre décembre 2021 et avril 2022 dans un établissement de SLD de 126 lits à Vancouver, en Colombie-Britannique. Un schéma de prescription d'IPP a été élaboré pour chaque prescripteur (n = 5) de l'établissement de SLD, contenant les paramètres personnels de prescription d'IPP du prescripteur par rapport à ceux de ses pairs dans tous les établissements de SLD au sein de la même autorité sanitaire; un résumé des données probantes pour la déprescription des IPP; et une liste personnalisée des résidents du prescripteur traités par IPP, ainsi que, respectivement, leurs indications d'IPP pour la déprescription des IPP. Trois mois après la réception des schémas de prescription d'IPP des prescripteurs, le nombre et les types d'ordonnances de déprescription d'IPP ont été enregistrés. Résultats: La mise en œuvre de schémas de prescription a permis à 17 (61 %) des 28 résidents traités par IPP de recevoir une ordonnance de déprescription pendant la période d'étude. Sur les 28 résidents traités par IPP, 20 ont été jugés admissibles à la déprescription des IPP sur la base du résumé des données probantes présentées dans le schéma de prescription; sur ces 20 résidents, 16 (80 %) ont reçu de manière appropriée une déprescription d'IPP. Conclusions: Les schémas de prescription individualisés avaient le potentiel d'augmenter la déprescription d'IPP fondée sur des données probantes chez les résidents des établissements de SLD, au-delà de l'étendue de la déprescription précédemment atteinte grâce aux normes de soins.

Switching Topical Diclofenac from Higher to Lower Strength: Financial and Clinical Evaluation.

Background: In February 2020, the Fraser Health Authority in British Columbia introduced an automatic therapeutic interchange policy, whereby orders for any strength of topical diclofenac would be automatically interchanged to the commercially available diclofenac 2.32% gel for twice-daily administration. The new policy was intended mainly as a cost-saving measure but had the potential for clinical impacts that needed to be considered. Objectives: To evaluate the financial and clinical impact of the automatic therapeutic interchange policy for topical diclofenac. Methods: A financial evaluation and a clinical evaluation were conducted. Expenditures for topical diclofenac before and after implementation of the automatic therapeutic interchange policy were compared. To obtain information about the clinical impact of the interchange, a retrospective chart review was conducted at long-term care sites. The primary outcome was a composite of 7 components that could indicate worsening of pain in 3 prespecified scenarios. Results: The financial evaluation showed that the interchange could potentially save the health authority more than $200 000 over 12 months. The clinical evaluation showed that 25%-48% of patients met the primary outcome of worsening pain (analyzed according to 3 different scenarios) after the switch to lower-strength diclofenac, with increases in use of as-needed topical diclofenac and other analgesics being the main indicators of worsening pain. Conclusions: An automatic therapeutic interchange policy that switched orders for higher strengths of diclofenac to the 2.32% concentration resulted in large financial savings and, in most cases (52%-75% of patients), did not appear to affect pain control. Prospective studies comparing the clinical impact of higher- and lower-strength topical diclofenac products are warranted.

Contexte: En février 2020, la Fraser Health Authority en Colombie-Britannique a introduit une politique d'échange thérapeutique automatique, selon laquelle les commandes de diclofénac topique (n'importe quelle concentration) seraient automatiquement échangées contre du diclofénac à 2,32 % (formule en gel) disponible dans le commerce pour une administration deux fois par jour. La nouvelle politique visait principalement à réduire les coûts, mais pouvait avoir une incidence clinique, qui devait être prise en compte. Objectifs: Évaluer l'impact financier et clinique de la politique d'échange thérapeutique automatique pour le diclofénac topique. Méthodes: Une évaluation financière et une évaluation clinique ont été réalisées. Les dépenses liées au diclofénac topique avant et après la mise en œuvre de la politique d'échange thérapeutique automatique ont été comparées. Pour obtenir des informations sur l'incidence clinique de l'échange, un examen rétrospectif des dossiers a été réalisé dans les sites de soins de longue durée. Le résultat principal était un composite de 7 éléments pouvant indiquer une aggravation de la douleur dans 3 scénarios prédéfinis. Résultats: L'évaluation financière a montré que l'échange pourrait potentiellement permettre à l'autorité sanitaire d'économiser plus de 200 000 $ sur 12 mois. L'évaluation clinique a quant à elle démontré que 25 à 48 % des patients ont atteint le principal résultat d'aggravation de la douleur (analysé selon 3 scénarios différents) après le passage au diclofénac à plus faible concentration. L'augmentation de l'utilisation au besoin de diclofénac topique et d'autres analgésiques constituait le principal indicateur d'aggravation de la douleur. Conclusions: Une politique d'échange thérapeutique automatique qui remplaçait les ordonnances de concentrations plus élevées de diclofénac par une concentration de 2,32 % a permis de réaliser d'importantes économies financières et, dans la plupart des cas (52 à 75 % des patients), cet échange ne semble pas avoir eu d'effet sur le contrôle de la douleur. Des études prospectives comparant l'incidence clinique des produits topiques à base de diclofénac à concentration plus élevée et plus faible sont justifiées.

Hiding in Plain Sight: Quantifying Salbutamol and Ipratropium Inhaler Wastage in Hospitals.

Background: Previous studies have found significant inhaler wastage in the inpatient setting, which contributes to unnecessary health care expenditures. Wastage may involve inhalers available in automated dispensing cabinets (ADCs). Objectives: To evaluate whether salbutamol and ipratropium inhalers were unnecessarily withdrawn from ADCs for hospital inpatients. Methods: This cross-sectional study included patients from 16 health care facilities in British Columbia. ADC reports were run for the period August 2021 to January 2022 to identify salbutamol and ipratropium inhalers removed from ADCs. Results: Over the study period, 8.3% (2180/26 324) of salbutamol and ipratropium inhalers were withdrawn from ADCs unnecessarily for the same patient encounter within a 2-day timeframe, and another 1118 (4.2%) represented instances when multiple inhalers were withdrawn for the same patient at the same time. Overall, 12.5% (3298/26 324) of all salbutamol and ipratropium inhalers were withdrawn unnecessarily. The total cost of these inhalers was about $31 600 over the 6-month period. Conclusions: This evaluation revealed considerable wastage of inhalers, leading to wasted expenditures. Other health authorities should conduct similar analyses to determine whether similar problems exist in their settings.

Contexte: De précédentes études ont mis au jour un gaspillage important d'inhalateurs en milieu hospitalier, ce qui contribue à des dépenses de soins de santé inutiles. Ce gaspillage peut comprendre des inhalateurs disponibles dans des cabinet de distribution automatisé (CDA). Objectif: Évaluer si les inhalateurs de salbutamol et d'ipratropium ont été inutilement retirés des CDA pour les patients hospitalisés. Méthodes: Cette étude transversale comprenait des patients provenant de 16 établissements de soins de santé en Colombie-Britannique. Des rapports portant sur les CDA ont été générés pour la période d'août 2021 à janvier 2022 afin de recenser les inhalateurs de salbutamol et d'ipratropium qui ont été retirés des CDA. Résultats: Pendant la période de l'étude, 8,3 % (2180/26 324) des inhalateurs de salbutamol et d'ipratropium ont été inutilement retirés des CDA pour la même rencontre avec le patient dans une fenêtre de 2 jours, et dans le cas de 1118 (4,2 %) inhalateurs, plusieurs inhalateurs ont été retirées en même temps pour un même patient. Dans l'ensemble, 12,5 % (3298/26 324) de tous les inhalateurs de salbutamol et d'ipratropium ont été inutilement retirés. Le coût total de ces inhalateurs s'élevait à environ 31 600 $ sur une période de 6 mois. Conclusions: Cette évaluation a révélé un gaspillage considérable d'inhalateurs, ce qui entraîne des dépenses inutiles. D'autres autorités sanitaires devraient mener des analyses similaires pour savoir si des problèmes similaires se produisent dans leurs établissements.

Recycling unused medications in hospitals is financially viable and good for the environment.

OBJECTIVES: Considerable pharmaceutical waste is generated in hospital settings which can be reduced by recycling of unused medications. We sought to determine the recycling practices as well as quantify the volume and the value of oral solid medications returned from nursing units to the pharmacy departments at three urban hospitals. METHODS: Unused oral solid medications were recycled at three sites and the net financial impact of this practice was calculated (cost recovered - labour costs). The results were extrapolated to all 21 hospitals within the health system. KEY FINDINGS: Recycling medications in 21 hospitals could divert ~461 000 units of medication from the incinerator, with an estimated net value of ~$415 000 per year. CONCLUSIONS: Recycling unused medications could save substantial amounts of money and reduce negative environmental impacts from disposal/incineration.

Assessment of Intravenous versus Oral Antimicrobials in a Large Regional Health Authority.

Background: Many antimicrobials given by the intravenous (IV) route have oral (PO) formulations with high oral bioavailability. The advantages of using the PO rather than the IV formulation include lower risk of adverse reactions, shorter length of hospital stay, and lower health care costs. Objectives: The primary objective was to determine the proportions of patients who received the IV and PO formulations of antimicrobials with high oral bioavailability. The secondary objectives were to determine the proportion of patients who were eligible to receive PO antimicrobials from the start of treatment, the proportion who qualified for IV-to-PO step-down, and areas of improvement to increase use of PO antimicrobials. Methods: A retrospective chart review was conducted in hospitals in the Fraser Health Authority, British Columbia, between October 18, 2019, and March 5, 2020. Two hundred charts were randomly selected for patients who had received either azithromycin, ciprofloxacin, clindamycin, fluconazole, levofloxacin, linezolid, moxifloxacin, metronidazole, sulfamethoxazole-trimethoprim, or voriconazole. Results: Of the 200 patients, 124 (62.0%) received the PO formulations, while 76 (38.0%) received the IV formulations. Of the 76 patients receiving IV antimicrobials, 39 (51.3%; 95% confidence interval 44.7%-57.9%) were eligible to receive PO antimicrobials from the start of treatment or could have been stepped down from IV to PO administration. Conclusions: More than half of patients who received IV therapy were eligible to receive the PO formulation of antimicrobials known to have high oral bioavailability; relative to earlier studies, this proportion has not improved over time. This finding highlights the need for continued vigilance in encouraging the use of PO rather than IV formulations for hospitalized patients.

Contexte: De nombreux antimicrobiens administrés par voie intraveineuse (IV) ont des formulations orales (PO) avec une biodisponibilité orale élevée. Les avantages de l'utilisation de cette formulation plutôt que de la formulation IV comprennent un risque moins élevé d'effets indésirables, une durée d'hospitalisation plus courte et des coûts de soins de santé inférieurs. Objectifs: L'objectif principal visait à déterminer les proportions de patients ayant reçu les formulations IV et PO d'antimicrobiens à haute biodisponibilité orale. Les objectifs secondaires consistaient, quant à eux, à déterminer la proportion de patients pouvant recevoir des antimicrobiens par voie orale dès le début du traitement, la proportion de patients qualifiés pour passer de l'administration IV à l'administration par voie orale et les domaines d'amélioration pour augmenter l'utilisation des antimicrobiens par voie orale. Méthodes: Un examen rétrospectif des dossiers a été effectué dans les hôpitaux de la Fraser Health Authority, en Colombie-Britannique, entre le 18 octobre 2019 et le 5 mars 2020. Deux cents dossiers ont été sélectionnés au hasard pour les patients qui avaient reçu soit de l'azithromycine, de la ciprofloxacine, de la clindamycine, du fluconazole, de la lévofloxacine, du linézolide, de la moxifloxacine, du métronidazole, de la sulfaméthoxazole-triméthoprime ou du voriconazole. Résultats: Sur les 200 patients, 124 (62,0 %) ont reçu les formulations PO, tandis que 76 (38,0 %) ont reçu les formulations IV. Sur les 76 patients recevant des antimicrobiens par voie intraveineuse, 39 (51,3 %; intervalle de confiance à 95 % 44,7 % à 57,9 %) étaient admissibles pour recevoir des antimicrobiens par voie orale dès le début du traitement ou auraient pu passer de l'administration IV à l'administration par voie orale. Conclusions: Plus de la moitié des patients ayant reçu une thérapie IV étaient admissibles pour recevoir la formulation PO d'antimicrobiens connus pour avoir une biodisponibilité orale élevée; par rapport aux études antérieures, cette proportion ne s'est pas améliorée avec le temps. Cette découverte souligne la nécessité d'une vigilance continue pour encourager l'utilisation de formulations PO plutôt que IV pour les patients hospitalisés.

Hidden Costs of Multiple-Dose Products: Quantifying Ipratropium Inhaler Wastage in the Hospital Setting.

BACKGROUND: Previous studies have quantified wastage involving drugs that are available in multiple-dose formats. Ipratropium bromide by metered dose inhaler (MDI) is commonly used in hospitals, and may be contributing to waste of pharmaceutical and financial resources. OBJECTIVES: The primary objective was to quantify the number of patients in the authors' health authority with waste of at least 1 ipratropium MDI. Secondary outcomes were the total number of wasted inhalers, the total number of wasted doses, the cost of wasted inhalers, the cost of wasted doses, and possible factors or explanations for inhaler wastage. METHODS: A retrospective chart review was conducted for patients with an order for ipratropium by MDI in 2019 at one of the acute care sites within the health authority (predefined sample size 336). The number of inhalers dispensed was compared with doses received to determine the number of inhalers wasted. Each patient's electronic chart was audited for possible factors and explanations for wasting of inhalers. RESULTS: Of the 336 patients, 79 (24%) had wastage of at least 1 inhaler. In total, 34% (98/290) of all inhalers dispensed and 87% (50 693/58 000) of all doses dispensed were wasted. The total cost of wasted inhalers for the sample population was $2156. The most common reason for inhaler wastage was no doses being administered after an inhaler was dispensed; the second most common reason was dispensing of an extra inhaler associated with a change in directions for use. CONCLUSIONS: The use of multiple-dose MDI products in hospitals can lead to wastage of drugs and financial resources. Procedures need to be implemented to aid pharmacy and nursing staff in ensuring the most efficient use of these products. Evaluations of pilot methods to mitigate this waste are encouraged.

CONTEXTE: Des études antérieures ont quantifié le gaspillage de médicaments disponibles dans des formats multidoses. Le bromure d'ipratropium administré par inhalateur-doseur (ID) est communément utilisé dans les hôpitaux et pourrait entraîner un gaspillage des ressources pharmaceutiques et financières. OBJECTIFS: L'objectif principal consistait à quantifier le nombre de patients relevant de l'autorité sanitaire des auteurs, qui étaient source d'un gaspillage d'au moins un ID d'ipratropium. Les résultats secondaires visaient à déterminer le nombre total d'inhalateurs et de doses gaspillés, le coût associé au gaspillage des uns et des autres, ainsi que les facteurs pouvant expliquer cette situation. MÉTHODES: Les dossiers des patients ayant reçu une prescription d'ipratropium administrée par ID en 2019 dans l'un des sites de soins intensifs de l'autorité sanitaire ont fait l'objet d'un examen rétrospectif (taille de l'échantillon prédéfinie : 336). Une comparaison entre le nombre d'inhalateurs distribués et les doses reçues a permis de déterminer le nombre d'inhalateurs gaspillés. La vérification de chaque dossier électronique des patients a révélé les facteurs et les explications possibles du gaspillage des inhalateurs. RÉSULTATS: Sur les 336 patients, on a noté un gaspillage d'au moins un inhalateur tous les 79 patients (24 %). Au total, le gaspillage se montait à 34 % (98/290) de tous les inhalateurs distribués et à 87 % (50 693/58 000) de toutes les doses distribuées. Le coût total des inhalateurs distribués à l'échantillon de population se montait à 2156 $. La raison du gaspillage la plus fréquente était l'absence de doses administrées après la distribution d'un inhalateur; la deuxième raison concernait la distribution d'un inhalateur supplémentaire associée à une modification des instructions relatives à son utilisation. CONCLUSIONS: L'utilisation de produits ID multidoses dans les hôpitaux peut entraîner un gaspillage de médicaments et de ressources financières. Des procédures doivent être mises en place pour aider les membres du personnel des pharmacies et le personnel infirmier à utiliser plus efficacement ces produits. Il serait indiqué de procéder à des évaluations de méthodes pilotes pour atténuer ce gaspillage.

Outcome reporting bias in Cochrane systematic reviews: a cross-sectional analysis.

BACKGROUND: Discrepancies in outcome reporting (DOR) between protocol and published studies include inclusions of new outcomes, omission of prespecified outcomes, upgrade and downgrade of secondary and primary outcomes, and changes in definitions of prespecified outcomes. DOR can result in outcome reporting bias (ORB) when changes in outcomes occur after knowledge of results. This has potential to overestimate treatment effects and underestimate harms. This can also occur at the level of systematic reviews when changes in outcomes occur after knowledge of results of included studies. The prevalence of DOR and ORB in systematic reviews is unknown in systematic reviews published post-2007. OBJECTIVE: To estimate the prevalence of DOR and risk of ORB in all Cochrane reviews between the years 2007 and 2014. METHODS: A stratified random sampling approach was applied to collect a representative sample of Cochrane systematic reviews from each Cochrane review group. DOR was assessed by matching outcomes in each systematic review with their respective protocol. When DOR occurred, reviews were further assessed if there was a risk of ORB (unclear, low or high risk). We classified DOR as a high risk for ORB if the discrepancy occurred after knowledge of results in the systematic review. RESULTS: 150 of 350 (43%) review and protocol pairings contained DOR. When reviews were further scrutinised, 23% (35 of 150) of reviews with DOR contained a high risk of ORB, with changes being made after knowledge of results from individual trials. CONCLUSIONS: In our study, we identified just under a half of Cochrane reviews with at least one DOR. Of these, a fifth were at high risk of ORB. The presence of DOR and ORB in Cochrane reviews is of great concern; however, a solution is relatively simple. Authors are encouraged to be transparent where outcomes change and to describe the legitimacy of changing outcomes in order to prevent suspicion of bias.

A cautionary tale of multiple-dose drug products: Fluticasone and salmeterol combination inhaler waste.

RATIONALE: Some drugs can only be dispensed in multiple-dose containers. Multiple-dose packaging may pose a problem for hospitals in terms of drug wastage and cost. Oral inhalers, such as fluticasone propionate and salmeterol combination inhalers, are only available as multiple-dose formats in Canada. OBJECTIVES: The objectives of this study are to quantify the amount of fluticasone propionate and salmeterol combination inhaler waste and to assess possible factors that could be contributing to waste. METHODS: A retrospective chart review of 189 patients was conducted. Patients were included if they had received an order for fluticasone propionate and salmeterol combination inhaler at one of the 12 acute hospital sites of Fraser Health Authority. The primary outcome was the proportion of patients who were dispensed one or more inhalers unnecessarily. The number of inhalers dispensed was compared with the number of inhalers needed to complete a patient's order duration. The chart was also reviewed for possible factors that could have contributed to extra inhalers being dispensed unnecessarily. RESULTS: Thirty-seven patients (19.6%) had at least one inhaler dispensed unnecessarily and thus wasted. About 17.4% of the total amount of inhalers dispensed were dispensed unnecessarily, and 76.3% of doses dispensed were wasted. The cost of inhalers wasted for our sample was $5151.12 (CAD). The most common factors that contributed to inhaler waste appeared to be loss of medication during patient transfers and storage of inhalers as wardstock. CONCLUSIONS: The use of drugs that are only available in multiple-dose formats results in significant drug wastage and unnecessary health care expenditure. To minimize wastage of drug product, procedures could be implemented to ensure that drugs are properly transferred with the patient when a patient transfers locations in the hospital. As well, a review of wardstock inventory may minimize waste. Further assessment of multiple-dose drug product waste and evaluations of methods to mitigate waste are encouraged.

Reassessment of venous thromboembolism and bleeding risk in medical patients receiving VTE prophylaxis.

RATIONALE, AIMS, AND OBJECTIVES: The majority of hospitalized nonsurgical medical patients receive pharmacological prophylaxis for venous thromboembolism (VTE), and reassessment of changes in thrombosis and bleeding risk factors during hospital admission may represent an opportunity to discontinue unnecessary or unsafe therapy. The use of validated, clinically derived risk assessment models (RAMs) represents a shift towards an individualized, patient-centred approach to VTE prophylaxis. We are interested in using these tools to assess whether risk categories for VTE and bleeding change during admission and to assess whether such changes result in discontinuation of prophylaxis. Our primary objective was to determine whether VTE and bleed risk categories changed during the course of admission to warrant discontinuation of VTE prophylaxis, using the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) VTE and Bleed RAMs, respectively. Secondary objectives were to determine the number of patients whose risk categorizations for VTE and bleeding warranted discontinuation of VTE prophylaxis and to survey whether prophylaxis was continued or discontinued. METHODS: A retrospective review was undertaken for a cross-sectional, randomly selected sample of patients who received VTE prophylaxis while admitted to medical wards in a collection of regional hospitals. RESULTS: Of the 351 medical records reviewed, only eight patients (2.3%) changed their VTE risk category and six (1.7%) changed their bleed risk category to warrant discontinuation of VTE prophylaxis. Ninety patients (26%) were at high risk of VTE and low risk of bleed throughout admission, warranting continued VTE prophylaxis. The majority of patients remained at low risk of VTE throughout admission but remained on VTE prophylaxis until discharge. CONCLUSIONS: Risk categories for VTE and bleeding for medical patients did not appreciably change throughout hospital admission. Use of VTE RAMs at admission and prior to initiation of therapy should reduce unnecessary prophylaxis in the majority of medical patients who are at low risk of VTE.

Pharmacotherapy for hypertension in adults 60 years or older.

BACKGROUND: This is the second substantive update of this review. It was originally published in 1998 and was previously updated in 2009. Elevated blood pressure (known as 'hypertension') increases with age - most rapidly over age 60. Systolic hypertension is more strongly associated with cardiovascular disease than is diastolic hypertension, and it occurs more commonly in older people. It is important to know the benefits and harms of antihypertensive treatment for hypertension in this age group, as well as separately for people 60 to 79 years old and people 80 years or older. OBJECTIVES: Primary objective• To quantify the effects of antihypertensive drug treatment as compared with placebo or no treatment on all-cause mortality in people 60 years and older with mild to moderate systolic or diastolic hypertensionSecondary objectives• To quantify the effects of antihypertensive drug treatment as compared with placebo or no treatment on cardiovascular-specific morbidity and mortality in people 60 years and older with mild to moderate systolic or diastolic hypertension• To quantify the rate of withdrawal due to adverse effects of antihypertensive drug treatment as compared with placebo or no treatment in people 60 years and older with mild to moderate systolic or diastolic hypertension SEARCH METHODS: The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to 24 November 2017: the Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid (from 1946), Embase (from 1974), the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. We contacted authors of relevant papers regarding further published and unpublished work. SELECTION CRITERIA: Randomised controlled trials of at least one year's duration comparing antihypertensive drug therapy versus placebo or no treatment and providing morbidity and mortality data for adult patients (≥ 60 years old) with hypertension defined as blood pressure greater than 140/90 mmHg. DATA COLLECTION AND ANALYSIS: Outcomes assessed were all-cause mortality; cardiovascular morbidity and mortality; cerebrovascular morbidity and mortality; coronary heart disease morbidity and mortality; and withdrawal due to adverse effects. We modified the definition of cardiovascular mortality and morbidity to exclude transient ischaemic attacks when possible. MAIN RESULTS: This update includes one additional trial (MRC-TMH 1985). Sixteen trials (N = 26,795) in healthy ambulatory adults 60 years or older (mean age 73.4 years) from western industrialised countries with moderate to severe systolic and/or diastolic hypertension (average 182/95 mmHg) met the inclusion criteria. Most of these trials evaluated first-line thiazide diuretic therapy for a mean treatment duration of 3.8 years.Antihypertensive drug treatment reduced all-cause mortality (high-certainty evidence; 11% with control vs 10.0% with treatment; risk ratio (RR) 0.91, 95% confidence interval (CI) 0.85 to 0.97; cardiovascular morbidity and mortality (moderate-certainty evidence; 13.6% with control vs 9.8% with treatment; RR 0.72, 95% CI 0.68 to 0.77; cerebrovascular mortality and morbidity (moderate-certainty evidence; 5.2% with control vs 3.4% with treatment; RR 0.66, 95% CI 0.59 to 0.74; and coronary heart disease mortality and morbidity (moderate-certainty evidence; 4.8% with control vs 3.7% with treatment; RR 0.78, 95% CI 0.69 to 0.88. Withdrawals due to adverse effects were increased with treatment (low-certainty evidence; 5.4% with control vs 15.7% with treatment; RR 2.91, 95% CI 2.56 to 3.30. In the three trials restricted to persons with isolated systolic hypertension, reported benefits were similar.This comprehensive systematic review provides additional evidence that the reduction in mortality observed was due mostly to reduction in the 60- to 79-year-old patient subgroup (high-certainty evidence; RR 0.86, 95% CI 0.79 to 0.95). Although cardiovascular mortality and morbidity was significantly reduced in both subgroups 60 to 79 years old (moderate-certainty evidence; RR 0.71, 95% CI 0.65 to 0.77) and 80 years or older (moderate-certainty evidence; RR 0.75, 95% CI 0.65 to 0.87), the magnitude of absolute risk reduction was probably higher among 60- to 79-year-old patients (3.8% vs 2.9%). The reduction in cardiovascular mortality and morbidity was primarily due to a reduction in cerebrovascular mortality and morbidity. AUTHORS' CONCLUSIONS: Treating healthy adults 60 years or older with moderate to severe systolic and/or diastolic hypertension with antihypertensive drug therapy reduced all-cause mortality, cardiovascular mortality and morbidity, cerebrovascular mortality and morbidity, and coronary heart disease mortality and morbidity. Most evidence of benefit pertains to a primary prevention population using a thiazide as first-line treatment.

Who has the guts to deprescribe proton pump inhibitors? A pharmacist-led intervention in a long-term care facility setting.

OBJECTIVE: Long-term use of proton pump inhibitors (PPIs) has been associated with an increased risk of harm. There are few studies evaluating pharmacist-led PPI deprescribing interventions within a long-term care facility setting. The aim of this study was to describe the changes and influencing factors seen with a pharmacist-led PPI deprescribing intervention in two Fraser Health Authority long-term care facilities in British Columbia. METHODS: This 4-month intervention involved lists of residents who had active PPI orders being handed out to physicians from two facilities. The pharmacist conducted weekly reviews of residents from Facility 1 and offered deprescribing recommendations. The number and methods of PPI deprescribing orders per facility were determined after the intervention. RESULTS: Out of 58 residents from the two facilities, 30 (62.5%) had a deprescribing order. Facility 1 had 83.3% (20/24) of residents with a PPI deprescribing order, in contrast to 41.7% (10/24) from Facility 2. Overall, 80.0% of residents had successfully completed PPI deprescribing orders by the end of the study period. CONCLUSION: Clinical pharmacist intervention may increase the rate of initiation in PPI deprescribing orders within a long-term care facility setting. Factors that influence success include intervention timing, active collaboration, having residents under direct care, and clear documentation of PPI indications.

Is There a Reason for the Proton Pump Inhibitor? An Assessment of Prescribing for Residential Care Patients in British Columbia.

BACKGROUND: The use of proton pump inhibitors (PPIs) may cause significant harm to patients in the residential care setting, as these patients are often frail with multiple morbidities. The extent of non-evidence-based use of PPIs in residential care sites of the Fraser Health Authority in British Columbia is unknown. OBJECTIVE: To determine the proportion of non-evidence-based use of PPI therapy for residential care patients of the Fraser Health Authority. METHODS: This retrospective cross-sectional study was conducted in 6 Fraser Health residential care facilities in British Columbia between April 1, 2015, and March 31, 2016. Two definitions of "evidence-based indications" were used. The first definition encompassed broad evidence-based indications for PPI use, specifically gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD), gastritis, esophagitis, Barrett esophagus, and gastrointestinal protection from concurrent oral steroids, oral nonsteroidal anti-inflammatory drugs, antiplatelet agents, and anticoagulants. The second definition involved common evidence-based indications for PPI use, specifically GERD or PUD. Descriptive statistics were used to evaluate the primary outcome: the proportion of PPI orders without a documented broad or common evidence-based indication for PPI treatment. RESULTS: A total of 331 residential care patients and 407 PPI orders were assessed. The proportion of PPI orders without a documented broad evidence-based indication was 16.2% (66/407). The proportion of PPI orders without a documented common evidence-based indication was 43.7% (178/407). The most frequently documented reason for a PPI order was GERD (214/407 or 52.6%). PPI orders for patients with GERD and gastrointestinal bleeding had the longest duration of therapy during residential care admission, averaging 205.1 and 218.1 days, respectively. CONCLUSION: About 1 in 6 PPI orders for Fraser Health residential care patients did not have a documented broad evidence-based indication, and about 2 in 5 PPI orders did not have a documented common evidence-based indication. These results indicate a need to assess the appropriateness of therapy for every patient with an active PPI order in residential care facilities.

CONTEXTE: L'emploi d'inhibiteurs de la pompe à protons (IPP) peut causer des torts importants aux patients qui résident en centre d'hébergement et de soins de longue durée, car souvent ces personnes sont fragiles et souffrent de multiples maladies. On ignore quelle est la proportion d'utilisation d'IPP ne reposant pas sur des données probantes dans les centres d'hébergement et de soins de longue durée de la Fraser Health Authority en Colombie-Britannique. OBJECTIF: Déterminer la proportion d'utilisation de traitement par IPP ne reposant pas sur des données probantes chez les patients en centre d'hébergement et de soins de longue durée de la Fraser Health Authority. MÉTHODES: Cette étude rétrospective transversale a été menée dans six centres d'hébergement et de soins de longue durée de la Fraser Health en Colombie-Britannique, entre le 1er avril 2015 et le 31 mars 2016. Deux définitions du terme « indications fondées sur des données probantes ¼ ont été utilisées. La première définition englobait des indications larges fondées sur des données probantes appuyant l'utilisation d'IPP, plus particulièrement : pour traiter le reflux gastro-œsophagien, l'ulcère gastroduodénal, la gastrite, l'œsophagite et l'œsophage de Barrett ainsi que pour fournir une protection gastrique contre les effets indésirables de la prise de médicaments anti-inflammatoires oraux stéroïdiens ou non stéroïdiens, d'antiplaquettaires et d'anticoagulants. La seconde définition comprenait les indications usuelles fondées sur des données probantes pour appuyer l'utilisation d'IPP, plus précisément : le reflux gastro-œsophagien ou l'ulcère gastroduodénal. Des statistiques descriptives ont été employées pour analyser le principal paramètre d'évaluation : la proportion d'ordonnances d'IPP pour lesquelles aucune indication, large ou usuelle, fondée sur des données probantes n'a été consignée. RÉSULTATS: Au total, les dossiers de 331 résidents de centres d'hébergement et de soins de longue durée et 407 ordonnances d'IPP ont été évalués. La proportion d'ordonnances d'IPP pour lesquelles aucune indication large fondée sur des données probantes n'a été consignée était de 16,2 % (66/407). La proportion d'ordonnances d'IPP pour lesquelles aucune indication usuelle fondée sur des données probantes n'a été consignée était de 43,7 % (178/407). La raison la plus souvent consignée pour l'émission d'une ordonnance d'IPP était le reflux gastro-œsophagien (214/407 ou 52,6 %). Les ordonnances d'IPP destinées aux patients souffrant de reflux gastro-œsophagien ou d'hémorragie gastro-intestinale étaient celles pour lesquelles la durée du traitement était la plus longue au cours du séjour en centre d'hébergement et de soins de longue durée, soit respectivement de 205,1 et 218,1 jours en moyenne. CONCLUSION: Environ 1 ordonnance d'IPP sur 6 pour les patients de centres d'hébergement et de soins de longue durée de la Fraser Health ne reposait pas sur une indication large consignée et fondée sur des données probantes et environ 2 ordonnances d'IPP sur 5 ne s'appuyaient pas sur une indication usuelle consignée et fondée sur des données probantes. Les résultats révèlent la nécessité d'évaluer la pertinence des traitements par IPP pour chaque patient ayant une ordonnance active d'IPP dans les centres d'hébergement et de soins de longue durée.

Are antidepressant and antipsychotic drug trials registered? A cross-sectional analysis of registration and reporting of methodologic characteristics.

INTRODUCTION: In 2005, the International Committee of Medical Journal Editors (ICMJE) proposed that all submitted trials in all 11 member journals must be prospectively registered in order to be considered for publication. Registering drug trials was meant to reduce the likelihood of selective reporting. The aim was to determine the proportion of antipsychotic and antidepressant trials that were registered. METHODS: We searched in Pubmed for all randomized controlled trials of any antidepressant or antipsychotic published between July and December 2014. The primary objective was to determine the proportion of trials that were registered. Secondary objectives included comparing the reporting of methodological details and positive study findings between registered and unregistered trials. RESULTS: Of the 67 studies identified, 58% were registered. 75% of the antipsychotic trials and 51% of the antidepressant trials were registered, respectively. Registered trials were more likely to report important methodological details associated with risk of bias in RCTs. There was no significant difference in trials reporting positive outcomes for the study intervention between registered and unregistered trials. CONCLUSION: Approximately 60% of published antidepressant and antipsychotic drug trials during July to December 2014 were registered. Unregistered trials were less likely to report important methodological details.