Emergency department opioid discharge instructions: a multidisciplinary national Delphi study.

OBJECTIVES: Currently, there are no Canadian guidelines for discharge instruction to be given to patients receiving an opioid prescription in the ED. This likely contributes to inadequate discharge instructions for these potentially dangerous medications. The principal goal of this study was to develop an interdisciplinary Canadian consensus regarding important concepts to be included in written opioid discharge instructions within the ED setting. METHODS: We conducted a modified Delphi study between May and August 2021. The national multidisciplinary panel consisted of 23 healthcare professionals and one patient partner. The survey consisted of 19 initial concepts developed after a review of the literature and a meeting with local experts. The panel added four new concepts after the first survey round. Three rounds of online surveys were distributed in total. Panel consensus was defined a priori as a disagreement index score less than 1, in accordance with the RAND/UCLA Appropriateness Method. RESULTS: We achieved a 100% response rate in round one and a 96% response rate in rounds two and three of our Delphi study. There was group consensus (disagreement index = 0.66, median importance = 9) that all patients receiving opioid prescriptions from the ED should receive written discharge instructions. The interdisciplinary panel arrived at a consensus on 21/23 concepts for ED opioid discharge instructions. The concepts with the highest level of agreement were related to minimizing the use of the prescribed opioid medication and opioid use safety (mixing with drugs/alcohol, storage, and impairment). CONCLUSION: This Delphi study with a national, multidisciplinary panel achieved consensus on 21 concepts that should be included in written discharge instructions to patients receiving an opioid prescription upon discharge from the ED.

RéSUMé: OBJECTIFS: Actuellement, il n'y a pas de lignes directrices canadiennes sur les instructions de sortie à donner aux patients qui reçoivent une ordonnance d'opioïdes aux urgences. Cela contribue probablement à des instructions de sortie inadéquates pour ces médicaments potentiellement dangereux. L'objectif principal de cette étude était d'établir un consensus canadien interdisciplinaire sur les concepts importants à inclure dans les directives écrites de sortie des opioïdes dans le contexte des urgences. MéTHODES: Nous avons mené une étude Delphi modifiée entre mai et août 2021. Le comité national multidisciplinaire était composé de 23 professionnels de la santé et d'un patient partenaire. L'enquête comprenait 19 concepts initiaux développés après un examen de la littérature et une réunion avec des experts locaux. Le panel a ajouté quatre nouveaux concepts après la première ronde d'enquête. Trois séries de sondages en ligne ont été distribuées au total. Le consensus du panel a été défini a priori comme un indice de désaccord inférieur à 1, conformément à la méthode de pertinence RAND/UCLA. RéSULTATS: Nous avons atteint un taux de réponse de 100 % au premier tour et un taux de réponse de 96 % aux deuxième et troisième tours de notre étude Delphi. Il y avait un consensus de groupe (indice de désaccord = 0,66, importance médiane = 9) sur le fait que tous les patients recevant une ordonnance d'opioïdes aux urgences devraient recevoir des instructions écrites à la sortie de l'hôpital. Le groupe interdisciplinaire est parvenu à un consensus sur les concepts 21/23 pour les instructions de sortie d'opioïdes aux urgences. Les concepts ayant fait l'objet du plus haut niveau d'entente étaient liés à la réduction de l'utilisation des médicaments opioïdes prescrits et à la sécurité de l'utilisation des opioïdes (mélange avec les drogues/alcool, stockage et affaiblissement des facultés). CONCLUSION: Cette étude Delphi avec un panel national multidisciplinaire a permis de parvenir à un consensus sur 21 concepts qui devraient être inclus dans les instructions écrites de sortie aux patients recevant une ordonnance d'opioïdes à leur sortie de l'urgence.

Potential effects of rational prescribing on national health care spending: More than half a billion dollars in annual savings.

OBJECTIVE: To estimate the cost savings that could result from implementation of a rational prescribing model for drug classes that are equivalent in terms of efficacy, toxicity, and convenience. DESIGN: The top 10 drug classes based on annual spending were gathered from the Canadian Institute for Health Information. They were reviewed for potential inclusion in the study based on the ability to compare intraclass medications. When equivalence in efficacy, toxicity, and convenience was determined from a literature review, annual prescribing data were gathered from the National Prescription Drug Utilization Information Systems Database. The potential cost savings were then calculated by comparing current market shares with potential future market shares. SETTING: Canada. MAIN OUTCOME MEASURES: Estimated differences in spending produced by a rational prescribing model. RESULTS: Statins, proton pump inhibitors, angiotensin-converting enzyme inhibitors, and selective serotonin reuptake inhibitors were determined to have class equivalence for efficacy, toxicity, and convenience. Total current annual spending on these classes is $856 million through public drug programs, and an estimated $1.97 billion nationally. Through rational prescribing, annual savings could reach $222 million for public drug programs, and $521 million nationally. CONCLUSION: Most of the potential savings are derived from deprescribing the newest patent-protected medications in each class. Avoiding prescribing the newest intraclass drug, particularly in the absence of research to support its superiority in relevant clinical outcomes, could lead to considerable savings in health care expenditures and might push the pharmaceutical industry to innovate rather than imitate.

Assessing potentially inappropriate prescribing (PIP) and predicting patient outcomes in Ontario's older population: a population-based cohort study applying subsets of the STOPP/START and Beers' criteria in large health administrative databases.

INTRODUCTION: Adverse drug events (ADEs) are common in older people and contribute significantly to emergency department (ED) visits, unplanned hospitalisations, healthcare costs, morbidity and mortality. Many ADEs are avoidable if attention is directed towards identifying and preventing inappropriate drug use and undesirable drug combinations. Tools exist to identify potentially inappropriate prescribing (PIP) in clinical settings, but they are underused. Applying PIP assessment tools to population-wide health administrative data could provide an opportunity to assess the impact of PIP on individual patients as well as on the healthcare system. This would open new possibilities for interventions to monitor and optimise medication management on a broader, population-level scale. METHODS AND ANALYSIS: The aim of this study is to describe the occurrence of PIP in Ontario's older population (aged 65 years and older), and to assess the health outcomes and health system costs associated with PIP-more specifically, the association between PIP and the occurrence of ED visits, hospitalisations and death, and their related costs. This will be done within the framework of a population-based retrospective cohort study using Ontario's large health administrative and population databases. Eligible patients aged 66 years and older who were issued at least 1 prescription between 1 April 2003 and 31 March 2014 (approximately 2 million patients) will be included. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Ottawa Health Services Network Ethical Review Board and from the Bruyère Research Institute Ethics Review Board. Dissemination will occur via publication, presentation at national and international conferences, and ongoing exchanges with regional, provincial and national stakeholders, including the Ontario Drug Policy Research Network and the Ontario Ministry of Health and Long-Term Care. TRIAL REGISTRATION NUMBER: Registered with clinicaltrials.gov (registration number: NCT02555891).

Potentially inappropriate prescribing (PIP) in long-term care (LTC) patients: validation of the 2014 STOPP-START and 2012 Beers criteria in a LTC population--a protocol for a cross-sectional comparison of clinical and health administrative data.

INTRODUCTION: Potentially inappropriate prescribing (PIP) is frequent and problematic in older patients. Identifying PIP is necessary to improve prescribing quality; ideally, this should be performed at the population level. Screening Tool of Older Persons' potentially inappropriate Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) and Beers criteria were developed to identify PIP in clinical settings and are useful at the individual patient level; however, they are time-consuming and costly to apply. Only a subset of these criteria is applicable to routinely collected population-level health administrative data (HAD) because the clinical information necessary to implement these tools is often missing from databases. The performance of subsets of STOPP/START and Beers criteria in HAD compared with clinical data from the same patients is unknown; furthermore, the performance of the updated 2014 STOPP-START and 2012 Beers criteria compared with one another is also unknown. METHODS AND ANALYSIS: A cross-sectional study of linked HAD and clinical data will be conducted to validate the subsets of STOPP/START and Beers criteria applicable to HAD by comparing their performance when applied to clinical and HAD for the same patients. Eligible patients will be 66 years and over and recently admitted to 1 of 6 long-term care facilities in Ottawa, Ontario. The target sample size is 275, but may be less if statistical significance can be achieved sooner. Medication, diagnostic and clinical data will be collected by a consultant pharmacist. The main outcome measure is the proportion of PIP missed by the subset of STOPP/START and Beers criteria applied to HAD when compared with clinical data. ETHICS AND DISSEMINATION: The study was approved by the Ottawa Health Services Network Research Ethics Board, the Bruyère Continuing Care Research Ethics Board and the ethics board of the City of Ottawa Long Term Care Homes. Dissemination will occur via publication, national and international conference presentations, and exchanges with regional, provincial and national stakeholders. TRIAL REGISTRATION NUMBER: NCT02523482.

Pharmacist surveillance of adverse drug events.

PURPOSE: The incidence of adverse drug events (ADEs), preventable ADEs, and potential ADEs was determined using pharmacist surveillance. Drug classes associated with ADEs were also identified. METHODS: The study was conducted in a 30-bed hospital ward of a Canadian teaching hospital between April 28, 2003, and May 26, 2003. All patients admitted to the general medicine service were eligible for study enrollment. A pharmacist performed surveillance to identify new or worsening symptoms, critical laboratory values, and medication errors. Surveillance consisted of daily communications with staff, daily chart reviews for all inpatients, and investigation of spontaneous incident reports. Data were collected to describe all identified outcomes. This information was rated independently by two clinicians to determine if the outcome was an ADE, a preventable ADE, or a potential ADE. Descriptive statistics were used to calculate outcome rates, which were reported as events per 100 patient-days. RESULTS: During 543 patient-days of observation, 24 ADEs occurred (4.4 per 100 patient-days), of which 14 were preventable (2.6 per 100 patient-days); 13 potential ADEs also occurred (2.4 per 100 patient-days). Of all ADEs, 3 (13%) were life threatening, 11 (46%) were serious, and 10 (42%) were significant. The 24 ADEs were associated with nine different drug classes. Four drug classes accounted for 17 ADEs (71%): antidiabetic agents, antibiotics, glucocorticoids, and sedatives and hypnotics. CONCLUSION: Pharmacist surveillance revealed that 4.4 ADEs occurred per 100 patient-days, over half of which were preventable. All preventable and potential ADEs occurred during the ordering and administration stages of medication delivery.