Evidence on the ‘Unmentionables’

BRENDALYNN ENS, DIRECTOR KNOWLEDGE MOBILIZATION & LIAISON OFFICER TEAM, CADTH

JANET CRAIN, MANAGERKNOWLEDGE MOBILIZATION, CADTH

EFTYHIA HELIS, KNOWLEDGE MOBILIZATION OFFICER, CADTH

KATHLEEN KULYK, LIAISON OFFICER-SASKATCHEWAN, CADTH

Disclosures

• I have no financial disclosures to declare.

• I have been an employee of CADTH for 10 years.

• Cost data shared are all-product combined averages from available provincial information from 3S Health Shared Services Saskatchewan and the Ministry of Health (March 2015).

Acknowledgements

Suzanne Boudreau-ExnerDirector – Materials Management Services3S Health Shared Services

Susie Hilton, Clinical Advisor3S Health Shared Services

Pamela BryceSenior Policy AnalystDrug Plan & Extended Benefits Branch, Saskatchewan Health

Susan Yee Manager - Client Services, Drug Plan & Extended Benefits Branch, Saskatchewan Health

Dave MorhartDirector - Client Services, Drug Plan & Extended Benefits Branch, Saskatchewan Health

What are the

‘unmentionables’?

Key Messages• Common hospital products are overlooked for evidence-

based decisions; assumed to be cheap and inconsequential in budgets.

• So many different products…so little time!

• Many unknowns: state-of-the-evidence, comparative data, unit costs/patient, and reasons for usage, facility-based economic analyses

• Absence of evidence does not mean evidence of absence*

*Altman, D. G. & Bland, J. M. (1995). Absence of evidence is not evidence of absence. British Medical Journal; 311(7003); 485.

Images retrieved from: http://www.google.com/in2art.com and http://www.amazon.com

Discussion In ContextFocus is on:

• “Average” or most-common clients in common (non-specialized) health care settings such as hospital units, long-term care facilities, community centres and home usage

• Clients with common medical or surgical conditions with usual/uncomplicated healing trajectory

• Standard usage rates and approved quantities for insurable benefits for clients; known (documented) health care professionals and personal care giver usage rates

What do we expect from evidence?

Source: http://ebp.lib.uic.edu/dentistry/?q=node/12

HTA“health technology assessment”

Single-use disposable gloves• No higher-pyramid evidence available showing:

• Safety differences, standardized clinical or cost-effectiveness across products, allergy-potential comparison, effectiveness to prevent pathogen transmission, or evidence-informed duration of use for latex versus non-latex gloves.

• effects of prolonged usage, impact of perspiration or salts

• Moderate-lower pyramid evidence showing*: • No difference in touch sensitivity or psychomotor performance

between latex and nitrile gloves; • Comfort rating differences across health care professionals• Latex gloves may be more resistant to punctures• Vinyl gloves permeability to cytotoxic agents

*CADTH Rapid Response (2013). Disposable Gloves for Use in Healthcare Settings: A Review of the Clinical Effectiveness, Safety, Cost-Effectiveness, and Guidelines http://www.bit.ly/1H6aCnW

Gloving Recommendations- WHO• The World Health Organization

(WHO)* indications guide for standard usage

• WHO loosely estimates usage as 20-60 pairs of gloves used daily by each health care worker worldwide in clinical care settings.

• Estimated Cost: $ 0.07/glove**

*World Health Organization (2014) http://www.who.int/gpsc/5may/Glove_Use_Information_Leaflet.pdf.** 3S Health Shared Services (Saskatchewan) Average procurement pricing for health care facility usage.

The Client at HomeA 3 month supply issued to individuals registered in the paraplegia program* eligible for coverage for disposable gloves used by clients at home:

Oct – Dec 2014 Non-Sterile Glove Usage N = 275

# of Individual Gloves Used 86,110

Average Price Per Glove $0.13

Average # Used Per Individual in 3 month timeframe 313

Average # Gloves Used per Day Per Person 4

Total Cost for Coverage - 3 month $10,983

* Drug Plan & Extended Benefits Branch, Saskatchewan Health

Single-use disposable polypropylene pleated face masksThere is no higher-pyramid evidence showing:

• Effectiveness of surgical face masks to protect from infectious material in ORs or other controlled settings;

• Cross-brand comparative fluid or droplet permeability rates • Safe wearability length of time to ensure personal protection***

Lower pyramid evidence suggests*: • General benefit derived from wearing masks in health settings to reduce

acute bacterial transmission from staff-to-patients and patients-to-staff• Lifespan recommendations for some products

Expert consensus without supporting evidence**:• When masks have become damp, visibly soiled, or contaminated they are no

longer deemed effective; recommend to always change between patients (IOM)

*CADTH Rapid Response (2013). Use of Surgical Masks in the Operating Room: A Review http://bit.ly/196aOVy **Institute of Medicine IOM (US). Reusability of facemasks during an influenza pandemic. Washington: 2006***Derrick JL, Gomersall ,CD. Protecting healthcare staff from severe acute respiratory syndrome: filtration capacity of multiple surgical masks Hosp Infect. 2005 Apr; 59 (4):365-8.

Masking Recommendations- CDC• Single-use disposable pleated polypropylene face masks are one of

many options of personal protective equipment (PPE)*

• Recommendations are for general for common or routine usage

• Recommendations for masks that cover both nose and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood or body fluids.

• Cost: $0.15 per mask; No average usage estimates

* 2013 Centers for Disease Control and Prevention: http://www.cdc.gov

Call for evidence – Face masks• Re-validation* that concepts of face mask usage more are entrenched

in clinical practice routines and trust that they prevent against airborne transmission.

• Issues are more complex than initially thought...

• Facemasks plus gloves and/or regular hand hygiene may better prevent infection in community settings.

• Respirators vs masks? No evidence• Cloth masks? Not recommended• Health economic analyses? Scarce

* MacIntyre, C. R. & Chughtai, A. A. (2015) Facemasks for the prevention of infection in healthcare and community settings. BMJ; 350. http://www.bmj.com/content/350/bmj.h694 Published April 9, 2015

Stool softener medicationsDocusate salts (sodium and calcium) are widely available, over-the-counter medications classified as stool softeners. Their surfactant mechanism of action has been (theoretically) believed to keep stool pliable and prevents straining during defecation.

There is limited moderate-high pyramid evidence showing:• Stool softener products do not increase stool frequency or soften stools

compared with placebo. • They do not improve the symptoms of constipation.• They do not improve the difficulties or completeness of stool evacuation in

patients taking opioids.

No rational argument for use of docusate in hospitalized patients or long-term care residents.

* CADTH Rapid Response (2014). Dioctyl Sulfosuccinate or Docusate (Calcium or Sodium) for the Prevention or Management of Constipation: A Review of the Clinical Effectiveness http://bit.ly/1MR8IWR

Reduced Usage Recommendations – Alberta Health Services• In 2013 there were over 2.1 million doses of 100mg given to

patients within Alberta Health Services*.

• Based on an estimated cost of $0.26/tablet (OTC estimated cost*), Docusate sodium (Colace) may in fact reflect “money flushed down the toilet” **

* Pasay, D. (2014). Drug & Therapeutics Backgrounder – Stool Softeners: Why are they still being used? Alberta Health Services. ** Mann, J. & Greenwood-Dufour, B. (2014) Docusate for constipation: money down the toilet? http://hospitalnews.com/docusate-constipation-money-toilet/

So what?

Awareness of the state-of-the-evidence, existence of comparative data, and actual unit costs can:

• Help to support optimal usage decisions • Potentially mitigate against “hype” and assumed knowledge when

definitive high pyramid evidence is not available*• Potentially assist in managing ever-increasing hospital medical

supply budgets

There is value in knowing & talking about the unmentionables!

*Altman, D. G. & Bland, J. M. (1995). Absence of evidence is not evidence of absence. British Medical Journal; 311(7003); 485.