How has legislation restricting paracetamol pack size affected patterns of deprivation related inequalities in self-harm in Scotland?

Measuring the impact of medicines regulatory interventions - Systematic review and methodological considerations

AIMS

Evaluating the public health impact of regulatory interventions is important but there is currently no common methodological approach to guide this evaluation. This systematic review provides a descriptive overview of the analytical methods for impact research.

METHODS

We searched MEDLINE and EMBASE for articles with an empirical analysis evaluating the impact of European Union or non-European Union regulatory actions to safeguard public health published until March 2017. References from systematic reviews and articles from other known sources were added. Regulatory interventions, data sources, outcomes of interest, methodology and key findings were extracted.

RESULTS

From 1246 screened articles, 229 were eligible for full-text review and 153 articles in English language were included in the descriptive analysis. Over a third of articles studied analgesics and antidepressants. Interventions most frequently evaluated are regulatory safety communications (28.8%), black box warnings (23.5%) and direct healthcare professional communications (10.5%); 55% of studies measured changes in drug utilization patterns, 27% evaluated health outcomes, and 18% targeted knowledge, behaviour or changes in clinical practice. Unintended consequences like switching therapies or spill-over effects were rarely evaluated. Two-thirds used before-after time series and 15.7% before-after cross-sectional study designs. Various analytical approaches were applied including interrupted time series regression (31.4%), simple descriptive analysis (28.8%) and descriptive analysis with significance tests (23.5%).

CONCLUSION

Whilst impact evaluation of pharmacovigilance and product-specific regulatory interventions is increasing, the marked heterogeneity in study conduct and reporting highlights the need for scientific guidance to ensure robust methodologies are applied and systematic dissemination of results occurs.

Acute liver failure in Scotland between 1992 and 2009; incidence, aetiology and outcome

AIM

To describe incidence, aetiology and outcome data for Scotland since the inception of the Scottish Liver Transplant Unit (SLTU) in 1992.

BACKGROUND

Acute liver failure (ALF) is a rare but frequently fatal condition. Few studies have adequate patient numbers to draw convincing conclusions over demographic features, aetiology and outcome.

DESIGN

Statistical analysis of prospectively collected data on aetiology, demographic, clinical and outcome of all admissions, including those with ALF, to the SLTU.

METHODS

Incidence data presented for admissions and ALF. Descriptive frequencies for aetiology, clinical, demographic and outcome data presented; including split analysis for paracetamol and non-paracetamol aetiologies. Univariate and multivariate analysis of admission factors predictive of outcome is described.

RESULTS

Nine hundred and forty-nine patients were admitted to the SLTU between 1992 and 2009. Five hundred and twenty-four patients had ALF. The annual incidence of ALF in the Scottish population is 0.62 per 100,000 and paracetamol overdose (POD) was the largest causative factor; responsible for 0.43 cases of ALF per 100,000 population per year. The odds ratio (OR) of transplantation or death was 0.47 in the POD group compared to other aetiologies; yet of not being a transplant candidate having met the Kings College Hospital poor prognostic criteria OR was 4.9. Of admissions listed for transplant 76.0% were transplanted. Of those listed and not transplanted mortality was approaching 100% and 76.1% of those transplanted survived to discharge.

CONCLUSION

This large, prospective, single centre study with a defined geographical area and well-recorded population provides accurate data regarding ALF between 1992 and 2009.

Acute liver failure

Acute liver failure is a rare disorder with high mortality and resource cost. In the developing world, viral causes predominate, with hepatitis E infection recognised as a common cause in many countries. In the USA and much of western Europe, the incidence of virally induced disease has declined substantially in the past few years, with most cases now arising from drug-induced liver injury, often from paracetamol. However, a large proportion of cases are of unknown origin. Acute liver failure can be associated with rapidly progressive multiorgan failure and devastating complications; however, outcomes have been improved by use of emergency liver transplantation. An evidence base for practice is emerging for supportive care, and a better understanding of the pathophysiology of the disorder, especially in relation to hepatic encephalopathy, will probably soon lead to further improvements in survival rates.

Detailed analyses of self-poisoning episodes presenting to a large regional teaching hospital in the UK

AIMS

The primary aim of this paper is to provide comprehensive contemporaneous data on the demographics, patterns of presentation and management of all episodes of deliberate self-poisoning presenting to a large regional teaching hospital over a 12 month period.

METHODS

We undertook detailed, retrospective analyses using information from electronic patient records and local patient-tracking, pathology and administrative databases. Statistical analyses were performed using Chi-squared tests, anova and two-tailed t-tests (Graphpad Prism).

RESULTS

One thousand five hundred and ninety-eight episodes of deliberate self-poisoning presented over the year. Demographic data and information on the month, day and time of admission are provided. 70.7% presented to the emergency department (ED) within 4 h of ingestion. 76.3% of patients had only one episode in an extended 29 month follow-up period. A mean of 1.72 drugs were taken per episode with just over half of all episodes involving a single drug only. Paracetamol and ibuprofen were the two most commonly ingested drugs involved in 42.5% and 17.3% of all overdoses respectively. 56.3% of patients taking paracetamol reported ingesting over 8 g (one over the counter packet). Detailed mapping of the patients' pathway through the hospital allowed an estimation of the hospital cost of caring for this patient group at pound 1.6 million pounds per year.

CONCLUSIONS

We present comprehensive and contemporary data on presentations to hospital resulting from deliberate self-poisoning. We include demographic information, presentation patterns, drugs used, a detailed analysis of episodes involving paracetamol and an estimate of the financial burden to hospitals of overdose presentations.

Socio-economic inequalities in suicide attempts and suicide mortality in Québec, Canada, 1990-2005

OBJECTIVES

Little research has evaluated changes in the association between area deprivation and suicidal behaviour over time. This study investigated patterns in suicide attempts and suicide mortality according to material deprivation in the province of Québec, Canada between 1990 and 2005.

STUDY DESIGN

Ecological analysis.

METHODS

Data on suicide attempts were extracted from the hospital discharge summary database (n=47,516) and data on suicides were extracted from the Québec death file (n=20,851). Gender- and age-specific (10-24, 25-44, 45-64 and > or = 65 years) suicide attempt and mortality rates were calculated for four time periods (1990-1993, 1994-1997, 1998-2001 and 2002-2005) for the entire Québec population aged 10 years and older residing in 162 communities ranked by decile of material deprivation. Absolute and relative measures of inequality were calculated to summarize differences between the most and least materially deprived areas. Commonly used methods of suicidal behaviour were examined.

RESULTS

Differentials in suicide attempt hospitalization between the most and least deprived areas were present for all age groups, and these decreased slightly among males and increased among females over time. Inequalities in suicide attempts were greatest among young adults (age 25-44 years) for both genders, and were smallest among the elderly (> or = 65 years). For suicide mortality, differentials increased among females but not males; these differentials were greatest among males and 25-44 year olds, and smallest among the elderly. Differentials in commonly used methods were evident for poisoning hospitalizations in both genders and for hanging deaths among males.

CONCLUSIONS

In Québec, differences in suicide attempts and mortality between the most and least materially deprived areas persisted or even increased over time. Inequalities were more pronounced for suicide attempts than for suicide mortality, and were greatest among adults of working age. Strategies to reduce socio-economic differences in suicidal behaviour may be important.

Limiting paracetamol pack size: has it worked in the UK?

INTRODUCTION

Paracetamol poisoning is a major health problem worldwide. Limitation of pack size is an approach increasingly advocated to reduce rates of suicide and serious self-harm from this agent. The United Kingdom adopted such a policy in 1998, restricting non-pharmacy sales to 8 g and pharmacy to pack sizes of 16 g.

METHODS

A literature review was conducted and commentary written on the impact of the change in the United Kingdom on a variety of indices of paracetamol overdose.

RESULTS

Potential markers of effect identified included paracetamol sales, poisons information data, laboratory results, liver unit referrals, and hospital activity and mortality data. Initial reports suggested effects associated with the legislation, but longer term suicide trend analysis has not confirmed these early findings, which were confounded by population trends in self-harm.

CONCLUSION

Paracetamol pack size limitation as applied in the United Kingdom has not reduced paracetamol-related death. Reasons postulated for this failure include patient avoidance of the legislation's intentions, patient confusion, and ineffectiveness of the regulations as conceived and implemented.