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Namiuchi S, Tanita A, Sunamura S, Onodera K, Ogata T, Noda K, Takii T, Nitta Y, Yoshida S. Effect of constipation on readmission for heart failure in patients with acute heart failure. ESC Heart Fail 2024; 11:819-825. [PMID: 38158646 DOI: 10.1002/ehf2.14650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/22/2023] [Accepted: 12/12/2023] [Indexed: 01/03/2024] Open
Abstract
AIMS Constipation is a common gastrointestinal disorder that is associated with a high cardiovascular event rate in the general population. Although constipation is common in patients with cardiovascular diseases, only a few studies have examined the relationship between constipation and the prognosis of patients with heart failure. This study aimed to evaluate the effects of constipation on the prognosis of patients with acute heart failure. METHODS AND RESULTS We investigated 397 patients admitted to our hospital from December 2020 to December 2022 with acute heart failure (mean age, 81 ± 13 years; 54% men). Patients with constipation were defined as those either taking laxatives regularly or diagnosed with constipation according to the International Statistical Classification of Diseases and Related Health Problems. During the follow-up periods (median, 173 days), 35 patients died, and 74 experienced readmission due to heart failure. Kaplan-Meier analysis before and after propensity score matching using 14 variables revealed that the risk of readmission due to heart failure was significantly higher in patients with constipation than in those without (before: log-rank P = 0.014, after: log-rank P = 0.0027). The adjusted Cox proportional hazards analysis revealed that the hazard ratio for readmission due to heart failure was 2.61 (95% confidence interval, 1.38-4.94, P = 0.0032). The risk of all-cause death was not significantly different between the two groups (hazard ratio, 1.76; 95% confidence interval, 0.61-5.06; P = 0.30). CONCLUSIONS Constipation status was strongly associated with a higher risk of readmission for heart failure in patients with acute heart failure.
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Affiliation(s)
- Shigeto Namiuchi
- Department of Cardiology, Sendai City Medical Center, Sendai, Japan
| | - Atsushi Tanita
- Department of Cardiology, Sendai City Medical Center, Sendai, Japan
| | | | - Kenta Onodera
- Department of Cardiology, Sendai City Medical Center, Sendai, Japan
| | - Tsuyoshi Ogata
- Department of Cardiology, Sendai City Medical Center, Sendai, Japan
| | - Kazuki Noda
- Department of Cardiology, Sendai City Medical Center, Sendai, Japan
| | - Toru Takii
- Department of Cardiology, Sendai City Medical Center, Sendai, Japan
| | - Yoshio Nitta
- Department of Cardiovascular Surgery, Sendai City Medical Center, Sendai, Japan
| | - Seijiro Yoshida
- Department of Cardiovascular Surgery, Sendai City Medical Center, Sendai, Japan
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Lucy AT, Massey GB, Cobbs P, Miltner RS, Cox MG, Russ K, Dasinger E, Parmar A. Successful de-implementation of an ineffective practice: The fall of docusate. Am J Surg 2024; 228:126-132. [PMID: 37652833 DOI: 10.1016/j.amjsurg.2023.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/18/2023] [Accepted: 08/25/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Reducing wasteful practices optimizes value in medicine. Docusate lacks treatment efficacy yet is widely prescribed. This quality improvement project aimed to de-implement docusate in place of a new evidence-based order set. METHODS This is an ambidirectional study of inpatient laxative orders from 2018 to 2022 at one institution. We stratified docusate data by service/unit to target prospective deimplementation initiatives. A new evidence-based constipation order set was embedded in Cerner. RESULTS There were 701,732 docusate orders across 75 services on 68 units. Top docusate ordering services were Trauma, Obstetrics and Hospitalist. Docusate administration rates were higher than for other laxatives. Our efforts reduced docusate orders by 44% over 4 months. PEG and senna orders increased by 58% and 35%. CONCLUSION Docusate has no efficacy yet is widely prescribed. A structured de-implementation strategy can drive systematic change by leveraging technology and applying multidisciplinary improvement efforts. Our work removed docusate from the inpatient formulary.
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Affiliation(s)
- Adam Timothy Lucy
- UAB Department of Surgery, 1808 7th Ave S, BDB 505, Birmingham, AL, 35233, USA.
| | | | - Parker Cobbs
- UAB Department of Surgery, 1808 7th Ave S, BDB 505, Birmingham, AL, 35233, USA
| | | | - Mary Grace Cox
- UAB Quality Improvement and Data Analytics, 619 19th St S, JT 1407, Birmingham, AL, 35249, USA
| | - Kirk Russ
- UAB Department of Medicine, Division of Gastroenterology, 1808 7th Ave S, BDB 349, Birmingham, AL, 35233, USA
| | - Elise Dasinger
- UAB Hospital Pharmacy, 619 19th St S, JT 1728, Birmingham, AL, 35249, USA
| | - Abhishek Parmar
- UAB Department of Surgery, 1808 7th Ave S, BDB 505, Birmingham, AL, 35233, USA
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Kaye AJ, Atkin S, Ziobro A, Donnelly J, Ahlawat S. Analysis of the economic burden of docusate sodium at a United States tertiary care center. Hosp Pract (1995) 2023; 51:168-173. [PMID: 37334679 DOI: 10.1080/21548331.2023.2225964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 06/13/2023] [Indexed: 06/20/2023]
Abstract
OBJECTIVES The primary objective was to determine the financial resources allocated to docusate at a representative U.S. tertiary care center. Secondary objectives included comparing docusate utilization between two tertiary care centers, and exploring alternative uses for the funds spent on docusate. METHODS The study population included all patients 18 years and older admitted to University Hospital in Newark, New Jersey. Every scheduled docusate prescription for the study population between January 1st, 2015 and December 31st, 2019 was collected. The annual total cost associated with docusate use per year was calculated. The 2015 data from this study and a 2015 McGill University Health Centre study were compared. Also, alternative uses for the money utilized on docusate were assessed. RESULTS Over the study period, 37,034 docusate prescriptions and 265,123 docusate doses were recorded. The average cost of prescribing docusate was $25,624.14 per year and $49.37 per hospital bed per year. A comparison between the 2015 data of University Hospital and McGill showed that McGill prescribed 107 doses and spent $10.09 more per hospital bed than University Hospital. Finally, alternative uses for the average yearly spending on docusate equated to 0.35 the salary of a nurse, 0.51 the salary of a secretary, 20.66 colonoscopies, 27.00 upper endoscopies, 186.71 mammograms, 1,399.37 doses of polyethylene glycol 3350, 3,826.57 doses of lactulose, or 4,583.80 doses of psyllium. CONCLUSION A single average size tertiary care hospital spent about $25,000 yearly on docusate despite its lack of clinical effectiveness. While this amount is small compared to an overall hospital budget, when considering likely comparable docusate use at the U.S's 6,090 hospitals, the economic burden of docusate becomes significant. The funds currently being used on docusate could be redirected to alternative, more cost-effective purposes.
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Affiliation(s)
- Alexander J Kaye
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Suzanne Atkin
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Aidan Ziobro
- Pharmacy Department, University Hospital, Newark, NJ, USA
| | - Jason Donnelly
- Pharmacy Department, University Hospital, Newark, NJ, USA
| | - Sushil Ahlawat
- Division of Gastroenterology and Hepatology, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
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Al Nou'mani J, Al Alawi AM, Al-Maqbali JS, Al Abri N, Al Sabbri M. Prevalence, Recognition, and Risk Factors of Constipation among Medically Hospitalized Patients: A Cohort Prospective Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1347. [PMID: 37512158 PMCID: PMC10385149 DOI: 10.3390/medicina59071347] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/15/2023] [Accepted: 07/21/2023] [Indexed: 07/30/2023]
Abstract
Background and Objective: Constipation is a prevalent gastrointestinal condition that has a substantial impact on individuals and healthcare systems. This condition adversely affects health-related quality of life and leads to escalated healthcare expenses due to an increase in office visits, referrals to specialists, and hospital admission. This study aimed to evaluate the prevalence, recognition, risk factors, and course of constipation among hospitalized patients in medical wards. Materials and Methods: A prospective study was conducted, including all adult patients admitted to the General Medicine Unit between 1 February 2022 and 31 August 2022. Constipation was identified using the Constipation Assessment Scale (CAS), and relevant factors were extracted from the patients' medical records. Results: Among the patients who met the inclusion criteria (n = 556), the prevalence of constipation was determined to be 55.6% (95% CI 52.8-58.4). Patients with constipation were found to be older (p < 0.01) and had higher frailty scores (p < 0.01). Logistic regression analysis revealed that heart failure (Odds ratio (OR) 2.1; 95% CI 1.2-3.7; p = 0.01), frailty score (OR 1.4; 95% CI 1.2-1.5; p < 0.01), and dihydropyridines calcium channel blockers (OR 1.8; 95% CI 1.2-2.8; p < 0.01) were independent risk factors for constipation. Furthermore, the medical team did not identify constipation in 217 patients (64.01%). Conclusions: Constipation is highly prevalent among medically hospitalized patients. To ensure timely recognition and treatment, it is essential to incorporate a daily constipation assessment scale into each patient's medical records.
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Affiliation(s)
- Jawahar Al Nou'mani
- Internal Medicine Residency Training Program, Oman Medical Specialty Board, Muscat 130, Oman
| | - Abdullah M Al Alawi
- Internal Medicine Residency Training Program, Oman Medical Specialty Board, Muscat 130, Oman
- Department of Medicine, Sultan Qaboos University Hospital, Muscat 123, Oman
| | - Juhaina Salim Al-Maqbali
- Department of Pharmacy, Sultan Qaboos University Hospital, Muscat 123, Oman
- Department of Pharmacology and Clinical Pharmacy, Sultan Qaboos University, Muscat 123, Oman
| | - Nahid Al Abri
- College of Medicine and Health Science, Sultan Qaboos University, Muscat 123, Oman
| | - Maryam Al Sabbri
- College of Medicine and Health Science, Sultan Qaboos University, Muscat 123, Oman
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Vlasov AA, Salikova SP, Golovkin NV, Grinevich VB. Intestinal Microbial-tissue Complex and Chronic Heart Failure (part 1): Pathogenesis. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-06-12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Antigenic and metabolic integration of the intestinal microbiota into the homeostasis of the human body is a factor that claims to play a key role in the pathogenesis of cardiovascular diseases. It acquires special significance against the background of the decrease in blood circulation and congestion in the digestive system during chronic heart failure. Aim of the review is analysis and synthesis of studies results on the role of intestinal microbiocenosis in the pathogenesis of heart remodeling and chronic heart failure. The search for articles was conducted in databases eLIBRARY.RU and Medline for the key terms "gut microbiota (microbiome, microbiocenosis)", "dysbiosis (dysbacteriosis)", "excessive bacterial growth syndrome", "lipopolysaccharide (endotoxin)", "trimethylamine-N-oxide" in combination with the terms "heart failure", "myocardial remodeling", "myocardium" in Russian and English, respectively. We selected articles containing the results of clinical and experimental studies published from 1995 to 2020. Review articles were considered only on the subject of the cited original publications. Most researchers have established the relationship between chronic heart failure and dysfunction and changes in the qualitative and quantitative composition of intestinal microbiocenosis. As negative changes, it is customary to note the proliferation of gram-negative opportunistic bacteria with concomitant endotoxinemia and a decrease in the pool of commensal microbiota. The available data suggest that the participation of the intestinal microbial-tissue complex in the pathogenesis of chronic heart failure and heart remodeling is realized through the activation of a local and then systemic inflammatory response, accompanied by cardiodepressive action of pro-inflammatory cytokines and universal proliferation factors, an imbalance of matrix metalloproteinases and their inhibitors, the initiation of apoptosis, fibrosis, and loss of contractile myocardium. Besides, a decrease in the production of short-chain and polyunsaturated fatty acids and vitamins by the commensal microbiota may be associated with changes in the electrical properties of cardiomyocyte membranes, a decrease in the systolic function of the left ventricle of the heart, and an increase in the risk of sudden cardiac death. It's also shown that the direct cardiotoxic effect of microbial molecules (lipopolysaccharides, peptidoglycans, trimethylamine-N-oxide, etc.), which interact with the receptors of cardiomyocytes and microenvironment cells, can cause the development of myocardial remodeling and its dysfunction. Recent studies have established mechanisms of myocardial remodeling mediated by microbial molecules, which may be associated with new strategies for the treatment and prevention of heart failure.
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Osuafor CN, Enduluri SL, Travers E, Bennett AM, Deveney E, Ali S, McCarthy F, Fan CW. Preventing and managing constipation in older inpatients. Int J Health Care Qual Assur 2018; 31:415-419. [PMID: 29865964 DOI: 10.1108/ijhcqa-05-2017-0082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose Constipation in hospitalised older adults leads to adverse events and prolonged stay. The purpose of this paper, therefore, is to effectively prevent and manage constipation in older adults undergoing inpatient rehabilitation using a multidisciplinary war on constipation (WOC) algorithm. Design/methodology/approach A quality improvement project in older adults undergoing rehabilitation for prevention and constipation management was conducted. Quality improvement "plan-do-study-act" cycles included an initial constipation audit in the wards and meetings with the multidisciplinary team (MDT) to develop an algorithm for the preventing, detecting and effectively treating constipation. Findings The project resulted in a 14 per cent reduction in constipation incidence after the newly developed WOC algorithm was introduced. The project also improved communication between patients and the MDT around patients' bowel habits. Practical implications The project shows that using quality improvement methods in rehabilitation settings, earlier detection, earlier intervention and overall reduction in constipation in older adults can be achieved. Originality/value The WOC algorithm has been developed and institutionalised in the current setting. This algorithm may also be applicable in other inpatient settings.
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Affiliation(s)
| | | | - Emma Travers
- Medicine for the Elderly, St Mary's Hospital, Phoenix Park, Dublin, Ireland
| | | | | | - Shabahat Ali
- Medicine for the Elderly, St Mary's Hospital, Phoenix Park, Dublin, Ireland
| | - Frances McCarthy
- Medicine for the Elderly, St Mary's Hospital, Phoenix Park, Dublin, Ireland
| | - Chie Wei Fan
- Medicine for the Elderly, St Mary's Hospital, Phoenix Park, Dublin, Ireland
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Advancements in the Treatment of Constipation in Hospitalized Older Adults: Utilizing Secretagogues and Peripherally Acting Mu-Opioid Receptor Antagonists. Am J Ther 2018. [DOI: 10.1097/mjt.0000000000000665] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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MacMillan TE, Kamali R, Cavalcanti RB. Missed Opportunity to Deprescribe: Docusate for Constipation in Medical Inpatients. Am J Med 2016; 129:1001.e1-7. [PMID: 27154771 DOI: 10.1016/j.amjmed.2016.04.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 04/10/2016] [Accepted: 04/11/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hospital admissions provide an opportunity to deprescribe ineffective medications and reduce pill burden. Docusate sodium is a stool softener that is frequently prescribed to treat constipation despite poor evidence for efficacy, thus providing a good target for deprescription. The aims of this study were to characterize rates of use and discontinuation of docusate among internal medicine inpatients, as well as use of other laxatives. METHODS We conducted a retrospective observational study over 1 year on all patients admitted to internal medicine at 2 urban academic hospitals to determine rates of docusate use. We also evaluated laxative and opioid medication use on a random sample of 500 inpatients who received docusate to characterize patterns of prescription and deprescription. RESULTS Fifteen percent (1169/7581) of all admitted patients received 1 or more doses of docusate. Among our random sample, 53% (238/452) received docusate before admission, and only 13% (31/238) had docusate deprescribed. Among patients not receiving docusate before admission, 33.2% (71/214) received a new prescription for docusate on discharge. Patients receiving opioids were frequently prescribed no laxatives or given docusate monotherapy (28%, 51/185). CONCLUSIONS Docusate was frequently prescribed to medical inpatients despite its known ineffectiveness, with low deprescription and high numbers of new prescriptions. Docusate use was common even among patients at high risk of constipation. One third of patients not receiving docusate before admission were prescribed docusate on discharge, potentially exacerbating polypharmacy. Among patients already receiving docusate, 80% had it continued on discharge, indicating significant missed opportunities for deprescribing. Given the availability of effective alternatives, our results suggest that quality-improvement initiatives are needed to promote evidence-based laxative use in hospitalized patients.
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Affiliation(s)
- Thomas E MacMillan
- Division of General Internal Medicine, University Health Network, Toronto, Ontario, Canada; Division of General Internal Medicine, Department of Medicine, University of Toronto, Ontario, Canada; HoPingKong Centre for Excellence in Education and Practice, University Health Network, Toronto, Ontario, Canada.
| | - Reza Kamali
- HoPingKong Centre for Excellence in Education and Practice, University Health Network, Toronto, Ontario, Canada
| | - Rodrigo B Cavalcanti
- Division of General Internal Medicine, University Health Network, Toronto, Ontario, Canada; Division of General Internal Medicine, Department of Medicine, University of Toronto, Ontario, Canada; HoPingKong Centre for Excellence in Education and Practice, University Health Network, Toronto, Ontario, Canada
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Arcopinto M, Salzano A, Ferrara F, Bobbio E, Marra AM, Abete R, Stagnaro F, Polizzi R, Giallauria F, Illario M, Menditto E, Vigorito C, Bossone E, Cittadini A. The Tosca Registry: An Ongoing, Observational, Multicenter Registry for Chronic Heart Failure. Transl Med UniSa 2016; 14:21-7. [PMID: 27326392 PMCID: PMC4912335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The ageing of the population in western countries, the continuous increase of the prevalence of chronic diseases, the frequent coexistence of several morbid conditions (comorbidity) requires health professionals and Institutions to face difficult challenges, including increasing costs, need for more effective and sustainable therapies, and organizational issues. The European Innovation Partnership on Active and Healthy Ageing aims at enabling European citizens to lead healthy, active and independent lives while ageing. We herein discuss some key concepts bearing a special significance in the light of the Partnership aims, and present research and educational projects active in our local environment. Among these, the multicentre project TOSCA (Trattamento Ormonale nello Scompenso CArdiaco) that, although primarily focused on the understanding of the interactions between hormones and chronic heart failure (CHF), is also aimed at developing more effective models of clinical care. We provide the scientific background and current stage of the project. In the context of a growing complexity of the patients' clinical management, the polipharmacy is a new arising challenge for clinicians, bearing direct economic, organizational and clinical implications. A better understanding, characterization and management of this issue represent an additional target of the TOSCA network.
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Affiliation(s)
- M Arcopinto
- IRCSS Policlinico San Donato Milanese, San Donato, Milano
| | - A Salzano
- Dipartimento di Scienze Mediche Traslazionali, Università Federico II, Napoli
| | - F Ferrara
- Ospedale Santa Maria dell’Olmo, Cava de’ Tirreni, Salerno
| | - E Bobbio
- Dipartimento di Scienze Mediche Traslazionali, Università Federico II, Napoli
| | - AM Marra
- Pulmonary Hypertension Center, Thoraxclinic, University of Heidelberg, Germany
| | - R Abete
- Dipartimento di Scienze Mediche Traslazionali, Università Federico II, Napoli
| | - F Stagnaro
- Dipartimento di Scienze Mediche Traslazionali, Università Federico II, Napoli
| | - R Polizzi
- Dipartimento di Scienze Mediche Traslazionali, Università Federico II, Napoli
| | - F Giallauria
- Dipartimento di Scienze Mediche Traslazionali, Università Federico II, Napoli
| | - M Illario
- Dipartimento di Scienze Mediche Traslazionali, Università Federico II, Napoli
| | - E Menditto
- CIRFF, Center of Pharmacoeconomics, Federico II University, Naples, Italy
| | - C Vigorito
- Dipartimento di Scienze Mediche Traslazionali, Università Federico II, Napoli
| | - E Bossone
- Ospedale Santa Maria dell’Olmo, Cava de’ Tirreni, Salerno
| | - A Cittadini
- Dipartimento di Scienze Mediche Traslazionali, Università Federico II, Napoli,Address for correspondence: Antonio Cittadini, MD, Department of Translational Medical Sciences, Via Sergio Pansini, 5 80131 Naples, ITALY, Telephone & Fax +39-081-7464375 E-mail:
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