Background: Constipation is commonly encountered in patients admitted to the hospital, with a variety of possible treatments to choose from. Docusate is often prescribed to treat constipation, though evidence suggests it is ineffective. Utilizing an ineffective medication adds to patients’ pill burden, health care costs, and may delay the use of effective medications with downstream consequences.
Methods: Docusate was removed from 512 admission order sets at 16 hospitals within the Jefferson Health system on April 4th, 2023. Order sets were simplified to contain evidence-based bowel regimens, for example, including polyethylene glycol (PEG) and senna. We reviewed data regarding administration of docusate, bisacodyl, PEG, senna, methylnaltrexone, enemas, and suppositories. Methylnaltrexone, enemas, and suppositories were also grouped as “rescue” medications, suggesting failure of initial oral options (e.g., docusate). We reviewed administration data for inpatient locations 180 days pre and post intervention, and used pricing data to extrapolate the economic effects of our intervention.
Results: Docusate dosing decreased significantly from 140,619 in the pre-intervention period to 75,180 in the post-intervention period (-47%, all values reported herein are significant at p< 0.0001) corresponding to 132,695 fewer doses per year and a cost savings (not including pharmacy or nursing time) of $7,500.39/year. PEG, senna, and bisacodyl dosing increased from 5-10% from the pre to post period. All oral bowel medications decreased 19% leading to 113,985 fewer doses per year and $565 cost annual cost savings. While enema increased a modest 3%, methylnaltrexone dosing rose 29% with combined rescue medications rising 4% leading to 738 more annual doses and a $24,185 annual cost increase. All medications (both oral and rescue medications) decreased 19% leading to 113,247 fewer annual doses and an overall price annual price increase of $23,619.
Conclusions: Docusate is an ineffective medication that adds to the medication burden of patients. Removing docusate from admission order sets and replacing with evidence-based regimens significantly decreased the amount of docusate administered to patients over the study period and increased the use of evidenced-based medications. Given a 29% increase in methylnaltrexone dosing, however, (4,627:1 cost ratio to docusate capsules)) there was a net increase in medication cost annually. Further study is needed to, first, determine if this unexpected methylnaltrexone use increase is sustained and is a reflection of PEG/senna regimen ineffectiveness and/or other causes, second, to account for cost savings to pharmacy and nursing staff by reducing ineffective medication dosing by 132,695 annually, and, third to explore patient-centered metrics.