Evidence on the ‘Unmentionables’
BRENDALYNN ENS, DIRECTOR
KNOWLEDGE MOBILIZATION & LIAISON OFFICER TEAM, CADTH
JANET CRAIN, MANAGER
KNOWLEDGE 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-Exner
Director – Materials Management
Services
3S Health Shared Services
Susie Hilton,
Clinical Advisor
3S Health Shared Services
Pamela Bryce
Senior Policy Analyst
Drug Plan & Extended Benefits
Branch, Saskatchewan Health
Susan Yee
Manager - Client Services, Drug
Plan & Extended Benefits Branch,
Saskatchewan Health
Dave Morhart
Director - Client Services, Drug Plan
& Extended Benefits Branch,
Saskatchewan Health
What are the
‘unmentionables’?
Key Messages
• Common hospital products are overlooked for evidencebased 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 Context
Focus 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?
HTA
Source: http://ebp.lib.uic.edu/dentistry/?q=node/12
“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 Home
A 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
Average Price Per Glove
Average # Used Per Individual in 3 month timeframe
Average # Gloves Used per Day Per Person
Total Cost for Coverage - 3 month
* Drug Plan & Extended Benefits Branch, Saskatchewan Health
86,110
$0.13
313
4
$10,983
Single-use disposable polypropylene
pleated face masks
There 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 medications
Docusate 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.