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Lee TC, McDonald EG, Bonnici A, Tamblyn R. Pattern of Inpatient Laxative Use: Waste Not, Want Not. JAMA Intern Med. 2016;176(8):1216–1217. doi:10.1001/jamainternmed.2016.2775
Constipation is common: present in up to 15% of healthy adults,1 39% of medical inpatients on admission, and develops over the course of hospitalization in 43%2 Given the frequency of bowel symptoms and provider diligence in treating constipation, laxative use in the hospital is common. While relatively inexpensive themselves, the indirect costs of laxatives include: pharmacy inventory management and distribution; nursing administration time; a contribution to polypharmacy; and downstream investigations (eg, Clostridium difficile testing) in the case of laxative-induced diarrhea. Evidence supporting the efficacy of certain laxatives is lacking, particularly docusate sodium/calcium,3 and so we quantified local patterns of laxative use, and estimated some of the associated costs.
We used pharmacy distribution data for fiscal year 2015 from the McGill University Health Centre (832 beds, Montreal, Canada). Based on the first 11 complete months, we extrapolated annual oral laxative use in terms of doses and drug costs (Canadian dollars) for medical and surgical units. Nursing time was estimated at 45 seconds4 for each administration and we used the Quebec base salary for university-trained nurses. We used data from the ongoing Right Rxclinical trial5 of electronic medication reconciliation to determine the proportion of patients discharged on oral laxatives during that time. The McGill University Health Centre Research Ethics Board approved this study.
The number of doses and associated pharmacy and nursing costs for fiscal year 2015 are summarized in the Table. Docusate products were most common, with over 165 000 doses, requiring an estimated 2065 nursing hours for administration. Overall, more than 258 000 doses of laxatives were dispensed requiring an estimated 3233 nursing hours. Among 1480 discharged patients, 738(49.9%) received exit prescriptions for docusate products, 163 (11%) for sennosides, and 142 (9.6%) for lactulose.
In our institution more than 250 000 doses of laxatives are administered annually, requiring the equivalent of almost 2 full-time nursing positions to dispense. Sixty-four percent of use involved docusate-based softeners, for which there is little quality evidence supporting efficacy in constipation prevention or treatment.3 These medications contribute to inpatient pill burden, which is particularly troublesome in cases of polypharmacy or in patients who have difficulty swallowing. Moreover, docusate use was perpetuated into the community in nearly 50% of patients. Since all medications are usually given equal urgency on most exit prescriptions, the pill burden caused by docusate products may increase the chance of nonadherence to other more important medications. Furthermore, some of these patients will become long-term users. While this may seem like a minor issue, the societal costs are striking, when taking into account the frequency of outpatient laxative use. Among the 2.8 million governmentally-insured beneficiaries in the province of Ontario (population 13.6 million), spending on laxatives exceeded $28 million Canadian dollars (CAD) in 20126 with nearly $9.7 million (CAD) spent on stool softeners, including docusate. A loose extrapolation to North America would suggest spending on docusate products is easily hundreds of millions of dollars.
Our single-center study may lack generalizability. It relies on pharmacy dispensing data, potentially overestimating doses given to patients; however, because our hospital policy restricts ward stock quantities, the estimates are likely close. Our discharge data does not guarantee that an exit prescription was filled, nor were we able to evaluate patient symptoms and cannot definitively infer a lack of benefit. Nonetheless, we believe that laxative use likely represents a common area where low-value health care is practiced.
Inpatient laxative use is common and frequently persists following discharge. While seemingly trivial, the routine use of docusate products in a constrained health care system is wasteful. Perhaps it is time for a trial to address the efficacy and clinical benefit of inpatient laxative use so that we might avoid flushing good money down the toilet.
Corresponding Author: Todd C. Lee, MD, MPH, Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Royal Victoria Hospital, 1001 Decarie Blvd, Rm D5.5843, Montréal, QC H4A 3J1 Canada (firstname.lastname@example.org).
Published Online: June 20, 2016. doi:10.1001/jamainternmed.2016.2775.
Author Contributions: Dr Lee had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Lee, McDonald, Tamblyn.
Acquisition, analysis, or interpretation of data: Lee, Bonnici.
Drafting of the manuscript: Lee.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Lee, Bonnici.
Administrative, technical, or material support: All authors.
Conflict of Interest Disclosures: None reported.
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