Benchmarking medications in the last 24 hours of life. Dr Brian Ensor & 19 NZ hospices 2015

Transcription

1 Benchmarking medications in the last 24 hours of life Dr Brian Ensor & 19 NZ hospices 2015

2 Benchmarking Hospices / Practitioners work in isolation Governance demands some sense of propriety Science vs Art / Culture

3 Three cycles hospices and 140 patients Hospices and 356 patients hospices and 512 patients

4 4

5 Data Diagnosis (NMDS) Age Gender Place of death Use of anticonvulsants Expected or sudden death Use of LCP

6 Opioids Benzodiazepines Antipsychotics Anticholinergics Metoclopramide Cyclizine Others Medications

7 Whangarei Hibiscus Coast North Shore Auckland West Auckland South Auckland Taranaki Wanganui Palmerston Nth Eastern BoP Hutt Valley Wellington Nelson Hastings Blenheim Gisborne Christchurch Dunedin Southland 7

8 Whangarei Hibiscus Coast North Shore Auckland West Auckland South Auckland Taranaki Wanganui Palmerston Nth Eastern BoP Hutt Valley Wellington Nelson Hastings Blenheim Gisborne Christchurch Dunedin Southland 8

9 Whangarei Hibiscus Coast North Shore Auckland West Auckland South Auckland Taranaki Wanganui Palmerston Nth Hutt Valley Wellington Nelson Christchurch Eastern BoP Gisborne Hastings Blenheim Dunedin Southland 9

10 PATTERNS OF USE

11 Opioid Footprints per patient % 90% 80% 70% 60% 50% 40% 30% Nil Combo Oxycodone Methadone Fentanyl Morphine 20% 10% 0% All Mary Potter Hospice 11

12 Opioid Footprints per patient % 90% 80% 70% 60% 50% 40% 30% Nil Combo Oxycodone Methadone Fentanyl Morphine 20% 10% 0% All Mary Potter Hospice 12

13 Opioid footprint by Drug % 90% 80% 70% 60% 50% 40% Nil Oxycodone Methadone Fentanyl Morphine 30% 20% 10% 0% All Mary Potter Hospice 13

14 Opioid footprint by Drug % 90% 80% 70% 60% 50% 40% Nil Oxycodone Methadone Fentanyl Morphine 30% 20% 10% 0% All Mary Potter Hospice 14

15 Opioid Footprints per drug % 90% 80% 70% 60% 50% 40% Nil Oxycodone Methadone Fentanyl Morphine 30% 20% 10% 0% All

16 Opioid footprint in order of increasing use of morphine 100% 90% 80% 70% 60% 50% 40% Nil Combo Oxycodone Methadone Fentanyl Morphine 30% 20% 10% 0% All

17 100% Opioid Footprint by drug ordered by methadone 90% 80% 70% 60% 50% 40% Nil Oxycodone Methadone Fentanyl Morphine 30% 20% 10% 0% All

18 100% Opioid footprint, ordered by Combo frequency 90% 80% 70% 60% 50% 40% 30% Nil Combo Other Oxycodone Methadone Fentanyl Morphine 20% 10% 0%

19 19

20 Syringe driver Opioids by Service Bed Size 100% 90% 80% 70% 60% 50% 40% Combo Oxycodone Methadone Fentanyl Morphine 30% 20% 10% 0% All No beds Beds<10 Beds>=10 20

21 Syringe Driver Antipsychotic footprint by Service Size 100% 90% 80% 70% 60% 50% 40% Nil Both Nozinan Haloperidol 30% 20% 10% 0% All Rural Beds<10 Beds>=10 21

22 Syringe Driver Benzo Footprint by Service Size 100% 90% 80% 70% 60% 50% 40% Nil Both Clonazepam Midazolam 30% 20% 10% 0% All No beds Beds<10 Beds>=10 22

23 Benzodiazepines in SD 100% 90% 80% 70% 60% 50% 40% Nil Combo Clonazepam Midazolam 30% 20% 10% 0% All

24 Benzodiazepine Footprint per patient % 90% 80% 70% 60% 50% 40% Nil Both Clonazepam Midazolam 30% 20% 10% 0% All

25 Use of psychoactive medication in SD 100% 90% 80% 70% 60% 50% 40% Neither Both Antipsychotic only Benzo Only 30% 20% 10% 0% All

26 DOSAGES ANALYSIS

27 pmedd doses ranked mg 27

28 Opioid doses 28

29 Histogram of log transform ation of total opioid dose 29

30 Morphine Equivalent Daily Dose (parenteral) Opioid Route Conversion Morphine Oral X 1.5 Subcut X 1 Fentanyl Patch X 0.1 Subcut X 0.1 Sublingual X 0.05 Oxycodone Oral X 0.63 Subcut X 1.5 Methadone Oral X 4 Subcut X 8

31 600 Opioid MEDD Geographic means & Std Dev (including Methadone) All

32 Opioid MEDD Geographic means & Standard Dev. 400 (Methadone not converted) All

33 ANOVA Transformed Dose Between Groups Sum of Squares df Mean Square F Sig Within Groups Total

34 95% Confidence Interval (I) Hospice 1 2 Mean Difference (I-J) Std. Error Sig. Lower Bound Upper Bound *

35 Opioid doses 2008 and 2015 (with 1x Stnd Dev) Morphine Fentanyl Methadone Oxycodone 35

36 Total Midazolam Dose (mg) 36

37 37

38 38

39 Morphine in the SD Total Morphine mg 47mg mg mg Midazolam in SD mg mg 0.84

40 50 45 Midazolam dose in syringe driver: Geo mean +/- 1 std dev High Low Mean All

41 Percentage of patients getting Buscopan 70% 60% 50% 40% 30% 20% 10% 0%

42 Benchmarking 50mg parenteral morphine in the last 24 hours Opioid dosages are reasonably constant Descriptive analyses of medication use has value for self reflection & governance The use of psychoactive medications and opioids is likely to vary by hospice, not by locality or diagnosis.

43 Acknowledgements Dr James Stanley, Biostatistician, University of Otago Marie Rose, Emma Griffiths, Mercy Auckland Willie Landman, South Auckland Christopher Diggle, North Shore Warrick Jones, Whangarei Marion Sephton and Nina Bray, Taranaki Marion Taylor, Wanganui Denise Hewitt, Arohanui Siew Tan, Te Omanga Juliet Fleming, Caroline Wright, Nelson Tasman

44 Acknowledgements Juliet Fleming, Caroline Wright, Nelson Tasman Hospice Andrew Wilson, Blenheim Marlborough Hospice Lee Anderson, Christchurch Nurse Maude Hospice Heather Parker, Ben Smith, Grahame Tosh, Dunedin Rachel MacDonald, Invercargill, Hospice Southland Sarah Grant, Penny Mainstone, Cranford Hospice Roger Yang, Hospice Hibiscus Coast Selena Chiu, Rebecca Stevenson, Moira Camilleri, Hospice West Auckland Robin Briant, Barbara Grout, Gisborne Shelley Moloney, Hospice Bay of Plenty