Improving appropriateness of acid-suppressive medication use via computerized clinical decision support

Herzig, Shoshana J.; Guess, Jamey; Feinbloom, David; Adra, May; Afonso, Kevin A.; Howell, Michael D.; Marcantonio, Edward R.

doi:10.1002/jhm.2260

Cited by 13 publications

(23 citation statements)

References 12 publications

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“…Second, the lack of a documented indication does not exclude the possibility that there was an undocumented evidenced‐based indication. Prompting clinicians to document an indication for long‐term prescriptions can mitigate this clinical uncertainty while simultaneously improving documentation and the quality of care …”

Section: Discussionmentioning

confidence: 99%

“…Prompting clinicians to document an indication for long-term prescriptions can mitigate this clinical uncertainty while simultaneously improving documentation and the quality of care. 12,24 CONCLUSIONS Older adults are receiving PPI prescriptions at an alarmingly high rate, often against guidelines. This study suggests that potentially minor changes in EHR-based stopping rules and/or targeted physician profiling could have a substantial impact on reducing low-value prescribing.…”

Section: Discussionmentioning

confidence: 99%

“…9,10 Promisingly, six randomized PPI deintensification trials in a metaanalysis found that deprescribing can reduce PPI use and pill burden. 11 Other well-designed quality improvement (QI) studies attempting to reduce potentially low-value PPI prescriptions have found mixed results 12,13 and importantly none of the six randomized trials were conducted among older Americans.…”

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confidence: 99%

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Low‐Value Proton Pump Inhibitor Prescriptions Among Older Adults at a Large Academic Health System

Mafi

May

Kahn

et al. 2019

J American Geriatrics Society

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BACKGROUND Older adults are particularly vulnerable to complications from proton pump inhibitor (PPI) drugs. We sought to characterize the prevalence of potentially low‐value PPI prescriptions among older adults to inform a quality improvement (QI) intervention. METHODS We created a cohort of patients, aged 65 years or older, receiving primary care at a large academic health system in 2018. We identified patients currently prescribed any PPI using the electronic health record (EHR) medication list (current defined as September 1, 2018). A geriatrician, a gastroenterologist, a QI expert, and two primary care physicians (PCPs) created multidisciplinary PPI appropriateness criteria based on evidenced‐based guidelines. Supervised by a gastroenterologist and PCP, two internal medicine residents conducted manual chart reviews in a random sample of 399 patients prescribed PPIs. We considered prescriptions potentially low value if they lacked a guideline‐based (1) short‐term indication (gastroesophageal reflux disease [GERD]/peptic ulcer disease/Helicobacter pylori gastritis/dyspepsia) or (2) long‐term (>8 weeks) indication (severe/refractory GERD/erosive esophagitis/Barrett esophagus/esophageal adenocarcinoma/esophageal stricture/high gastrointestinal bleeding risk/Zollinger‐Ellison syndrome). We used the Wilson score method to calculate 95% confidence intervals (CIs) on low‐value PPI prescription prevalence. RESULTS Among 69 352 older adults, 8729 (12.6%) were prescribed a PPI. In the sample of 399 patients prescribed PPIs, 63.9% were female; their mean age was 76.2 years, and they were seen by 169 PCPs. Of the 399 prescriptions, 143 (35.8%; 95% CI = 31.3%‐40.7%) were potentially low value—of which 82% began appropriately (eg, GERD) but then continued long term without a guideline‐based indication. Among 169 PCPs, 32 (18.9%) contributed to 59.2% of potentially low‐value prescriptions. CONCLUSION One in eight older adults were prescribed a PPI, and over one‐third of prescriptions were potentially low‐value. Most often, appropriate short‐term prescriptions became potentially low value because they lacked long‐term indications. With most potentially low‐value prescribing concentrated among a small subset of PCPs, interventions targeting them and/or applying EHR‐based automatic stopping rules may protect older adults from harm. J Am Geriatr Soc 67:2600–2604, 2019

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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Low‐Value Proton Pump Inhibitor Prescriptions Among Older Adults at a Large Academic Health System

Mafi

May

Kahn

et al. 2019

J American Geriatrics Society

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“…The results demonstrated a significant but small reduction in the caesarean delivery rate. Herzig et al (2015) described a quasi-experimental study using interrupted time series to improve the appropriateness of acid-suppressive medication (Herzig et al, 2015). This type of medication is not indicated but is commonly used for stress ulcer prophylaxis in patients outside intensive care.…”

Section: Implementation Vs De-implementationmentioning

confidence: 99%

Towards a systematic approach for (de)implementation of patient blood management strategies

Voorn

Bodegom‐Vos

So‐Osman

2018

Transfusion Medicine

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Despite the increasing availability of evidence in transfusion medicine literature, this evidence does not automatically find its way into practice. This is also applicable to patient blood management (PBM). It may concern the lack of implementation of effective new techniques or treatments, or it may apply to the (over)use of techniques and treatments (e.g. inappropriate transfusions) that have proven to be of limited benefit for patients (low-value care) and could be abandoned (de-implementation). In PBM literature, the implementation of restrictive transfusion thresholds and the de-implementation of inappropriate transfusions are described. However, most implementation strategies were not preceded by the identification of relevant barriers, and the used strategies were not often supported by literature on behavioural changes. In this article, we describe implementation vs de-implementation, highlight the current situation of (de)implementation in PBM and describe a systematic approach for (de)implementation illustrated by an example of a PBM de-implementation study regarding '(cost-) effective patient blood management in total hip and knee arthroplasty'. The systematic approach used for (de)implementation is based on the implementation model of Grol, which consists of the following five steps: the detection of improvement goals, a problem analysis, the selection of (de)implementation strategies, the execution of the (de)implementation strategy and an evaluation. Based on the description of the current situation and the experiences in our de-implementation study, we can conclude that de-implementation may be more difficult than expected as other factors may play a role in effective de-implementation compared to implementation.

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“…In the study by Herzig et al 4 investigators took on the challenge of implementing stress ulcer prophylaxis guidelines developed by the Society of Hospital Medicine. The investigators first demonstrated that targeted electronic prompts captured patients' indications for acid suppressive therapy, and could be used to prohibit prescribers from ordering acid suppressive therapy among patients outside the intensive care unit (ICU) setting.…”

mentioning

confidence: 99%

Clinical decision support: A tool of the hospital trade

Poon

2015

J. Hosp. Med.

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Improving appropriateness of acid-suppressive medication use via computerized clinical decision support

Cited by 13 publications

References 12 publications

Low‐Value Proton Pump Inhibitor Prescriptions Among Older Adults at a Large Academic Health System

Low‐Value Proton Pump Inhibitor Prescriptions Among Older Adults at a Large Academic Health System

Towards a systematic approach for (de)implementation of patient blood management strategies

Clinical decision support: A tool of the hospital trade

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