Reduction of inappropriate exit prescriptions for proton pump inhibitors: A before‐after study using education paired with a web‐based quality‐improvement tool

Abstract

BACKGROUND Proton pump inhibitors (PPIs) are overprescribed despite concerns regarding associated adverse drug events. OBJECTIVE To reduce inappropriate PPI prescriptions using hospitalization as the point of contact to effect meaningful change. DESIGN Before‐after study design. SETTING Forty‐six–bed medical clinical teaching unit in a 417‐bed university teaching hospital in Montreal, Canada. PATIENTS Four hundred sixty‐four consecutively admitted patients in the preintervention control group, and 640 consecutively admitted patients in the intervention group. INTERVENTION A monthly educational intervention paired with a Web‐based quality improvement tool. MEASUREMENTS We determined the proportion of patients admitted on PPIs, their indications, and appropriateness of use. We then compared the proportion of patients whose PPIs were discontinued at discharge before and after our intervention. RESULTS Forty‐four percent of patients were already using a PPI prior to their hospitalization. In evaluated patients, only 54% of these patients had an evidence‐based indication for ongoing use. The proportion of PPIs discontinued at hospital discharge increased from 7.7% per month in the 6 months prior to intervention, to 18.5% per month postintervention (P = 0.03). CONCLUSIONS Strategies to combat PPI overuse are needed to improve the overall quality of patient care. We significantly reduced discharge prescriptions for PPIs through the implementation of an educational initiative paired with a Web‐based quality improvement tool. An active interventional strategy is likely required considering the increasingly recognized and preventable adverse events associated with PPI misuse. Journal of Hospital Medicine 2015;10:281–286. © 2015 Society of Hospital Medicine

Recent Literature Update on Medication Risk in Older Adults, 2015–2016

“…Finally, hospitalization can lead to starting a “drive by drug” like docusate. Other examples of “drive by” drugs during hospitalization include inappropriate/ineffective/unnecessary medications such as antipsychotics, expectorants, vitamins, and proton pump inhibitors for stress ulcer prophylaxis . A strength of the MacMillan et al.…”

“…Other examples of "drive by" drugs during hospitalization include inappropriate/ineffective/unnecessary medications such as antipsychotics, expectorants, vitamins, and proton pump inhibitors for stress ulcer prophylaxis. 17,18 A strength of the MacMillan et al study is the use of a random sample, documenting not only medications started in the hospital but those taken at home and continued. One potential concern is the lack of accounting for other constipating drugs besides opioids and employment of a multivariable model with data from the random sample to help identify predictors of docusate new prescribing or deprescribing to guide future intervention studies.…”

The MedSafer Study: A Controlled Trial of an Electronic Decision Support Tool for Deprescribing in Acute Care

“…All sites had a strong baseline culture of deprescribing and were highly sensitized to the issues of polypharmacy and ADEs. 20,22,31,36 Hospitalization can serve as an opportunity for deprescribing because many admissions (eg, for falls or delirium) relate to adverse effects of medications. 22,37 Although one recent large longitudinal study using the STOPP criteria identified hospitalization as a risk factor for PIM acquisition at discharge (odds ratio = 1.72), 38 this is in contrast to our intervention and demonstrates the importance of establishing a culture of deprescribing in acute care.…”

Potential harms of proton pump inhibitor therapy: rare adverse effects of commonly used drugs

“…One strategy paired a 20minute educational session on the benefits and harms of PPI use with a Web based tool cueing medical residents to reassess the appropriateness of PPI prescriptions for medi cal inpatients. 5 A total of 49% of patients without a clear indication for treatment had their PPI stopped before hospital discharge. Another strat egy involved a nurseled dyspepsia clinic in which a nursing team developed action plans with patients to stop unnecessary PPI use.…”

“…Furthermore, as suggested by the Can adian Association of Gastroenterology, 4 many patients receive longterm PPI therapy and can benefit from periodic reassessment. 5 Proton pump inhibitors are associated with a number of rare but potentially serious adverse effects. These uncommon effects become highly relevant when considering the tens of millions of patients who take PPIs worldwide.…”