Expanding the Scope of High Value Practice Beyond Guideline Based Care

From the 2018 HVPAA National Conference

NEIL KESHVANI (University of Texas Southwestern Medical Center), Timothy J. Brown (University of Texas Southwestern Medical Center, Dallas, TX;), Arjun Gupta (University of Texas Southwestern Medical Center, Dallas, TX;), Kristin S. Alvarez (Parkland Health and Hospital System), Deepak Agrawal (University of Texas Southwestern Medical Center, Dallas, TX;)


Proton pump inhibitors (PPIs) remain one of the most overused medications in the United States. Current guidelines recommend PPI infusions in patients with suspected acute upper gastrointestinal bleeding before endoscopy and in patients with ulcerated lesions with high-risk features on endoscopy.


To promote high value care by narrowing the absolute indications for PPI infusions at our institution beyond broad guideline-based indications.


Data indicate that intermittent PPI therapy (oral or intravenous) is safe after endoscopic therapy of a high-risk ulcer, and some experts believe that the guidelines recommending PPI infusions should be revised. While many institutions have tried to reduce overall PPI use, the issue of unnecessary PPI infusion has largely been ignored. Following a critical national shortage of intravenous PPIs in March 2015, we had an urgency to optimize the use of intravenous PPI. PPI infusion was allowed for suspected upper gastrointestinal bleeding before endoscopy. However, after successful endoscopic treatment of ulcers with high-risk features, the treatment was changed from PPI infusion for 72 hours to intermittent oral or intravenous PPI (unless otherwise requested by the endoscopist on a case by case basis).


Since the change, 149 patients had high-risk ulcers requiring endoscopic treatment. Re-bleeding or requiring repeat endoscopy within 72 hours occurred in 5 (3.3%) patients, unchanged from 4.1% of cases over the previous 3 years where PPI infusion was given as standard of care. Of the 5 patients with re-bleeding after the change, 3 received oral PPIs, 1 received intravenous bolus PPI and 1 received PPI infusion. Overall, 75% received oral, 20% received intravenous bolus and 5% received infusion PPI.


We successfully reduced the use of PPI infusions in patients with high-risk ulcers after endoscopic treatment by 95% without an increase in adverse events. The use of less costly intermittent PPIs compared to PPI infusions has similar outcomes and may allow patients to be discharged earlier, making a compelling high value care argument.

Implications for the Patient

Adhering to guideline-based care is important in providing optimal patient care, however, guidelines are often conservative and lag behind the available evidence. When presented with strong evidence, clinicians should not be limited by guidelines. Instead, we should attempt to improve upon guidelines to further high value care.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

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