From the 2024 HVPA National Conference
Sonia Alicea MD (University of Central Florida/HCA Healthcare GME, Greater Orlando, Florida/Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, Florida), Emmanuel Magsino MD, Sriya Reddy MD, Alfredo Palomino Abella MD, Faris Alamin MD, Raj Shah MD, Ashwini Komarla MD, David Simmons MD, Amar Mandalia MD
Background:
Proton pump inhibitors (PPIs) are one of the most commonly prescribed medications. PPI prescriptions at Veterans Health Administration accounts for over 11 million 30-day prescriptions and nearly $50 million in medication costs annually (1). Some of the common uses of PPIs are for peptic ulcer disease, esophagitis, functional dyspepsia, non-erosive reflux disease, prevention of nonsteroidal anti-inflammatory drug-associated ulcers, and Zollinger-Ellison syndrome (2). Long term use of high-dose PPIs affects absorption of calcium, vitamin B12 and magnesium by decreasing stomach acid production (3). When used beyond the indicated time, PPIs increase the risk of chronic kidney disease, infections, osteoporosis, fractures, vitamin deficiencies, and dementia contributing to polypharmacy and increasing healthcare costs (4,5).
Objective:
Attempt de-escalation of PPIs in 50% of eligible patients in the resident run (Patriot) clinic by May 30, 2024 as tracked by self report by residents and attendings.
Methods:
A retrospective chart review was conducted among all patients prescribed PPIs in 2023 in the Patriot Clinic in the Orlando Veteran Affairs (VA) Healthcare System to identify the baseline number of patients who can be de-escalated. Inclusion criteria for review consisted of all patients on PPIs. Patients with indication for long term PPI were excluded. Following root cause analysis, the interventions involved provider education and reminders, posters directed at patients in the exam rooms, and patient education pamphlets, as well as a competition between resident groups to attempt de-escalation of PPIs for their patients. The primary outcome was the number of self-reported PPI de-escalation attempts by clinic providers. Secondary outcomes included theoretical and actual cost savings annually based on the cost of each medication through the VA per the number of potential and attempted PPI de-escalations.
Results:
Out of 158 patients chart reviewed, 67 patients (42%) had potential for PPI de-escalation. Twenty-five patients attempted de-escalation by April 2024. The range of cost savings annually based on the number of patients with attempted de-escalation are as follows: pantoprazole ($351 to $909), omeprazole ($153 to $306), and esomeprazole ($1,971 to $6,192). There are more potential cost savings when accounting for decreased number of Clostridium difficile infections and bone fractures.
Conclusions:
This study shows an effective intervention for PPI de-escalation in our resident clinic with 22 de-escalations from January to April 2024. This study also showed notable theoretical and actual cost savings.
Clinical Implications:
Long term PPIs can lead to significant health care costs in terms of the medication itself and adverse effects. This study demonstrates that there is room for improvement in the de-escalation of PPIs in primary care clinics. A successful intervention to reduce long term PPI prescription in a resident clinic is illustrated here.