Preventing Complications of High Dose Steroids for Patients at the Orlando VA Healthcare System

From the 2023 HVPA National Conference

Emmanuel Magsino MD (1. University of Central Florida HCA Healthcare GME, Greater Orlando Florida 2. Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, Florida), Sriya Reddy MD, Alfredo Palomino Abella MD, Sonia Alicea MD, Faris Abby Alamin MD, Liliana Franco MD, Alexander Kong Ibanez MD, Ashwini Komarla MD

High-dose steroids are the mainstay of therapy for a wide variety of conditions. However, it has been well established that systemic steroids are associated with an increased risk of multiple adverse effects including serious infections such as pneumocystis jirovecii (PCP), gastrointestinal bleeding, and osteoporosis leading to fractures. Although guidelines exist from a multitude of specialties regarding prophylaxis of steroid-induced adverse events for patients on prolonged high-dose steroid therapy, there is a paucity of data regarding the practice patterns among providers who prescribe prolonged high-dose steroids. As part of a quality improvement initiative, provider prescription practices were assessed among patients receiving long-term glucocorticoid therapy.

To increase the percentage of patients on appropriate PCP prophylaxis by 1/1/24 to 50% and ensure providers are considering proton pump inhibitors (PPIs) and bone prophylaxis for patients on high dose steroids.

A retrospective chart review was conducted in CPRS among all patients prescribed prednisone from January to December 2022 in the Orlando Veteran Affairs (VA) Healthcare System. Inclusion criteria for review consisted of patients on prednisone > 20mg daily for a 30 day duration or a dose equivalent. Criteria for appropriate PCP, gastrointestinal, and osteoporosis fracture prophylaxis was based on current guidelines and literature.<sup>1,2,3</sup> They are as follows: PCP criteria: Prednisone or dose equivalent of > 20mg with other immunosuppressives or > 30 mg a day for > 30 days, PPI criteria: patients with previous peptic ulcer disease, heavy smokers, heavy alcohol users, patients > 65 years of age, and patients taking other medications that may increase the risk of Peptic ulcer disease (PUD), Bone fracture prophylaxis criteria: Prednisone or dose equivalent of > 30mg for > 30 days. The primary outcomes included identifying the prevalence of patients meeting criteria for prophylaxis and how many patients were placed on prophylaxis among those who qualified. The most common prescribing provider specialties were also evaluated. Additionally, cases of PCP from 2019 to 2022 were reviewed to identify cases where high dose steroids may have been prescribed prior to infection.

Of 87 patients prescribed high dose prednisone in 2022, 50 patients met inclusion criteria. 33 patients qualified for PCP prophylaxis and of these, 12 (36%) were found to be on appropriate prophylaxis. 36 patients qualified for PPI prophylaxis and 25 (69%) were found to be on appropriate prophylaxis. 32 qualified for fracture prophylaxis and 8 (25%) were found to be on appropriate prophylaxis. The most common specialties prescribing high dose steroids without PCP prophylaxis included Dermatology, Gastroenterology, and Neurology. Of 15 PCP cases identified between 2019 to 2022, 5 cases were prescribed high dose steroids, however these were all prescribed by a provider outside the VA. Among these cases, 2 required hospital admission and were discharged and 3 expired.

This study demonstrates wide provider variability in prescribing PCP, PPI, and bone prophylaxis despite existing national guidelines.

Clinical Implications:
These findings indicate there is room for improvement on placing patients on appropriate prophylaxis. Identifying the most common providing specialties and addressing the reasons for practice variability in prescribing prophylaxis will aid in reducing future adverse events related to high dose steroids. This may include provider education, pharmacy review, and EMR alerts. Our next steps are to meet with providers and explore reasoning and ways to help with considering guidelines for prophylaxis.

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.

Learn more about HVPA on Health Affairs Blog