From the 2018 HVPAA National Conference
Alexander Sun (Johns Hopkins Hospital), Emily Pherson (JHH), Paul O’rourke (Johns Hopkins Hospital), Amit Pahwa (Jhu), Sara Keller (Johns Hopkins Hospital)
Acid suppression therapy (AST), including proton pump inhibitors (PPI) and H2 receptor antagonists (H2RA), is commonly prescribed and increasingly associated with new side effects. The inpatient setting may be an underutilized opportunity to optimize a patient’s chronic medications (PMID 24616183), and this study aimed to reduce AST during hospitalization.
To reduce the number of patients on chronic acid suppression therapy discharged from general medicine services.
The design was a prospective pre-post study at two large academic medical centers of adult patients admitted to general medicine services over four weeks. Only the post intervention period is analyzed here. The intervention consisted of an educational presentation as well as information cards with recommended indications for AST. On weekdays, pharmacists screened patients who were on AST prior to admission and recommended to continue, increase, or decrease therapy. Recommendations were documented in the electronic medical record and provided to residents for approval. The primary outcome was the percentage of patients who were on AST prior to admission whose therapy was discontinued or deescalated (dose lowered or changed from a PPI to H2RA) at discharge.
Over the intervention period, 116 patients were on AST prior to admission who were evaluated by pharmacists. Of these, 97 met inclusion criteria (15 were discharged outside of the study window, 3 patients passed away or were discharged to hospice, and 1 patient was transferred). For the primary outcome, 61 patients (62.9%) were discharged on no therapy or deescalated therapy. Twenty seven patients (27.8%) were discharged on their home AST and 9 patients (9.3%) had their dose increased. Patients whose AST was discontinued or deescalated were called 4-6 weeks after discharge and 38 of 61 patients agreed to participate (62.3%) in the follow up questionnaire (7 declined, 13 were not reached and 3 had passed away). Twenty two of the 38 patients who participated (57.8%) had not restarted their original AST and remained on the deescalated dose or no therapy at all. Fourteen patients (37%) had restarted their medications at the time of follow up. (Of these, 4 reported they had no symptoms of acid reflux and were restarted on AST by their doctor and 3 patients reported they had never stopped taking AST at discharge due to patient preference.)
This study confirms that a large number of patients on acid suppression therapy may be eligible for de-escalation of therapy or even discontinuation of therapy all together. More than half of these patients were still on their de-escalated therapy 4-6 weeks after discharge. A simple educational initiative and pharmacist intervention to examine the appropriateness of medications may help reduce unnecessary medications reducing both poly-pharmacy and potential side effects.
Implications for the Patient
The inpatient setting may be an ideal time for multidisciplinary teams to reexamine the indications and appropriateness of medications for their patients to help reduce unnecessary side effects, costs, and improve the quality of patient care.