Understanding the scope and causes of unnecessary Proton Pump Inhibitor (PPI) prescribing in patients admitted to the hospital and at discharge

From the 2018 HVPAA National Conference

Shailavi Jain (University Texas Southwestern Medical School), Jessica Garza (Parkland Hospital), Subhasri Kannan (University Texas Southwestern Medical Center), Thomas Tsai (University of Texas Southwestern Medical Center, Dallas, TX;), Eugene Chu (University of Texas Southwestern Medical Center, Dallas, TX;), Deepak Agrawal (University Texas Southwestern Medical Center)

Background

Proton pump inhibitors (PPIs) are one of the most prescribed classes of drugs in the United States. Their efficacy and relatively low adverse event profile has resulted in their significant overuse. Long-term PPI use is increasingly being associated with many health consequences and any unnecessary PPI prescribing causes unnecessary expenditures.

Objectives

This study aimed to determine the degree of inappropriate prescribing of PPIs in patients admitted to non-ICU beds and discharged from one county hospital. Furthermore, we determined the reasons for inappropriate PPI prescribing, with the ultimate goal of this study being to design and implement interventions to decrease unnecessary prescribing of PPIs.

Methods

Retrospective analysis of patients admitted to the hospitalist service and prescribed an inpatient PPI during one month (June 2017) was performed to understand the scope of the problem. Detailed chart review was performed to determine the indications for prescribed PPIs and the prescription was deemed appropriate if it was consistent with published guidelines on use of PPIs. The hospitalists were surveyed to understand their current prescribing practices and their perspective on inappropriate PPI use. Using this data, interventions addressing the various causes of inappropriate PPI use were rated using a prioritization matrix, and the best interventions were chosen.

Results

A total of 319 patients were prescribed PPIs as inpatients by hospitalists. In 195 (61%) patients the PPI was newly prescribed and in 124 (39%) patients it was prescribed as a continuation of an outpatient prescription. Overall, 186 (58%) prescriptions were deemed inappropriate – 118 (37%) inappropriate new prescriptions of PPIs and 68 (21%) inappropriate continuations of outpatient PPIs. Based on chart review, the major reasons for inappropriate inpatient PPI prescriptions were stress ulcer prophylaxis, steroid use, and automatic continuation of outpatient PPIs.

Of all the patients prescribed PPIs as inpatients, 212 (67%) were discharged on one. Of these, 111 (52%) did not have valid indications for outpatient use of PPIs. At 6- month follow-up, 52 (47%) of the patients inappropriately discharged on a PPI were still taking a PPI.

The main reasons providers gave for inappropriate prescription of PPIs included automatic continuation of outpatient medications, reluctance to stop PPIs ordered by another provider (even if there is no indication), ordered as part of an order set, and low perceived risks.

Our focused interventions, based on our findings, include improving communication between primary care physicians and hospitalists, providing individualized feedback on PPI use to hospitalists, educating providers and patients about PPI indications and adverse events, and placing restrictions in the electronic health records system.

Conclusion

Inappropriate prescription of PPIs in hospitalized patients is common and these patients are often discharged on these medications. This is especially concerning since the unnecessary use continues for many months, exposing patients to the adverse effects of PPIs. Our findings have helped develop a multimodal, focused approach to deprescribing inappropriate PPIs.

Implications for the Patient

Targeted interventions based on our chart review and survey results will help achieve greater success in decreasing inappropriate use of PPIs. This will help patients avoid many potential adverse effects of PPIs and decrease health care costs. Our interventions may be appropriate for other similar hospitals.

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