Can Intervention Reduce Abuse of Proton Pump Inhibitors?

Abstract

Purpose: We previously reported proton pump inhibitor (PPI) overuse in hospital patients, especially for stress ulcer prophylaxis (SUP). To evaluate the effectiveness of education, we examined the indication and frequency of PPI use in hospitalized patients again after intervention. Methods: We prospectively analyzed pharmacy orders of all adult patients admitted to the hospital who received a PPI in two separate phases. Phase 1 (P1) was for 45 days in 2005 and phase 2 (P2), after the intervention, was for 45 days in 2008. Indication for PPI use, hospital prescribing service and discharge PPI use were determined. Between P1 and P2, didactic conferences were conducted for the Internal Medicine (IM) residents on appropriate PPI prescribing and the IM admission template was updated to exclude routine SUP. Appropriate indications for PPI use included: maintenance of healed duodenal ulcers, H. pylori eradication, GERD, upper GI hemorrhage, maintenance/healing of erosive esophagitis, prevention/healing of NSAID-induced ulcers, relief from dyspepsia, SUP in high risk ICU patients, and continuation of home PPI. A two-proportion z- test was used to compare percentage of PPI use between the two phases. Results: Twenty-six percent (n=463) of adult patients admitted in P1 were prescribed a PPI and 36% (n=688) of patients in P2. Patients received a PPI for: SUP, GERD, not documented, GI bleed, continuation of home medication, peptic ulcer disease, esophagitis, and other. Inappropriate PPI administration decreased from 64% in P1 to 52% in P2 (p<0.0001). Inappropriate PPI use for SUP decreased from 86% to 76% (p<0.003). Importantly, in the intervention group, inappropriate use for SUP decreased from 62% to 41% (p<0.0001). Also, while 55% of patients in P1 were discharged on a PPI without appropriate indication, this decreased to 17% after the intervention in P2 (p<0.0001). Patients discharged on a PPI after being prescribed one for SUP decreased from 36% in P1 to 18% in P2 (p<0.0001). Although there was an overall increase in PPIs prescribed for inpatients in P2, a significant decrease was seen in PPIs prescribed for inappropriate reasons. Conclusion: Caution must be used when initiating PPI therapy in the hospital setting. Long-term therapy often continues unnecessarily at discharge leading to increased healthcare costs, polypharmacy, and increased risk for potential adverse effects. In conclusion, this study indicates that intervention through physician education can lead to a significant decrease in inappropriate inpatient PPI use.