Four-Year Trends of Inappropriate Proton Pump Inhibitor Use After Hospital Discharge

BackgroundA large proportion of proton pump inhibitor (PPI) prescriptions, including those for stress ulcer prophylaxis (SUP), are inappropriate. Our study purpose was to systematically review the effectiveness of de-implementation strategies aimed at reducing inappropriate PPI use for SUP in hospitalized, non-intensive care unit (non-ICU) patients.MethodsWe searched MEDLINE and Embase databases (from inception to January 2020). Two authors independently screened references, performed data extraction, and critical appraisal. Randomized trials and comparative observational studies were eligible for inclusion. Criteria developed by the Cochrane Effective Practice and Organisation of Care (EPOC) group were used for critical appraisal. Besides the primary outcome (inappropriate PPI prescription or use), secondary outcomes included (adverse) pharmaceutical effects and healthcare use.ResultsWe included ten studies in this review. Most de-implementation strategies contained an educational component (meetings and/or materials), combined with either clinical guideline implementation (n = 5), audit feedback (n = 3), organizational culture (n = 4), or reminders (n = 1). One study evaluating the de-implementation strategy effectiveness showed a significant reduction (RR 0.14; 95% CI 0.03–0.55) of new inappropriate PPI prescriptions. Out of five studies evaluating the effectiveness of de-implementing inappropriate PPI use, four found a significant reduction (RR 0.21; 95% CI 0.18–0.26 to RR 0.76; 95% CI 0.68–0.86). No significant differences in the occurrence of pharmaceutical effects (n = 1) and in length of stay (n = 3) were observed. Adverse pharmaceutical effects were reported in two studies and five studies reported on PPI or total drug costs. No pooled effect estimates were calculated because of large statistical heterogeneity between studies.DiscussionAll identified studies reported mainly educational interventions in combination with one or multiple other intervention strategies and all interventions were targeted at providers. Most studies found a small to moderate reduction of (inappropriate) PPI prescriptions or use.

BackgroundIn accordance with current guidelines, proton pump inhibitors (PPIs) are now generally prescribed as a protective co-medication in patients taking non-steroidal anti-inflammatory drugs (NSAIDs) or low-dose acetylsalicylic acid (LDASA). However, less attention is paid to the corresponding discontinuation of a PPI after cessation of NSAID or LDASA treatment.ObjectiveThe aim of this study was to assess the extent of inappropriate PPI use, as the proportion of patients who started a PPI as a protective co-medication but continued using these drugs after cessation of NSAID and LDASA treatment. We also sought to estimate the potential cost savings and effect gains of discontinuing inappropriate PPI use and the resulting decrease in adverse effects and their detrimental consequences.MethodsPharmacy dispensing data were used to map inappropriate PPI use in 2014 for community-dwelling patients. Strategies with or without PPI continuation were compared in the cost–utility analysis for a time horizon of 5 years from a healthcare perspective. Subsequently, incremental costs and effects (quality-adjusted life-years) were estimated with a Markov model.ResultsRelated to NSAID and LDASA treatment, 11.0% and 5%, respectively, of the PPI users were found to inappropriately continue PPI co-treatment. Discontinuation in 71- to 80-year-old patients suggested cost savings of €170.46 (95% confidence interval 75–282) at a 0.003 (95% confidence interval 0.001–0.005) quality-adjusted life-year increase. The total budget impact of stopping inappropriate PPI use related to NSAID/LDASA treatment in the Netherlands would amount to almost €1,050,000 after 1 year. Correspondingly, successful interventions to stop a patient’s inappropriate use would cost up to €29 and probably would pay for themselves in the following years.ConclusionsA substantial number of patients inappropriately continue to use a PPI after cessation of NSAID or LDASA treatment. Because adverse effects and their detrimental consequences are avoided, interventions to stop inappropriate PPI use, particularly in older patients, are likely to pay for themselves.Electronic supplementary materialThe online version of this article (10.1007/s40266-019-00713-5) contains supplementary material, which is available to authorized users.

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.

Introduction. Overutilization of Proton Pump Inhibitors (PPIs) both in ambulatory care and in the inpatient setting possesses economic implications and increases the risk for adverse drug reactions. This study was undertaken to identify factors associated with inappropriate PPI use among consecutively unplanned admissions of elderly patients at the time of admission. Materials and Methods. In 758 patients (54.2% women), mean age 80.3±8.0 (M±1SD), demographic characteristics, and medical and medication history were recorded. Parametric tests and multiple logistic regression analysis were applied to identify the predictors of inappropriate PPI use. Results. 232 patients (30.6%) were receiving PPIs. 37 (4.9%) were receiving PPIs appropriately and 195 (25.7%) were receiving PPIs without a proper indication. Consequently, PPIs prescribing was inappropriate in 195/232 (84%). Moreover, 512 patients (67.5%) were not receiving PPIs appropriately and 14 patients (1.8%) were not receiving PPIs but they had a proper indication. When we compared patients receiving PPIs without a proper indication with those who were not receiving PPIs, a statistical difference was found according to Charlson Comorbidity Index (p≤0.001, U=37922.00), number of diseases (p≤0.001, U=33269.00) and medications (p≤0.001, U=31218.50), Katz Index score (p=0.01, U=45328.00), and the use of blood thinners (p≤0.001, χ2=21.15). In multivariate analysis the only independent predictor of inappropriate PPI use was the number of medications (p=0.001, OR=1.16, 95%CI 1.06-1.27). Conclusions. The main predictor of inappropriate PPI use was the number of received medications. Εfforts needed to apply the predefined criteria for PPI prescription and to deprescribe PPIs received inappropriately.

The potentially inappropriate use of the proton pump inhibitors is prevalent in older adults. To evaluate the impact of a clinical pharmacist-led stewardship program for the appropriate use of acid suppression therapy in older hospitalized patients. This parallel nonrandomized controlled study was conducted at an internal medicine service of a tertiary training and research hospital between September 2019 and August 2021. Older patients (≥ 65 years old and received proton pump inhibitors within 48h of admission) were allocated to two groups according to their number of medical file records, whether odd or even, two groups: control and clinical pharmacist-led stewardship program for the appropriate use of acid suppression therapy (including medication reconciliation and medication review) during the hospital stay. Primary outcome measures were the rate of appropriate use of proton pump inhibitors during hospitalization and potentially inappropriate proton pump inhibitor use at discharge. The rate of appropriate proton pump inhibitor use during hospitalization was significantly higher in the clinical pharmacist-led program (n = 100) than in the control group (n = 97) (46.4% vs. 79.0%; P < 0.001). The rate of potentially inappropriate proton pump inhibitor use at discharge was significantly lower (61.7% vs. 35.1%; P < 0.05) in the clinical pharmacist-led program among the older patients discharged with a proton pump inhibitor prescription. A clinical pharmacist-led stewardship program for the appropriate use of acid suppression therapy improved the rate of appropriate proton pump inhibitor use and reduced the potentially inappropriate proton pump inhibitor use during the hospital stay. NCT05113667 (17 October 2021-registered retrospectively).

Proactive Measures Aimed at Improving Appropriateness of Use of Proton Pump Inhibitors in Clinical Practice

Inappropriate use of proton pump inhibitors (PPIs) is associated with severe adverse drug reactions and may significantly increase health care costs. Deprescribing should be considered when inappropriate use is identified. To evaluate the effectiveness of a patient- and general practitioner (GP)-facing intervention in reducing potentially inappropriate PPI use in primary care. This pragmatic, cluster-randomized, open-label, clinical trial was conducted between November 12, 2020, and November 11, 2021. Participants were adults aged 18 years or older with at least 1 year of PPI use in GP practices in 2 regions of western France, and their GPs were included. Data were analyzed from January to July 2025. GP practices were randomized to 3 groups in a 1:1:1 ratio as follows: (1) a patient- and GP-facing deprescribing intervention combining a patient education brochure on PPI deprescribing posted directly to patients with a letter outlining a PPI deprescribing algorithm sent to their GPs; (2) a GP-facing intervention, in which only the GP received the letter and algorithm; or (3) usual care. The primary outcome was PPI dose reduction, defined as a 50% or more reduction in annual PPI use, measured in defined daily doses (DDDs) and proxied by reimbursement claims. Secondary measures included Gastroesophageal Reflux Disease Impact Scale (GIS) scores, assessed in a 10% sample. A total of 1498 GPs and 34 409 patients were included from 683 primary care practices. The mean (SD) patient age was 68.6 (14.0) years, and 19 507 (56.7%) were female. Mean (SD) baseline annual PPI use was 413.7 (113.9) DDDs. PPI dose reduction was higher in the patient- and GP-facing intervention group compared with the usual care groups (1710 of 11 442 patients [14.9%] vs 825 of 11 732 [7.0%]; adjusted absolute difference, 6.9%; 95% CI, 5.7%-8.3%; P < .001) and with the GP-facing intervention (1710 of 11 442 patients [14.9%] vs 862 of 11 235 [7.7%]; adjusted absolute difference, 6.7%; 95% CI, 5.4%-8.2%, P < .001). GIS scores did not significantly differ between groups. This randomized clinical trial found that the patient- and GP-facing intervention was effective in reducing potentially inappropriate PPI use without any meaningful impact on long-term gastroesophageal reflux disease activity. ClinicalTrials.gov Identifier: NCT04255823.

Proton pump inhibitor (PPI) therapy is commonly initiatedin hospitals for a variety of reasons including stress ulcer prophylaxis. Outpatient use of inpatient-initiated PPI use may be medically unwarranted. To (a) describe in a longitudinal analysis the incidence and reasons for hospital initiation of PPI therapy, (b) identify the proportion of members continued on PPI therapy at hospital discharge that is not medically warranted, and (c) estimate the total costs incurred by the managed care organization (MCO) and its members due to inappropriate continuation of hospital-initiated PPI therapy after discharge. A retrospective review of de-identified medical and pharmacy claims was performed to identify commercial and Medicare patients with an acute care hospital admission and subsequent discharge on a PPI from January 1, 2003, through December 31, 2006, in an MCO with approximately 2.5 million members with medical and prescription drug coverage. Hospital-initiated PPI therapy was assumed based on the presence of a paid pharmacy claim for a PPI within the 30-day period following hospital discharge. All patients who during the study period had (a) no PPI claims during the 90 days prior to an inpatient admission, followed by (b) a hospital stay, and (c) at least 1 pharmacy claim for a PPI during 30 post-discharge days were included in this analysis. Patients with PPI claims during the 90 days prior to their inpatient admission were excluded from analysis as this use was assumed to be appropriate. Any member (a) initiated on PPI therapy during hospital admission without a medically appropriate diagnosis, either primary or secondary, 3 months prior to or during hospitalization and (b) continuing therapy after discharge, as determined by at least 1 pharmacy claim for a PPI during the first 30 post-discharge days, was categorized as an inappropriate user. For the sample subgroup with inappropriate PPI use, costs due to inappropriate PPI therapy were calculated as the total cost incurred by the MCO and its members-including ingredient cost, dispensing fees, member copayments, and coinsurance-for PPI claims during the first 30 days after hospital discharge. Of 29,348 study-eligible members, 68.8% (n = 20,197) were prescribed a PPI inappropriately at hospital discharge. Rates of inappropriate PPI use were approximately equal for patients who stayed in the intensive care unit or coronary care unit (ICU/CCU) versus non-ICU/CCU patients (68.7% vs. 68.9%, respectively, P = 0.796 using the Pearson chi-square test). Over the 4-year period of this analysis, the total cost to the MCO and its members associated with inappropriate continuation of PPI therapy during the first 30 days after hospital discharge was $3,013,069. Increased health care costs associated with the utilization of PPIs can result from the inappropriate prescribing and continuation of PPI therapy after hospital discharge. Education of health care practitioners regarding medication reconciliation in general, and regarding continuation of PPI therapy specifically, is needed to increase responsible postdischarge medication utilization.

Background: Proton pump inhibitors (PPIs) are among the most widely prescribed class of medications in the United States. Although effective in the treatment of acid related disease, inappropriate PPI use is prevalent, and long-term PPI use has been associated with adverse effects. Objectives: This evaluation explores the novelty of a student-pharmacist directed PPI deprescribing telehealth program with the goals of (1) determining whether PPIs are appropriately prescribed in Veterans via remote student-led chart reviews, (2) identifying if a gap exists between urban and rural Veterans prescribed a PPI, and (3) assessing the feasibility of integrating student pharmacists into the PPI deprescribing process utilizing telehealth visits through a pilot study. Methods: Student pharmacists evaluated PPI appropriateness in Veterans at the William S. Middleton Veterans Hospital. Students collected data via remote chart reviews, compared appropriateness of PPI therapy in rural versus urban Veterans, and conducted a deprescribing pilot call study in rural Veterans with inappropriate PPI indications. Clinical decision-making was agreed upon in collaboration with pharmacist preceptors, however all means of communication with Veterans was performed by student pharmacists. Results: 51% of Veterans were found to have an inappropriate indication for their PPI, though comparison of inappropriate PPI use in rural versus urban Veterans was not statistically significant (n=170, p-value 0.34). 83% of Veterans agreed to proceed with PPI deprescribing and 71% of Veterans ended the pilot study with at least some degree of PPI dose reduction (n=33). Conclusion: Inappropriate PPI use among rural and urban Veterans is prevalent, however a significant difference was not observed between the two cohorts. Student pharmacists are capable of successful telehealth deprescribing interventions in collaboration with pharmacists.

BackgroundMisuse of proton pump inhibitors (PPIs) is an alarming issue for patients and healthcare systems.MethodsWe conducted a 3-phase interventional, prospective study in a Greek university hospital. During Phase I, we collected data from patients’ records to evaluate the appropriate use of PPIs. During Phase II, educational seminars about the proper use of PPIs were offered to the medical staff. In Phase III we collected data from the records of patients admitted to the hospital department with the highest rate of inappropriate PPI administration during Phase I, to evaluate the efficacy of the intervention. Inappropriate use was defined as either PPI administration without indication, or lack of use despite adequate indication. Appropriateness of PPI use was measured at admission, during hospitalization and at discharge.ResultsThe rate of inappropriate PPI use was higher (51.7% and 48.6%) during hospitalization than at admission (34.9% and 21.9%), but at discharge was similar to pre-hospitalization levels (26.9% and 23.6%), in Phases I and III, respectively. At discharge during Phase I, the inappropriate use of PPIs was significantly higher (odds ratio 3.79, 95% confidence interval 1.98-7.19) for internal medicine patients than for surgical patients. The educational intervention failed to reduce the inappropriate use of PPIs during hospitalization (51.7% vs. 48.6%, P=0.478) or at discharge (26.9% vs. 23.6%, P=0.391) in the internal medicine patients.ConclusionsThe rate of inappropriate PPI use is almost double during hospitalization compared to the rates at admission and at discharge. Implementation of an educational intervention failed to reduce the inappropriate use of PPIs in internal medicine patients.

Proton pump inhibitors (PPIs) are widely prescribed for acid-related disorders; however, concerns have emerged regarding their misuse, particularly in patients with liver cirrhosis. This study aimed to assess the appropriateness of PPI prescriptions in patients with cirrhosis and to identify factors contributing to their overutilization in this patient population. In this cross-sectional study, 1000 patients with cirrhosis receiving PPIs were enrolled. Data on demographics, clinical parameters, and endoscopic findings were collected, and indications for PPI therapy were assessed according to established guidelines. Among patients with cirrhosis, 60.5% were prescribed PPIs, with pantoprazole being the most prescribed (55.7%). Inappropriate PPI use was observed in 53.6% of the patients, mainly because of lacking an approved indication (78.54%) or exceeding the recommended treatment duration (21.46%). Causes contributing to misuse included prolonged PPI use postendoscopic band ligation (29.1%), extended treatment for functional dyspepsia (21.46%), failure to discontinue PPIs upon hospital discharge (17.54%), using PPIs for preventing portal hypertensive gastropathy (PHG) or variceal bleeding (16.42%), and stress ulcer prophylaxis in non-ICU patients (15.86%). Multivariate analysis identified independent predictors of inappropriate PPI use, including Child classification C, Mayo End-Stage Liver Disease score greater than 18, hepatocellular carcinoma, and previous variceal bleeding, whereas hematemesis was identified as an independent predictor of appropriate use. This study underscores the prevalent inappropriate prescription of PPIs in patients with liver cirrhosis, particularly in those with advanced liver disease or a history of variceal bleeding. Enhancing prescribing practices and adhering to evidence-based guidelines are essential to mitigate the risks associated with PPI misuse in patients with cirrhosis.

At present, studies on the usage of proton-pump inhibitors (PPIs) have universal significance. In clinical practice, PPIs are widely used to treat a variety of acid-related diseases, but they can be inappropriately prescribed, leading to increased medical costs and patient harm. The study comprehensively evaluated the clinical effects of a clinical pharmacist intervention on inappropriate PPI prescriptions in a tertiary general hospital hepatobiliary surgery ward. A retrospective, single-centre intervention study covering the periods of July-December 2018 and July-December 2019 was conducted. In the intervention group, clinical pharmaceutical care was initiated by a clinical pharmacist in the hepatobiliary surgery ward. Outcomes, including the clinical pattern of PPI utilization, the rate of inappropriate PPI use and safety outcomes, were compared between the two periods. In total, 1150 patients were admitted to the hepatobiliary surgery ward in our hospital in the study periods. Of these, 717 patients met the inclusion criteria for this study, and 420 and 297 patients were included in the preintervention and post-intervention groups, respectively. The PPI utilization rates before and after the intervention were 82.0% and 55.0%, respectively. The rates of inappropriate PPI use before and after the intervention were 48.9 and 22.7 per 100 patient-days, respectively. Clinical safety outcomes were nearly identical between before and after the intervention, but patients treated with PPIs were more likely to experience nosocomial pneumonia (2.4% vs. 0.6%). The implementation of a clinical pharmacist intervention for PPI use decreased inappropriate PPI use during hospitalization without sacrificing clinical safety outcomes.

Background and Objectives: Proton Pump Inhibitors (PPIs) are the most effective agents for treating acid-related gastrointestinal disorders. The prescription of an intravenous (IV) formulation of PPIs has increased dramatically. The aims of this study were to assess the appropriateness of IV PPI use and to define the risk factors and outcomes associated with its inappropriate use. Materials and Methods: A case-control retrospective study included all the hospitalized patients who received IV PPIs was conducted. Patient health records were reviewed, data were collected covering the period of the individual patients' admission to the hospital until discharge or death, and over the 3-month post-discharge period. The appropriateness of the IV PPI use and the resulting clinical outcomes were analyzed. Results: Overall, 540 patients were analyzed. Among them, 130/540 (24%) had inappropriate PPI use in terms of indication, dosage, and duration of treatment vs. 410 patients who had appropriate indications. Two parameters were associated with inappropriate use: congestive heart failure (OR 1.77; p = 0.02) and prescription of IV PPIs by surgeons vs. internists (OR 1.53; p = 0.05). Conclusions: Inappropriate IV PPI use is still common in daily clinical practice. Significant predictors of inappropriate use were the presence of congestive heart failure, elderly age, current use of anticoagulants and antithromotics, and the cases managed by surgeons, naturally due to suspected upper gastrointestinal bleedings.

Inappropriate use of proton pump inhibitors (PPIs) for prophylaxis among hospitalized patients continues to be a significant issue. Previous interventions have often been ineffective and lack evaluation of their longer-term impacts. This study aims to assess the clinical and economic effects of a nudge theory-based multifaceted intervention on reducing inappropriate PPI prophylaxis in hospitalized patients. This non-randomized controlled study was carried out in a teaching hospital's wards from January 2021 to June 2023, with a 12-month pre-intervention period, a 12-month intervention period (including the first and second stages of intervention), and a post-intervention period with 6-month follow-up. The intervention, based on nudge theory, was implemented among 114 doctors across 10 wards, sequentially involved peer comparison, information provision, and face-to-face feedback. The outcomes were assessed by randomly selecting cases of adult patients who received at least one PPI treatment during hospitalization, and the statistical analysis included univariate analysis, and multivariate and subgroup analyses. The study included 1782 patients, with a median age of 61 years. During and after intervention, the rate of appropriate PPI use significantly increased by 2.83- to 5.47-fold, rising from 23.82% (147/617) to 46.96% (139/296) after the first stage, to 63.13% (202/320) after the second stage, and remained at 53.01% (291/549) later on. The rate of PPI injections decreased from 92.54 to 74.13-84.12%, the median defined daily doses from 16 to 7-12, and PPI-related expenditures from 484.80 to 156.00-262.99 CNY per-patient. The cost associated with inappropriate PPI use dropped from 161.60 to 0-45.58 CNY per-patient. Subgroup analyses supported these findings. A nudge theory-based multifaceted intervention led to increased appropriate PPI use, decreased PPI injections, and cost savings, with benefits lasting at least 6 months post-intervention.

Proton pump inhibitor (PPI) therapy is commonly used outside of Food and Drug Administration indication for a broad range of conditions such as extra-esophageal reflux and PPI-responsive esophageal eosinophilia. While this may be appropriate in some scenarios, it has also resulted in widespread inappropriate PPI use. At the same time, data suggesting adverse effects of long-term PPI therapy are multiplying, albeit mainly from low quality studies. The systematic review by Scarpignato et al. (BMC Med 14:179, 2016) addresses this dilemma with a comprehensive analysis of the risks and benefits of PPI use. The authors concluded that, while PPIs are highly efficacious in erosive acid-peptic disorders, efficacy is not equaled in other conditions. In some instances, they found no supportive evidence of benefit. With respect to side effects, they indicated that the questionable harms associated with PPI therapy do not outweigh the benefits afforded by appropriate PPI use. However, inappropriate PPI use results in increased healthcare costs and unnecessary exposure to potential adverse effects. Ideally, PPI therapy should be personalized, based on indication, effectiveness, patient preference, and risk assessment.Please see related article: http://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-0718-z.