Identifying Risk Factors Associated With Inappropriate Use of Acid-Suppressive Therapy at a Community Hospital

Abstract

Introduction: By examining the prescribing patterns and inappropriate use of acid suppressive therapy (AST) during hospitalization and at discharge at our community hospital we sought to identify the risk factors associated with such practices. Methods: In this retrospective observational study, we reviewed the inpatient records at an academiccommunity hospital with a sample size of 20 random patients per month from January 2011 to December 2013. Pediatric patients and those lacking complete documents at admission were excluded. Treatment with AST was considered appropriate if the patient had a known specific indication [e.g. gastroesophageal reflux disease (GERD), peptic ulcer disease, dyspepsia, acute or suspected gastrointestinal (GI) bleeding, H. pylori treatment, hypersecretory conditions], met criteria for stress ulcer prophylaxis derived from American society of health system pharmacists guidelines, or, met other recommended GI prophylaxis criteria including use of chronic non-steroidal anti-inflammatory or anti-platelet agents. Logistic regression model, two-sample t-tests and Fishers exact tests were used to assess the risk factors associated with inappropriate AST use. Results: Of the total 720 charts reviewed, 588 were included in the study after exclusion. In 2011, 58 out of 198 patients were started on AST on admission, of which 32 were newly started on AST and 23 (72%) were inappropriate. In 2012, 97 out of 191 patients were started on AST, of which 61 were newly started on AST and 51 (84%) were inappropriate. In 2013, 99 out of 199 patients were started on AST, of which 48 were newly started and 36 (75%) were inappropriate. In total, 19% of the 110 inappropriately started were discharged on AST in 3 years. Thirty-five percent of the patients newly started on AST were prescribed histamine-2 receptor antagonists, while 65% were prescribed proton pump inhibitors. Except for AST started with no indication (34.04%), GI prophylaxis (26.24%) was the most commonly used indication though was deemed inappropriate since no criteria were met. Younger age (p=0.0029), female sex (p=0.0313), 1 or more handoffs between services (p=0.0162) were significantly and longer duration of stay (p=0.0608) was marginally associated with increased risk of inappropriate AST. Teaching vs. nonteaching and admitting physician (resident vs. attending) were not risk factors. Conclusion: Our findings reflect previous studies highlighting inappropriate prescription of AST. This practice leads to increase costs of care and unnecessarily puts the patient at risk for potential adverse events. The results of this study emphasize the importance of examining the patient’s need for AST at each level of care especially when the identified risk factors are present.