Inappropriate Use of Proton Pump Inhibitor (PPI) Infusion in Upper Gastrointestinal Bleeding (UGIB) Patients and the Impact of Proper Physician Education on Outcome: An Experience in Two Community Hospitals

Abstract

Introduction: UGIB remains a major health care burden in the United States. Recent ACG guidelines for ulcer bleeding supports no improvement in clinical outcome with pre-endoscopic PPI treatment in UGIB patients. However, if endoscopy is delayed or can't be performed or patient is hemodynamically unstable, IV PPI is recommended to reduce further bleeding. In addition to that, patients with suspected variceal bleeding might be benefited with pre-endoscopic PPI infusion along with vasopressin/octreotide infusion. Aim: To identify the prevalence of inappropriate use of pre-endoscopic PPI infusion in UGIB patients. To educate physicians about appropriate use of pre-endoscopic PPI infusion in UGIB and evaluate the change in clinical outcomes following education. Methods: A retrospective study was conducted in patients admitted with UGIB from July 2015 to May 2016. Physicians were educated via emails & posters about the appropriate use of pre-endoscopic PPI infusion in UGIB patients in January 2016. PPI infusion use was defined appropriate prior to endoscopy if patients were hemodynamically unstable, or EGD was delayed or could not be performed or in patients with history of cirrhosis in which variceal bleeding was suspected. Patients who did not meet the criteria for appropriate use of PPI infusion received PPI intermittent bolus. Patients were divided in two groups: Pre-education cohort and post-education cohort. Data was collected in each group to assess patients' demographics, laboratory values at the time of presentation, length of stay, cost, blood transfusion, complications and death. Results: Of 419 patients admitted with UGIB, 73 patients (17.4%) received PPI infusion prior to endoscopy. Inappropriate use of PPI infusion was reduced in post-education group compared to pre-education group. (35% vs 71%, p value 0.0069) (Table 1). Pre-education group was associated with higher length of stay and higher cost compared to post-education group. There was no difference in mortality, re-bleeding rate, and requirement of blood transfusion between two groups. (table 2).Table 1: Effect of education on inappropriate use of PPI infusion in UGIB patientsConclusion: Inappropriate use of pre-endoscopic PPI infusion in UGIB patients is very prevalent in our hospitals. Proper physician education leads to decrease in the inappropriate use of PPI infusion and was associated with reduce length of stay and hospital cost, without change in mortality, re-bleeding rate and requirement of blood transfusion. Further studies are warranted to support our data.Table 2