Long-term Proton Pump Inhibitor Use in Primary Care Internal Medicine Resident Clinic

Abstract

Introduction: Proton pump inhibitor (PPI) use is increasingly associated with nosocomial infections, including pneumonia, clostridium difficile and chronic diseases such as kidney disease and osteoporosis. The American Gastroenterological Association (AGA) recommends the dose of long-term PPIs should be periodically re-evaluated so that the lowest effective dose can be used, or a safer alternative can be used to manage the condition. Our aim is to evaluate and improve the appropriateness of PPIs used in our internal medicine resident clinic. Methods: The resident clinic at our tertiary care medical center is divided into five firms for primary care continuity. We performed a search on outpatient electronic health records for PPI orders on patients from all five firms of internal medicine resident clinic (5 attending providers and 60 residents). A sample size of 47 subjects was needed from each firm pre and post-intervention to achieve the significant power to detect a statistical difference between both groups. A pre-intervention retrospective chart review was performed on 47 patients from each firm to collect data on demographics, indications for PPI use, number of PPI tablets dispensed, refills offered, dosage and duration of treatment. Results: A detailed chart review of 201 patients was carried out. Mean age of our patient population was 53 years. Gastroesophageal reflux disease (GERD) was the most common indication (48%). Other indications were Barrett's esophagus (5.5%), peptic ulcer disease (2%), erosive gastritis (2%) while 17% did not have a clear indication. 75% of the patients were on PPI for greater than two months. EGD was performed in 24% (N=48) of the patients. A majority of the patients were on a 20mg once daily dose of PPI (44%). Most patients received three refills (28%, N=14) for their prescription with an average number of thirty tablets dispensed (47%, N= 94). Conclusion: Our study shows that 48% of our patients were prescribed PPIs for GERD, and none of the patients were treated with H2 receptor antagonists previously. 76% of our patient population on PPI had no documented EGD findings to support PPI use. Patients with uncomplicated GERD who respond to short-term PPIs should subsequently undergo attempts to stop or reduce them. The next step will be to develop and implement guidelines on appropriate PPI use in the ambulatory care setting and perform a post intervention data analysis to assess for outcomes.