S1270 Inappropriate PPI Use in an Urban Resident Primary Care Clinic

Abstract

INTRODUCTION: Proton pump inhibitors (PPIs) are an efficacious treatment for gastroesophageal reflux disease (GERD) and dyspepsia. The American College of Gastroenterology (ACG) guidelines recommend a time-limited 8 weeks of therapy with PPIs for GERD and dyspepsia. PPIs are frequently prescribed in the primary care setting but can be over-prescribed or prescribed for too long. This can result in polypharmacy and other adverse medication-associated side effects. We evaluated the appropriateness of PPI use in patients with GERD and dyspepsia at LAC + USC Medical Center's resident primary care clinic. METHODS: We retrospectively analyzed all the patients seen in one week at LAC + USC's resident primary care clinic. Provider documentation was used to determine reasons for PPI use, indications to continue, and plans to trial off. RESULTS: Patients prescribed a PPI tended to be older (mean age 57.3 [55.8–58.9] vs 53.3 [52.0–54.5], P < 0.01), had more medical issues (7.3 [6.8–7.8] vs 5.6 [5.4–5.8], P < 0.01), specifically rheumatologic conditions (14.2% vs 5.9%, P < 0.01), and were more frequently followed in Gastroenterology specialty clinic (9.7% vs 2.6%, P < 0.01). Among patients on PPIs, 47% were prescribed it for GERD or dyspepsia, while 32% had no reason documented (Figure 1). 49 of 73 (67%) patients on a PPI for GERD or dyspepsia had been on a PPI for greater than two months without an indication to continue PPI therapy, and only 2 of 49 (4%) had a trial off PPI. CONCLUSION: The majority of patients prescribed a PPI for GERD or dyspepsia at the LAC + USC Resident Primary Care Clinic were on the medication for longer than the 8 weeks recommended by the ACG. During the root cause analyses for the inappropriate use of PPIs, gaps in house staff knowledge around guideline directed therapy and PPI side effects, time constraints associated with caring for a patient population with multiple comorbidities, and poor provider documentation in the electronic medical records were identified as significant contributing factors. To address gaps in knowledge, we plan to implement succinct and high yield didactic sessions for residents on appropriate PPI use and monitor for improvements in both documentation and adherence to ACG recommendations.Table 1.: Patient demographics and PPI use in primary care clinic. PPI = proton pump inhibitor, IDDM = insulin-dependent diabetes mellitus, NIDDM = noninsulin dependent diabetes mellitus, CKD = chronic kidney disease, CHF = congestive heart failure, CAD = coronary artery disease, ESRD = end stage renal disease, GERD = gastrointestinal esophageal reflux disease, PUD = peptic ulcer diseaseFigure 1.: Analysis of PPI prescriptions in primary care clinic. PPI = proton pump inhibitor, GERD = gastroesophageal reflux disease.