S709 Proton-Pump Inhibitor Infusion Misuse in the Community Hospital Setting

Abstract

Introduction: Proton pump inhibitors (PPIs) are the most potent acid suppressants available. Several studies have shown that in hospitalized patients with acute upper gastrointestinal (GI) bleeding from peptic ulcer disease, high-dose PPI therapy via continuous infusion reduces the rate of high-risk bleeding lesions (active bleeding, visible vessel, adherent clot) on initial endoscopy. While the benefits of PPI infusions have been clearly described for these specific indications, they are often over-prescribed to inpatients. Our study aim was to determine the rate of misuse in a tertiary care community hospital setting. Methods: A retrospective cohort study was conducted at Lankenau Medical Center, a 370 bed community hospital. The usage of pantoprazole infusion was determined among hospitalized patients between March 1, 2018 and March 1, 2021 through review of the EPIC electronic medical record system. Appropriate candidates for pantoprazole infusion were defined as patients with hematemesis, melena, coffee-ground emesis, or hematochezia with hemodynamic instability. All other indications were categorized as inappropriate. Variables including age, sex, race, serum hemoglobin at the time of PPI infusion initiation, and antiplatelet use were collected. The rate of PPI infusion misuse was determined. Factors which significantly affected utilization of PPI infusion were determined through multivariate analysis. Results: A total of 348 pre-endoscopic PPI infusions were ordered during the three-year period. Approximately 35% of these prescriptions were ordered without an appropriate indication. The mean age of patients who were prescribed PPI infusions was 68.8 years. 48.6% were on an antiplatelet agent. The only significant variable between patients who were given a PPI infusion for an appropriate versus inappropriate indication was age, where the mean patient age was 68.8 compared to 71.1 years (p=0.04). Patient sex, race, antiplatelet use, and hemoglobin value did not significantly affect PPI infusion use. (Table) Conclusion: Pre-endoscopic PPI infusion was prescribed inappropriately in 34.8% of patients in a community hospital setting. Misuse of this drug leads to unnecessary healthcare costs and reflects poor understanding among prescribers of its appropriate clinically indicated uses. While PPIs are generally regarded as safe, misuse can increase the risk of adverse side effects. A follow-up study looking at a quality improvement intervention will follow this study. Table 1. - Characteristics and Multivariate Analysis of PPI Infusion Misuse Inappropriate PPI Infusion No Yes Total p-value n = 227 n = 121 n = 348 Age (Mean/SD) 67.6 (14.8) 71.1 (15.1) 68.8 (15.0) 0.04 Sex 0.571 Male 131 (57.7%) 66 (54.6%) 197 (56.6%) Female 96 (42.3%) 55 (45.5%) 151 (43.4%) Race 0.705 White 104 (46.0%) 59 (48.8%) 163 (47.0%) Black 112 (49.6%) 55 (45.5%) 167 (48.1%) Other 10 (4.4%) 7 (5.8%) 17 (4.9%) Ethnicity 0.12 Not Hispanic 225 (99.6%) 116 (97.5%) 341 (98.8%) Hispanic 1 (0.4%) 3 (2.5%) 4 (1.2%) Total Number of Antiplatelets 0.629 0 121 (53.3%) 58 (47.9%) 179 (51.4%) 1 70 (30.8%) 41 (33.9%) 111 (31.9%) 2 36 (15.9%) 22 (18.2%) 58 (16.7%) Antiplatelet Type (n = 169 Yes Only) Aspirin 103 (45.4%) 61 (50.4%) 164 (47.1%) 0.37 Clopidogrel 36 (15.9%) 23 (19.0%) 59 (17.0%) 0.456 Ticagrelor 4 (1.8%) 4 (3.3%) 8 (2.3%) 0.456 Prasugrel 1 (0.4%) 0 1 (0.3%) 1 Last Hemoglobin (Mean/SD, g/dl) 8.9 (2.6) 8.6 (2.9) 8.8 (2.7) 0.344 Missing Hemoglobin 19 8 27 Transfusion Units (median/IQR) 2 (0-6) 2 (0-4) 2 (0-5) 0.478