Inappropriate Proton Pump Inhibitors Research Articles

Is there overuse of proton pump inhibitors in B-cell non-Hodgkin lymphomas? A cohort study based on the French health insurance database in the Midi-Pyrénées region.

Patients suffering from B-cell non-Hodgkin lymphomas (B-NHL) have an increased likelihood of being exposed to proton pump inhibitors (PPIs), related to several factors which have been reported in the literature. PPIs are among the drugs most likely to be prescribed inappropriately. Consequently, B-NHL patients could be particularly at risk of inappropriate PPI prescription, with potential adverse drug reactions. We aimed to evaluate the incidence of PPIs use and to identify factors associated with PPIs initiation during the active treatment phase of B-NHL. We conducted a new-user cohort study using regional data from the French national health insurance database in the Midi-Pyrénées region (southwestern France). Incident B-NHL patients were selected according to an algorithm of selection, validated with data from a cancer registry. Our study revealed that 48.9% (95% confidence interval [CI]: 45.2-52.6) of patients initiated PPIs during chemotherapy after B-NHL diagnosis. According to information available in the SNDS, recommended indications for PPI prescriptions were identified in 21.1% of cases. Median duration of treatment was 65.3days (CI: 35-112). Determinants of PPIs initiation were peptic ulcer disease, gastroprotection (appropriate or not) for medications considered at risk (NSAIDs, glucocorticoids and anticoagulants), age, nonfollicular lymphoma, polypharmacy, gastroenterologists' consultations and being hospitalized in a university hospital. Around 50% of patients initiated PPI treatment during the chemotherapy phase with only one-fifth identified as appropriate prescriptions and with long durations of treatment in most cases. Given this background, appropriate PPI prescription should be promoted in B-NHL to avoid potential inappropriate chronic use and related adverse events.

Predictors of Inappropriate Proton Pump Inhibitors Use in Elderly Patients.

Introduction. Overutilization of Proton Pump Inhibitors (PPIs) both in ambulatory care and in the inpatient setting possesses economic implications and increases the risk for adverse drug reactions. This study was undertaken to identify factors associated with inappropriate PPI use among consecutively unplanned admissions of elderly patients at the time of admission. Materials and Methods. In 758 patients (54.2% women), mean age 80.3±8.0 (M±1SD), demographic characteristics, and medical and medication history were recorded. Parametric tests and multiple logistic regression analysis were applied to identify the predictors of inappropriate PPI use. Results. 232 patients (30.6%) were receiving PPIs. 37 (4.9%) were receiving PPIs appropriately and 195 (25.7%) were receiving PPIs without a proper indication. Consequently, PPIs prescribing was inappropriate in 195/232 (84%). Moreover, 512 patients (67.5%) were not receiving PPIs appropriately and 14 patients (1.8%) were not receiving PPIs but they had a proper indication. When we compared patients receiving PPIs without a proper indication with those who were not receiving PPIs, a statistical difference was found according to Charlson Comorbidity Index (p≤0.001, U=37922.00), number of diseases (p≤0.001, U=33269.00) and medications (p≤0.001, U=31218.50), Katz Index score (p=0.01, U=45328.00), and the use of blood thinners (p≤0.001, χ2=21.15). In multivariate analysis the only independent predictor of inappropriate PPI use was the number of medications (p=0.001, OR=1.16, 95%CI 1.06-1.27). Conclusions. The main predictor of inappropriate PPI use was the number of received medications. Εfforts needed to apply the predefined criteria for PPI prescription and to deprescribe PPIs received inappropriately.

Educational Intervention Improves Proton Pump Inhibitor Stewardship in Outpatient Gastroenterology Clinics.

BackgroundImproper chronic proton pump inhibitor (PPI) use has risen significantly in the last few decades. In our gastroenterology trainees’ clinics, we aimed to optimize PPI usage.MethodsWe collected baseline data on patients’ PPI use for 8 weeks. Based on gastroenterology society guidelines, we determined conditions for appropriate PPI use. If the indication could not be determined, it was categorized as “unknown”. Generated from the three most frequent causes for inappropriate PPI use, interventions were developed to correct each issue. Following a brief educational session, trainees implemented these interventions over a subsequent 8-week interval.ResultsDuring our pre-intervention period, trainees evaluated 263 patients who were prescribed a PPI. In 49% of the cases, the use of PPI was deemed inappropriate. The most common reasons were: gastroesophageal reflux disease (GERD) which was never titrated to the lowest effective dose, twice daily dosing for Barrett’s esophagus (BE) chemoprevention and unknown indication. During our intervention period, trainees evaluated 145 patients prescribed a PPI for GERD with well-controlled symptoms in 101 cases. PPI had not been titrated to lowest effective dose in 37 cases prompting intervention which was successful in 23 cases. PPI indication was unknown in 17 cases prompting a message to the prescribing provider to review appropriateness. Two cases of BE chemoprevention with twice daily dosing were appropriately reduced to daily dosing. Ultimately, after intervention, PPI use was deemed appropriate after intervention in 172 (77%) cases.ConclusionsImproper chronic PPI use was significant. Focusing intervention efforts on PPI use for GERD, BE and unknown indications substantially increased appropriateness of PPI use.

Limiting the Inappropriate Use of Acid Suppression Therapy for Stress Ulcer Prophylaxis in Hospitalized Patients at Cleveland Clinic Florida: A Quality Improvement Project

Introduction: The use of acid suppression therapy (AST) for stress ulcer prophylaxis (SUP) has been recommended in a specific patient population in the intensive care unit (ICU) setting. This population includes patients with mechanical ventilation longer than 48 hours, coagulopathy, multi-organ failure, shock, thermal or major trauma, neurologic trauma, and history of upper gastrointestinal (GI) bleed, peptic ulcer, or erosive gastritis in the past year. However, AST is often misused to include patients without indication for SUP. The overuse of AST increases hospital cost and potential adverse side effects. Two of the most commonly uses ASTs are proton pump inhibitors (PPIs) and H2-blockers. The main objective of this quality improvement project was to decrease the inappropriate use of PPIs and H2-blockers for SUP in patients hospitalized at Cleveland Clinic Florida (CCF). Methods: We obtained the medical records of patients prescribed (PPIs) or H2 blockers during January 2016. We performed a retrospective chart review of the January 2016 patients and explored seven data variables: admitting diagnosis, AST prescribed, route of administration, whether AST was used for treatment of prophylaxis, appropriateness of AST use for prophylaxis, appropriateness of AST use for treatment, and number of doses administered. We performed the intervention in December of 2016 by removing the “GI prophylaxis” section on the general admission order set of our electronic medical records. We then collected data looking at the same variables in inpatients who received AST in January 2017. Our primary endpoint was the rate of inappropriate use of AST. We used measures of central tendency and Pearson Chi Square testing to compare the rates of inappropriate AST use in the preintervention and post-intervention groups. Results: 365 out of 939 (36%) patients admitted during January 2016 inappropriately received AST with PPIs or H2-blockers for SUP. In the post-intervention period (January 2017), 243 out of 945 (25.7%) patients received inappropriate PPIs or H2-blockers for SUP. This was statistically significant (p value <.0001). Conclusion: Acid suppression therapy for stress ulcer prophylaxis is frequently misutilized in hospitalized patients. This increases hospital costs and adverse events. More interventions should be performed to ensure the appropriate use of SUP, which would decrease resource expenditures without negatively impacting the quality of care patients receive.1097 Figure 1 No Caption available.

Inappropriate Prescription of Proton Pump Inhibitors in a Community Setting

Proton pump inhibitors (PPIs) are widely prescribed for gastrointestinal conditions, such as gastroesophageal reflux disease and dyspepsia, and for prevention of gastric ulcer. Although previous reports have described inappropriate prescription of PPIs in the hospital setting, data from the community are lacking. To assess PPI prescriptions in the ambulatory setting. Patients presenting to the emergency department of a teaching hospital between June 2016 and March 2017 were prospectively assessed for use of a PPI at home. The appropriateness of PPI prescription was evaluated on the basis of an interview with the patient and review of the medical record. The indication for PPI therapy was verified against current guidelines for the province of Quebec. Over the 9-month study period, 2417 patients were screened, of whom 871 were included in the study. In relation to the Quebec guidelines, PPI prescription was inappropriate for 267 (30.7%) of the patients. When prescription of PPI for ulcer prevention in certain groups of patients (age ≥ 65 years and using acetylsalicylic acid or platelet aggregation inhibitors; age ≥ 75 years and using celecoxib) was re-classified as appropriate, the proportion of inappropriate PPI prescriptions declined to 20.3% (177/871). These findings suggest that inappropriate prescribing of PPIs remains problematic in the community setting in the province of Quebec.

Do recent reports about the adverse effects of proton pump inhibitors change providers' prescription practice?

Proton pump inhibitors (PPI) are utilized for a variety of indications, including treatment of gastroesophageal reflux disease, peptic ulcer disease, and prevention of gastrointestinal (GI) bleeding. Several studies have documented an increasing prevalence of inappropriate PPI use. Furthermore, recent media reports have highlighted new research data suggesting a possible association between chronic PPI use and several adverse medical outcomes, leading to frequent patient inquiries about these associations. Thus, providers face the challenge of counseling patients about the balance of risks and benefits related to PPI use. We aimed to explore providers' knowledge and attitudes toward reported adverse effects of PPI use and compare providers' prescription practices. A comprehensive, non-incentivized electronic survey was sent to all providers (residents, fellows, advanced practice providers, and consultants across 8 internal medicine specialties) at our tertiary academic medical center. The survey contained 21 questions covering provider demographics and responses to challenging clinical scenarios dealing with PPI use. Chi-square was used to compare responses from providers. The survey was distributed to 254 providers, of which 94 (24 GI and 70 non-GI) completed the survey (37% response rate). Among those 94 providers, 48 were consultants, 17 were advanced practice providers, and 29 were trainees. Non-GI providers included cardiology, pulmonary, endocrinology, family medicine, general internal medicine, hematology/oncology, and nephrology. Over half of the providers (51 [54%]) described their practice as outpatient setting, 29 (31%) providers defined their practice as a mixed setting (inpatient and outpatient), while 14 (15%) designated it as inpatient only. Nineteen (80%) GI providers and 48 (69%) non-GI providers discussed the risks and benefits with patients (P=0.64). Fifteen (63%) GI providers and 33 (47%) non-GI providers indicated that recent reports changed their practice (P=0.49). More GI providers (5 [21%]) lowered the dose of PPI compared with non-GI (1[1%]) (P=0.004); 18 (26%) of non-GI and 3 (13%) of GI providers discontinued PPI and substituted it with a histamine 2 (H2) blocker (P=0.29). A larger but nonsignificant percentage of trainees (8 [28%]) switched PPI to H2 blockers compared with consultants (8 [17%]; P=0.39). Six (25%) of GI providers and 14 (20%) of non-GI providers were concerned about Clostridium difficile infection (P=0.58). Twenty-four (34%) of the non-GI were worried about kidney diseases compared with 3 (13%) of the GI providers (P=0.1). Ten (21%) consultants were concerned about risk of osteoporosis compared with 3 (10%) trainees (P=0.38), while 8 (28%) trainees were worried about the risk of C. difficile infection compared with 10 (21%) consultants (P=0.69). Most providers (85 [90%]) agreed that educational activities would be helpful to address these challenges. More GI providers lowered the dose of PPI compared with non-GI; non-GI providers were more likely to discontinue PPI and substitute it with an H2 blocker. Educating patients and providers about potential adverse effects of PPI is imperative.

Outcomes From a Pharmacist - led Proton Pump Inhibitor Stewardship Program at a Single Institution.

Background: Proton pump inhibitors (PPIs) are effective medications for acid-related disorders; however, they are also overused and may be associated with several adverse effects. A PPI stewardship program was implemented at one institution to combat the overuse of PPIs. Objective: The purpose of this study is to evaluate the effectiveness of an inpatient PPI stewardship program in reducing PPI use, both during hospitalization and upon discharge. Methods: This was a retrospective cohort study of all patients admitted to an internal medicine service at a single institution from March 14, 2016, to August 14, 2016, with an intervention by the PPI stewardship team. The primary objective was to determine the percentage of patients who tolerated inpatient and outpatient PPI discontinuation, or dose de-escalations upon discharge. Secondary objectives included the identification of risk factors for intolerance of PPI discontinuation, the occurrence of gastrointestinal (GI) complications after PPI discontinuation, and the percentage of patients who required "as needed" acid suppressive therapy (AST) with an antacid or histamine-2 receptor antagonist (H2RA) to control their symptoms while hospitalized. Results: During the study time period, 537 patients with an active outpatient prescription for a PPI were admitted to an internal medicine team with 41.0% (n = 220) not meeting criteria for inpatient continuation. Of these patients, 95.9% (n = 211) tolerated inpatient PPI discontinuation, with 83.4% (n = 176) not requiring any "as needed" AST during hospitalization. Upon discharge, 57.1% patients (n = 24 of 42) tolerated PPI discontinuation at 3 months, while 81.8% patients (n = 18 of 22) tolerated PPI dose de-escalations at 3 months. Risk factors for intolerance of inpatient PPI discontinuation were a higher body mass index (BMI) (33.7 vs 30.3 kg/m2, P = .046) and longer length of stay (7.0 vs 4.0 days, P = .03), while longer duration of PPI use (9.0 vs 5.5 years, P = 0.03) was identified as a risk factor for intolerance of outpatient PPI discontinuation. One patient experienced reflux esophagitis 2 months after PPI discontinuation. Conclusion: A PPI stewardship program at a single institution resulted in the reduction of inappropriate PPI use in both the inpatient and outpatient settings.

Proton Pump Inhibitor Usage and the Risk of Mortality in Hemodialysis Patients

IntroductionLong-term inappropriate proton pump inhibitors use (PPIs) is a matter of concern because of the risks associated with their long-term use in older patients with chronic conditions. The risk of PPI treatment in hemodialysis patients remains unexplored.MethodsWe assessed the relationship between the use of PPIs and the risk of death in hemodialysis patients throughout a retrospective multicenter propensity score–matched study. Information about demographic, hemodialysis treatment, laboratory data, and concomitant medication was obtained from the EuCliD database (Fresenius Medical Care). We studied 1776 hemodialysis patients on PPI therapy compared to 466 patients not receiving PPIs. The resulting population comprising 2 groups of 410 matched patients was studied.ResultsPPI use was associated with hypomagnesemia (Mg <1.8 mg/dl (0.75 mmol/l); odds ratio [OR] = 2.70, 95% confidence interval [CI] = 1.38−5.27, P < 0.01). The exposure to PPIs in the full patient cohort was identified as an independent predictor for all-cause mortality in both univariate (HR = 3.16, 95% CI = 1.69–5.90, P < 0.01) and multivariate (HR = 2.70, 95% CI = 1.38–5.27, P < 0.01) Cox regression models. Moreover PPI use was identified as a predictor of CV mortality (HR = 1.51, 95% CI = 1.05−2.20, P = 0.03) Of the 820 patients matched throughout the propensity score analysis, the hazard ratios for all-cause mortality (HR = 1.412, 95% CI = 1.04–1.93, P = 0.03) and CV mortality (HR = 1.67, 95% CI = 1.03−2.71, P = 0.04) were higher among patients on PPIs versus those not on PPIs.ConclusionThe study data suggest that the PPI treatment should be regularly monitored and prescribed only when indicated.

Evaluation of a Trainee-Led Project to Reduce Inappropriate Proton Pump Inhibitor Infusion in Patients With Upper Gastrointestinal Bleeding

This trainee-led quality improvement study evaluates the use of the Culture, Oversight, Systems Change, Training framework to reduce inappropriate proton pump inhibitor infusions in patients with upper gastrointestinal bleeding.

We have had a gutful: The need for deprescribing proton pump inhibitors.

Proton pump inhibitor (PPI) prescribing may often be inappropriate and expose patients to a risk of adverse effects, while incurring unnecessary healthcare expenditure. Our objective was to determine PPI usage in Australia since 2002 and review international studies investigating inappropriate PPI prescribing, including those that discussed interventions to address this issue. Australian Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Scheme (RPBS) data were analysed. A narrative literature review relevant to the objective was conducted. Time series analysis was also used to examine the trend of reported PPI appropriate use across the international studies included in this review. Proton pump inhibitor use in Australia increased between 2002 and 2010 and then gradually decreased. Estimates of the extent of inappropriate use in the international literature had a wide variation (11-84%). There appeared to be little change in the extent of appropriate PPI use reported through 34 international studies from 2000 to 2016. Interventions to address inappropriate use included patient-centred deprescribing, academic detailing, educational programmes and drug safety notifications. Proton pump inhibitors continue to be overused worldwide and should be a focus for deprescribing programmes. Ongoing education and awareness campaigns for health professionals and patients, including electronic reminders at the point of prescribing, are strategies that have potential to reduce PPI use in individuals who do not have an evidence-based clinical indication for their long-term use.

Effectiveness of Interventions to Deprescribe Inappropriate Proton Pump Inhibitors in Older Adults.

The use of proton pump inhibitors (PPIs) in older adults is high, often inappropriate, and may cause harm. Deprescribing is defined as the reduction, withdrawal, or discontinuation of inappropriate medication. We conducted a systematic review to determine the effectiveness of interventions to deprescribe inappropriate PPIs in older adults. We searched MEDLINE, PubMed, Embase, the Cochrane Library, ProQuest Dissertations and Theses Global, and Google from inception to January 2017 for randomized and non-randomized studies describing the outcomes of interventions to deprescribe inappropriate PPIs in older adults (mean or median age of ≥65years). Where available, clinically relevant outcomes were also assessed. We included 21 articles in our review. Six studies demonstrated effective interventions, 11 were inconclusive, and four were ineffective. Effective interventions included a population-wide education and promotion strategy, academic detailing for general practitioners, and inpatient geriatrician-led deprescribing. Methodological issues limited the interpretation of several studies. Standardization in outcome reporting was lacking, and clinical outcome data were absent. A comparison of intervention effectiveness was not possible because of their heterogeneity, which precluded a meta-analysis. The limited available evidence suggests that some strategies are more successful than others in effectively deprescribing inappropriate PPIs in older adults. However, whether PPI deprescribing translates into better clinical outcomes remains unclear.

PIH14 - Evaluating The Economic Impact Of Potentially Inappropriate Prescribing In Older People In Ireland Using A Markov Modelling Approach

Potentially inappropriate prescribing (PIP), the use of medications where the risks may outweigh the benefits, is prevalent in people aged ≥65 years. Only direct medication costs have been assessed to date, therefore, the aim of this study is to determine the economic impact of adverse effects associated with three common types of PIP (long-term use of non-steroidal anti-inflammatory drugs (NSAIDs), benzodiazepines, and proton pump inhibitors (PPIs) at maximal dose). Markov models were developed incorporating the adverse effects of each PIP (e.g. falls and fractures for benzodiazepines). Models were populated with published estimates of probabilities, Irish health system costs (in 2014 euro), and utilities and were run on a cohort of 65 year olds over 35 one-year cycles with discounting at 5%. Probabilistic sensitivity analysis estimated confidence intervals (CI) for cost and QALY differences between each PIP and an appropriate non-PIP alternative. The models were then used to evaluate the cost effectiveness of hypothetical interventions to reduce PIP. The largest incremental cost and effect was for benzodiazepines compared to no pharmacotherapy (€3,470, 95%CI €2,434, €5,001; -0.07 QALYs, 95%CI -0.089, -0.047), followed by maximal dose PPIs relative to maintenance dose PPIs (€989, 95%CI -€69, €2,127; -0.01 QALYs, 95%CI -0.029, 0.003), and NSAIDs compared to paracetamol (€806, 95%CI €415, €1,346; -0.07 QALYs, 95%CI -0.131, -0.026). Considering prevalence and effectiveness of published interventions for each PIP, at a willingness-to-pay of €45,000/QALY, an intervention to reduce long-term NSAIDs would be cost effective up to the highest once-off intervention cost per person of €1,970. Interventions for inappropriate benzodiazepines and PPIs would be cost effective up to costs of €1,480 and €831 respectively. Potentially inappropriate use of long-term benzodiazepines and NSAIDs were associated with significantly increased costs and reduced QALYs. Targeting inappropriate NSAID prescribing appears to be the most cost effective PIP intervention.

Impact of Training Hospitalists on the Reduction of Inappropriate Proton Pump Inhibitors Use in a Small-sized Community Hospital

Impact of Training Hospitalists on the Reduction of Inappropriate Proton Pump Inhibitors Use in a Small-sized Community Hospital

Do Recent Reports About the Adverse Effects of Proton Pump Inhibitors Change Providersʼ Prescription Practice?

Introduction: Proton pump inhibitors (PPI) are indicated to treat gastroesophageal reflux disease, peptic ulcer disease, dyspepsia and to prevent GI bleeding. Studies have shown increasing inappropriate PPI use. Recent reports in the press and social media have highlighted new data suggesting a possible link between chronic PPI use and several medical problems, leading to frequent patient inquiries about these associations. Providers face the challenges of balancing PPI benefits and risks. We aimed to explore providers' knowledge and attitudes toward reported adverse effects of PPI and compare gastrointestinal (GI) and Non-GI providers' prescription practices.Table 1: Concerning side effects PPI to the patients reported by providersTable 2: Concerning side effects of PPI to providersFigure 1Methods: A comprehensive non-incentivized electronic survey was sent to all providers (residents, fellows, advanced practice providers and consultants across seven specialties) at a tertiary academic center. The survey contained 21 questions covering the following provider aspects: (1) demographics (2) responses to challenging clinical scenarios dealing with PPI use. Chi-square was used to compare responses from GI providers to those from non-GI providers. Results: We sent the survey to 254 providers at our center. 88 providers (22 GI and 66 non-GI) completed the survey (34.6 % response rate). Non-GI providers included cardiology, pulmonary medicine, endocrinology, family medicine, general internal medicine, hematology/oncology, and nephrology. More GI providers reported that these potential side effects changed their practice (63.6% in GI vs 48.5 in non-GI, p-value 0.4). A larger percentage of GI providers lowered the dose of PPI (18.2 % vs 1.5% p-value 0.003). Table (1) shows what providers do when facing challenging patients on PPI therapy. When asked which side effects are more concerning to patients, GI providers were more likely to cite osteoporosis or fractures than non-GI providers (40.9% vs 15.1% p-value 0.01) and dementia (31.8% vs 25.8 p-value 0.58). Table (2) and (3) show concerning side effects per patients and providers, respectively. Most providers (GI and non-GI) agreed that educational activities (e.g. grand rounds), would be helpful to address these challenges (95.5% vs 89.4%, p-value 0.67). Conclusion: Educating patients and providers about potential side effects of PPI is imperative. More GI providers reduced the dose of PPI for their patients while more non-GI providers switched to another medication (e.g. H2 blockers) or referred to GI clinic. Educational activities might be helpful in addressing these challenges.

Overuse of proton pump inhibitors for stress ulcer prophylaxis in Jordan.

To determine the frequency of inappropriate proton pump inhibitor (PPI) prescriptions during hospitalization for stress ulcer prophylaxis on the general medical ward in a tertiary Jordanian hospital. A retrospective chart review was executed on 236 patient admissions prescribed any PPI in a tertiary Jordanian hospital. For each patient, a detailed range of demographic and clinical variables was recorded. Patient's clinical variables were clustered into major vs. minor criteria for using PPIs in stress ulcer prophylaxis according to the American society of health-system pharmacists' (ASHP) therapeutic guidelines on stress ulcer prophylaxis. The 236 patients (51% females) had a mean age of 52 ± 18.1 years. Approximately 56% of the patients were using PPIs before admission. All our patients started PPI use for stress ulcer prophylaxis. Of these, 86% were unnecessary and should be avoided since they do not have at least 1 major or 2 minor indications. Previous PPI use before admission or the presence of one risk factor for stress ulcer motivated initiation of therapy predominately. Recent gastrointestinal (GI) ulcer/bleeding (23%) and coagulopathy (8%) were the main major indications. High-dose corticosteroid (24%) was the most frequent minor indication. The high frequency of inappropriate PPI prescriptions in stress ulcer prophylaxis for inpatients is a major issue in Jordan. Following the current recommended therapeutic guidelines of stress ulcer prophylaxis could minimize the overuse of PPIs in inpatient settings and thus decrease both the possible safety issues of PPIs and the economic burden on the health-care system.

Sa1103 Inappropriate Proton Pump Inhibitor Use in a Community Hospital Setting

Sa1103 Inappropriate Proton Pump Inhibitor Use in a Community Hospital Setting

Sustained effectiveness of a multifaceted intervention to reduce potentially inappropriate prescribing in older patients in primary care (OPTI-SCRIPT study).

BackgroundPotentially inappropriate prescribing (PIP) is common in older people in primary care and can result in increased morbidity, adverse drug events and hospitalisations. We previously demonstrated the success of a multifaceted intervention in decreasing PIP in primary care in a cluster randomised controlled trial (RCT).ObjectiveWe sought to determine whether the improvement in PIP in the short term was sustained at 1-year follow-up.MethodsA cluster RCT was conducted with 21 GP practices and 196 patients (aged ≥70) with PIP in Irish primary care. Intervention participants received a complex multifaceted intervention incorporating academic detailing, medicine review with web-based pharmaceutical treatment algorithms that provide recommended alternative treatment options, and tailored patient information leaflets. Control practices delivered usual care and received simple, patient-level PIP feedback. Primary outcomes were the proportion of patients with PIP and the mean number of potentially inappropriate prescriptions at 1-year follow-up. Intention-to-treat analysis using random effects regression was used.ResultsAll 21 GP practices and 186 (95 %) patients were followed up. We found that at 1-year follow-up, the significant reduction in the odds of PIP exposure achieved during the intervention was sustained after its discontinuation (adjusted OR 0.28, 95 % CI 0.11 to 0.76, P = 0.01). Intervention participants had significantly lower odds of having a potentially inappropriate proton pump inhibitor compared to controls (adjusted OR 0.40, 95 % CI 0.17 to 0.94, P = 0.04).ConclusionThe significant reduction in the odds of PIP achieved during the intervention was sustained after its discontinuation. These results indicate that improvements in prescribing quality can be maintained over time.Trial registrationCurrent controlled trials ISRCTN41694007.

The use of proton pump inhibitors in an Italian hospital: focus on oncologic and critical non-ICU patients.

Proton pump inhibitors (PPIs) are among the most misused drugs both at the community and hospital level. Recently, possible risks have been underscored, suggesting the importance of limiting PPI use to proven indications. To survey the appropriateness of PPI use in a University hospital in Italy. Setting Azienda Ospedaliera Universitaria Policlinico 'P. Giaccone', in Palermo, Italy. A one day-observational study, reviewing patients' medical records to identify treatments with PPIs and the indications for their use. After discharge, a subgroup of the cohort was followed up to assess the continuation of therapy at home. Appropriateness was evaluated according to the indications stated in the official product information sheet and supported by the AIFA notes. Prevalence and appropriateness of PPI use in the hospital and after discharge. In the index day 62.9 % of 343 evaluable patients received a PPI. In only 29.1 % of these, the treatment could be considered appropriate. The most frequent reasons for inappropriate treatment were stress ulcer prophylaxis in low risk patients and unwarranted gastro-protection in drug treated patients. 30.9 % of patients received PPIs for uncertain indications: of these, 25.7 % were "critical" patients admitted in non-ICU wards. Furthermore, as much as 88.2 % of anticancer drug treated patients received PPIs as gastroprotective agents. At discharge 48.6 % of patients received a prescription to continue PPI therapy at home and 75.9 % of the 83 followed up patients were found to be still taking these drugs after on average 3 months from discharge. This study confirms a high proportion of inappropriate PPI therapy into the hospital that translates in a prolonged unnecessary administration in the community setting. Further studies are needed to assess the cost-effectiveness of PPI therapy in subgroups of patients at moderate risk for gastric complications to optimize current guidelines.

The Inappropriate Prescription of Oral Proton Pump Inhibitors in the Hospital Setting: A Prospective Cross-Sectional Study.

Proton pump inhibitors (PPIs) are used to treat upper gastrointestinal tract disorders. Their efficacy and perceived safety have led to widespread prescription. This is not without effect, in terms of adverse events and resource utilization. To prospectively assess oral PPI prescription in hospitalized patients. PPI prescription in consecutive hospitalized patients was assessed. Indication and dose were assessed by patient interview and medical record review. Comparisons with current published prescribing guidelines were made. Four hundred and forty-seven patients were included. 57.5% were prescribed PPIs. 26.8% prescriptions were for inappropriate or unclear indications. 68.4% were on higher doses than guidelines recommended, of which 41.6% could have undergone dose reduction, and 26.5% discontinued. In a multivariate analysis, age, gender, and length of stay had no association with PPI prescription. Although aspirin use was appropriately associated with PPI prescription (RR: 1.8, 95% CI 1.127-3.69; p<0.05), the PPI was often given at higher than recommended doses (p<0.001). This may reflect older age and multiple risk factors in this subset. Surgical patients commenced more PPIs and at higher dosages (p<0.001). Omeprazole and lansoprazole were most often inappropriately prescribed (p<0.01, p<0.001, respectively). Inappropriate PPI therapy is still a problem in hospitals, though it appears to be at a lower level compared with previous studies. Awareness of evidence-based guidelines and targeted medicine reconciliation strategies are essential for cost-effective and safe use of these medications.

Reduction of inappropriate exit prescriptions for proton pump inhibitors: A before-after study using education paired with a web-based quality-improvement tool.

Proton pump inhibitors (PPIs) are overprescribed despite concerns regarding associated adverse drug events. To reduce inappropriate PPI prescriptions using hospitalization as the point of contact to effect meaningful change. Before-after study design. Forty-six-bed medical clinical teaching unit in a 417-bed university teaching hospital in Montreal, Canada. Four hundred sixty-four consecutively admitted patients in the preintervention control group, and 640 consecutively admitted patients in the intervention group. A monthly educational intervention paired with a Web-based quality improvement tool. We determined the proportion of patients admitted on PPIs, their indications, and appropriateness of use. We then compared the proportion of patients whose PPIs were discontinued at discharge before and after our intervention. Forty-four percent of patients were already using a PPI prior to their hospitalization. In evaluated patients, only 54% of these patients had an evidence-based indication for ongoing use. The proportion of PPIs discontinued at hospital discharge increased from 7.7% per month in the 6 months prior to intervention, to 18.5% per month postintervention (P = 0.03). Strategies to combat PPI overuse are needed to improve the overall quality of patient care. We significantly reduced discharge prescriptions for PPIs through the implementation of an educational initiative paired with a Web-based quality improvement tool. An active interventional strategy is likely required considering the increasingly recognized and preventable adverse events associated with PPI misuse.