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Stollings JL, Poyant JO, Groth CM, Rappaport SH, Kruer RM, Miller E, Whitten JA, Mcintire AM, McDaniel CM, Betthauser KD, Mohammad RA, Kenes MT, Korona RB, Barber AE, MacTavish P, Dixit D, Yeung SYA. An International, Multicenter Evaluation of Comprehensive Medication Management by Pharmacists in ICU Recovery Centers. J Intensive Care Med 2023; 38:957-965. [PMID: 37198935 DOI: 10.1177/08850666231176194] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
BACKGROUND Post-intensive care syndrome (PICS) is defined as a new or worsening impairment in physical, cognitive, or mental health following critical illness. Intensive care unit recovery centers (ICU-RC) are one means to treat patients who have PICS. The purpose of this study is to describe the role of pharmacists in ICU-RCs. RESEARCH QUESTION What is the number and type of medication interventions made by a pharmacist at an ICU-RC at 12 different centers? STUDY DESIGN AND METHODS This prospective, observational study was conducted in 12 intensive care units (ICUs)/ICU-RCs between September 2019 and July 2021. A full medication review was conducted by a pharmacist on patients seen at the ICU-RC. RESULTS 507 patients were referred to the ICU-RC. Of these patients, 474 attended the ICU-RC and 472 had a full medication review performed by a pharmacist. Baseline demographic and hospital course data were obtained from the electronic health record and at the ICU-RC appointment. Pharmacy interventions were made in 397 (84%) patients. The median number of pharmacy interventions per patient was 2 (interquartile range [IQR] = 1,3). Medications were stopped and started in 124 (26%) and 91 (19%) patients, respectively. The number of patients that had a dose decreased and a dose increased was 51 (11%) and 43 (9%), respectively. There was no difference in the median total number of medications that the patient was prescribed at the start and end of the patient visit (10, IQR = 5, 15). Adverse drug event (ADE) preventive measures were implemented in 115 (24%) patients. ADE events were identified in 69 (15%) patients. Medication interactions were identified in 30 (6%) patients. INTERPRETATION A pharmacist plays an integral role in an ICU-RC resulting in the identification, prevention, and treatment of medication-related problems. This paper should serve as a call to action on the importance of the inclusion of a pharmacist in ICU-RC clinics.
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Affiliation(s)
- Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | | | - Christine M Groth
- Department of Pharmacy, University of Rochester Medical Center, Rochester, NY, USA
| | - Stephen H Rappaport
- Department of Pharmacy, University of Rochester Medical Center, Rochester, NY, USA
| | - Rachel M Kruer
- Department of Pharmacy, Indiana University Health, Adult Academic Health Center, Indianapolis, IN, USA
| | - Emily Miller
- Department of Pharmacy, Indiana University Health, Adult Academic Health Center, Indianapolis, IN, USA
| | | | | | - Cara M McDaniel
- Department of Pharmacy, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kevin D Betthauser
- Department of Pharmacy Services, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Rima A Mohammad
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Michael T Kenes
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | | | - Alexandra E Barber
- Department of Pharmacy, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | | | - Deepali Dixit
- Ernest Mario School of Pharmacy, Rutgers University, New Brunswick, NJ, USA
| | - Siu Yan A Yeung
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, MD, USA
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Pluenneke JC, Semler MW, Casey JD, Qian ET, Rice TW, Stollings JL. Quantifying Critical Care Pharmacist Interventions in COVID-19. J Intensive Care Med 2023; 38:651-656. [PMID: 36755415 PMCID: PMC9912037 DOI: 10.1177/08850666231156551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 02/10/2023]
Abstract
Purpose/Background: Pharmacists have been shown to play an important role in the medication management of critically ill patients. Pharmacist interventions in the care of critically ill patients with coronavirus disease 2019 (COVID-19) have not been quantitatively described. Methodology: A single center, retrospective, observational study was conducted at Vanderbilt University Medical Center in Nashville, Tennessee. All adult patients admitted to the COVID-19 intensive care unit (ICU) or Medical ICU with a COVID-19 diagnosis between March 1, 2020, and June 30, 2021, were included. All interventions made by pharmacists were documented electronically, collected, categorized, and analyzed. The primary outcome of this study was the median number of interventions by pharmacists per patient. The secondary outcome was the number of different types of interventions performed. Results: A total of 768 patients were included in the analysis. The median age was 63 years old; 63% of patients were male and 71% were Caucasian. Median hospital length of stay (LOS) was 12 days (interquartile range (IQR) 7-21) and ICU LOS was 5 days (IQR 1-11). The median Sequential Organ Failure Assessment score was 4 (IQR 2-7) and Charlson Comorbidity Index was 3 (IQR 2-5). Mortality at 60 days occurred in 352 patients (46%). Pharmacists performed a total of 7027 interventions for 655 patients with a median number of pharmacist interventions per patient of 6 (IQR 3-14). The most common pharmacist interventions were medication discontinuation (24%), completion of components of the ICU liberation bundle (19%), medication dose adjustment (18%), therapeutic drug monitoring (15%), and medication initiation (10%). Conclusions: Pharmacists made multiple interventions related to medication use and management in critically ill patients with COVID-19. This study adds important information of the evolving role clinical pharmacists play in the care of critical illness, specifically during the COVID-19 pandemic.
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Affiliation(s)
- Jack C. Pluenneke
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew W. Semler
- Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan D. Casey
- Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edward T. Qian
- Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W. Rice
- Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joanna L. Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, TN, USA
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3
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Aubert CE, Blum MR, Gastens V, Dalleur O, Vaillant F, Jennings E, Aujesky D, Thompson W, Kool T, Kramers C, Knol W, O'Mahony D, Rodondi N. Prescribing, deprescribing and potential adverse effects of proton pump inhibitors in older patients with multimorbidity: an observational study. CMAJ Open 2023; 11:E170-E178. [PMID: 36854455 PMCID: PMC9981164 DOI: 10.9778/cmajo.20210240] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Proton pump inhibitors (PPIs) contribute to polypharmacy and are associated with adverse effects. As prospective data on longitudinal patterns of PPI prescribing in older patients with multimorbidity are lacking, we sought to assess patterns of PPI prescribing and deprescribing, as well as the association of PPI use with hospital admissions over 1 year in this population. METHODS We conducted a prospective, longitudinal cohort study using data from the Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM) trial, a randomized controlled trial testing an intervention to reduce inappropriate prescribing (2016-2018). This trial included adults aged 70 years and older with at least 3 chronic conditions and prescribed at least 5 chronic medications. We assessed prevalence of PPI use at time of hospital admission, and new prescriptions and deprescribing at discharge, and at 2 months and 1 year after discharge, by intervention group. We used a regression with competing risk for death to assess the association of PPI use with readmissions related to their potential adverse effects, and all-cause readmission. RESULTS Overall, 1080 (57.4%) of 1879 patients (mean age 79 yr) had PPI prescriptions at admission, including 496 (45.9%) patients with a potentially inappropriate indication. At discharge, 133 (24.9%) of 534 patients in the intervention group and 92 (16.8%) of 546 patients in the control group who were using PPIs at admission had deprescribing. Among 680 patients who were not using PPIs at discharge, 47 (14.6%) of 321 patients in the intervention group and 40 (11.1%) of 359 patients in the control group had a PPI started within 2 months. Use of PPIs was associated with all-cause readmission (n = 770, subdistribution hazard ratio 1.31, 95% confidence interval 1.12-1.53). INTERPRETATION Potentially inappropriate use of PPI, new PPI prescriptions and PPI deprescribing were frequent among older adults with multimorbidity and polypharmacy. These data suggest that persistent PPI use may be associated with clinically important adverse effects in this population.
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Affiliation(s)
- Carole E Aubert
- Department of General Internal Medicine (Aubert, Blum, Aujesky, Rodondi), Inselspital, Bern University Hospital, University of Bern; Institute of Primary Health Care (Aubert, Blum, Gastens, Rodondi), University of Bern, Bern, Switzerland; Clinical Pharmacy Research Group (Dalleur), Université Catholique de Louvain, Louvain Drug Research Institute; Pharmacy Department (Dalleur, Vaillant), Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Department of Medicine (Geriatrics) (Jennings, O'Mahony), Cork University Hospital, University College Cork, Cork, Ireland; Women's College Hospital Research Institute (Thompson), Toronto, Ont.; Department of Anesthesiology, Pharmacology, and Therapeutics (Thompson), Faculty of Medicine, University of British Columbia, Vancouver, BC; Departments of Internal Medicine and Pharmacology-Toxicology (Kool, Kramers), Radboud University Medical Center, Radboud University Nijmegen, Nijmegen, the Netherlands; Department of Geriatric Medicine and Expertise Centre Pharmacotherapy in Old Persons (Knol), University Medical Centre Utrecht, University of Utrecht, the Netherlands
| | - Manuel R Blum
- Department of General Internal Medicine (Aubert, Blum, Aujesky, Rodondi), Inselspital, Bern University Hospital, University of Bern; Institute of Primary Health Care (Aubert, Blum, Gastens, Rodondi), University of Bern, Bern, Switzerland; Clinical Pharmacy Research Group (Dalleur), Université Catholique de Louvain, Louvain Drug Research Institute; Pharmacy Department (Dalleur, Vaillant), Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Department of Medicine (Geriatrics) (Jennings, O'Mahony), Cork University Hospital, University College Cork, Cork, Ireland; Women's College Hospital Research Institute (Thompson), Toronto, Ont.; Department of Anesthesiology, Pharmacology, and Therapeutics (Thompson), Faculty of Medicine, University of British Columbia, Vancouver, BC; Departments of Internal Medicine and Pharmacology-Toxicology (Kool, Kramers), Radboud University Medical Center, Radboud University Nijmegen, Nijmegen, the Netherlands; Department of Geriatric Medicine and Expertise Centre Pharmacotherapy in Old Persons (Knol), University Medical Centre Utrecht, University of Utrecht, the Netherlands
| | - Viktoria Gastens
- Department of General Internal Medicine (Aubert, Blum, Aujesky, Rodondi), Inselspital, Bern University Hospital, University of Bern; Institute of Primary Health Care (Aubert, Blum, Gastens, Rodondi), University of Bern, Bern, Switzerland; Clinical Pharmacy Research Group (Dalleur), Université Catholique de Louvain, Louvain Drug Research Institute; Pharmacy Department (Dalleur, Vaillant), Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Department of Medicine (Geriatrics) (Jennings, O'Mahony), Cork University Hospital, University College Cork, Cork, Ireland; Women's College Hospital Research Institute (Thompson), Toronto, Ont.; Department of Anesthesiology, Pharmacology, and Therapeutics (Thompson), Faculty of Medicine, University of British Columbia, Vancouver, BC; Departments of Internal Medicine and Pharmacology-Toxicology (Kool, Kramers), Radboud University Medical Center, Radboud University Nijmegen, Nijmegen, the Netherlands; Department of Geriatric Medicine and Expertise Centre Pharmacotherapy in Old Persons (Knol), University Medical Centre Utrecht, University of Utrecht, the Netherlands
| | - Olivia Dalleur
- Department of General Internal Medicine (Aubert, Blum, Aujesky, Rodondi), Inselspital, Bern University Hospital, University of Bern; Institute of Primary Health Care (Aubert, Blum, Gastens, Rodondi), University of Bern, Bern, Switzerland; Clinical Pharmacy Research Group (Dalleur), Université Catholique de Louvain, Louvain Drug Research Institute; Pharmacy Department (Dalleur, Vaillant), Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Department of Medicine (Geriatrics) (Jennings, O'Mahony), Cork University Hospital, University College Cork, Cork, Ireland; Women's College Hospital Research Institute (Thompson), Toronto, Ont.; Department of Anesthesiology, Pharmacology, and Therapeutics (Thompson), Faculty of Medicine, University of British Columbia, Vancouver, BC; Departments of Internal Medicine and Pharmacology-Toxicology (Kool, Kramers), Radboud University Medical Center, Radboud University Nijmegen, Nijmegen, the Netherlands; Department of Geriatric Medicine and Expertise Centre Pharmacotherapy in Old Persons (Knol), University Medical Centre Utrecht, University of Utrecht, the Netherlands
| | - Fanny Vaillant
- Department of General Internal Medicine (Aubert, Blum, Aujesky, Rodondi), Inselspital, Bern University Hospital, University of Bern; Institute of Primary Health Care (Aubert, Blum, Gastens, Rodondi), University of Bern, Bern, Switzerland; Clinical Pharmacy Research Group (Dalleur), Université Catholique de Louvain, Louvain Drug Research Institute; Pharmacy Department (Dalleur, Vaillant), Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Department of Medicine (Geriatrics) (Jennings, O'Mahony), Cork University Hospital, University College Cork, Cork, Ireland; Women's College Hospital Research Institute (Thompson), Toronto, Ont.; Department of Anesthesiology, Pharmacology, and Therapeutics (Thompson), Faculty of Medicine, University of British Columbia, Vancouver, BC; Departments of Internal Medicine and Pharmacology-Toxicology (Kool, Kramers), Radboud University Medical Center, Radboud University Nijmegen, Nijmegen, the Netherlands; Department of Geriatric Medicine and Expertise Centre Pharmacotherapy in Old Persons (Knol), University Medical Centre Utrecht, University of Utrecht, the Netherlands
| | - Emma Jennings
- Department of General Internal Medicine (Aubert, Blum, Aujesky, Rodondi), Inselspital, Bern University Hospital, University of Bern; Institute of Primary Health Care (Aubert, Blum, Gastens, Rodondi), University of Bern, Bern, Switzerland; Clinical Pharmacy Research Group (Dalleur), Université Catholique de Louvain, Louvain Drug Research Institute; Pharmacy Department (Dalleur, Vaillant), Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Department of Medicine (Geriatrics) (Jennings, O'Mahony), Cork University Hospital, University College Cork, Cork, Ireland; Women's College Hospital Research Institute (Thompson), Toronto, Ont.; Department of Anesthesiology, Pharmacology, and Therapeutics (Thompson), Faculty of Medicine, University of British Columbia, Vancouver, BC; Departments of Internal Medicine and Pharmacology-Toxicology (Kool, Kramers), Radboud University Medical Center, Radboud University Nijmegen, Nijmegen, the Netherlands; Department of Geriatric Medicine and Expertise Centre Pharmacotherapy in Old Persons (Knol), University Medical Centre Utrecht, University of Utrecht, the Netherlands
| | - Drahomir Aujesky
- Department of General Internal Medicine (Aubert, Blum, Aujesky, Rodondi), Inselspital, Bern University Hospital, University of Bern; Institute of Primary Health Care (Aubert, Blum, Gastens, Rodondi), University of Bern, Bern, Switzerland; Clinical Pharmacy Research Group (Dalleur), Université Catholique de Louvain, Louvain Drug Research Institute; Pharmacy Department (Dalleur, Vaillant), Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Department of Medicine (Geriatrics) (Jennings, O'Mahony), Cork University Hospital, University College Cork, Cork, Ireland; Women's College Hospital Research Institute (Thompson), Toronto, Ont.; Department of Anesthesiology, Pharmacology, and Therapeutics (Thompson), Faculty of Medicine, University of British Columbia, Vancouver, BC; Departments of Internal Medicine and Pharmacology-Toxicology (Kool, Kramers), Radboud University Medical Center, Radboud University Nijmegen, Nijmegen, the Netherlands; Department of Geriatric Medicine and Expertise Centre Pharmacotherapy in Old Persons (Knol), University Medical Centre Utrecht, University of Utrecht, the Netherlands
| | - Wade Thompson
- Department of General Internal Medicine (Aubert, Blum, Aujesky, Rodondi), Inselspital, Bern University Hospital, University of Bern; Institute of Primary Health Care (Aubert, Blum, Gastens, Rodondi), University of Bern, Bern, Switzerland; Clinical Pharmacy Research Group (Dalleur), Université Catholique de Louvain, Louvain Drug Research Institute; Pharmacy Department (Dalleur, Vaillant), Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Department of Medicine (Geriatrics) (Jennings, O'Mahony), Cork University Hospital, University College Cork, Cork, Ireland; Women's College Hospital Research Institute (Thompson), Toronto, Ont.; Department of Anesthesiology, Pharmacology, and Therapeutics (Thompson), Faculty of Medicine, University of British Columbia, Vancouver, BC; Departments of Internal Medicine and Pharmacology-Toxicology (Kool, Kramers), Radboud University Medical Center, Radboud University Nijmegen, Nijmegen, the Netherlands; Department of Geriatric Medicine and Expertise Centre Pharmacotherapy in Old Persons (Knol), University Medical Centre Utrecht, University of Utrecht, the Netherlands
| | - Tijn Kool
- Department of General Internal Medicine (Aubert, Blum, Aujesky, Rodondi), Inselspital, Bern University Hospital, University of Bern; Institute of Primary Health Care (Aubert, Blum, Gastens, Rodondi), University of Bern, Bern, Switzerland; Clinical Pharmacy Research Group (Dalleur), Université Catholique de Louvain, Louvain Drug Research Institute; Pharmacy Department (Dalleur, Vaillant), Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Department of Medicine (Geriatrics) (Jennings, O'Mahony), Cork University Hospital, University College Cork, Cork, Ireland; Women's College Hospital Research Institute (Thompson), Toronto, Ont.; Department of Anesthesiology, Pharmacology, and Therapeutics (Thompson), Faculty of Medicine, University of British Columbia, Vancouver, BC; Departments of Internal Medicine and Pharmacology-Toxicology (Kool, Kramers), Radboud University Medical Center, Radboud University Nijmegen, Nijmegen, the Netherlands; Department of Geriatric Medicine and Expertise Centre Pharmacotherapy in Old Persons (Knol), University Medical Centre Utrecht, University of Utrecht, the Netherlands
| | - Cornelius Kramers
- Department of General Internal Medicine (Aubert, Blum, Aujesky, Rodondi), Inselspital, Bern University Hospital, University of Bern; Institute of Primary Health Care (Aubert, Blum, Gastens, Rodondi), University of Bern, Bern, Switzerland; Clinical Pharmacy Research Group (Dalleur), Université Catholique de Louvain, Louvain Drug Research Institute; Pharmacy Department (Dalleur, Vaillant), Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Department of Medicine (Geriatrics) (Jennings, O'Mahony), Cork University Hospital, University College Cork, Cork, Ireland; Women's College Hospital Research Institute (Thompson), Toronto, Ont.; Department of Anesthesiology, Pharmacology, and Therapeutics (Thompson), Faculty of Medicine, University of British Columbia, Vancouver, BC; Departments of Internal Medicine and Pharmacology-Toxicology (Kool, Kramers), Radboud University Medical Center, Radboud University Nijmegen, Nijmegen, the Netherlands; Department of Geriatric Medicine and Expertise Centre Pharmacotherapy in Old Persons (Knol), University Medical Centre Utrecht, University of Utrecht, the Netherlands
| | - Wilma Knol
- Department of General Internal Medicine (Aubert, Blum, Aujesky, Rodondi), Inselspital, Bern University Hospital, University of Bern; Institute of Primary Health Care (Aubert, Blum, Gastens, Rodondi), University of Bern, Bern, Switzerland; Clinical Pharmacy Research Group (Dalleur), Université Catholique de Louvain, Louvain Drug Research Institute; Pharmacy Department (Dalleur, Vaillant), Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Department of Medicine (Geriatrics) (Jennings, O'Mahony), Cork University Hospital, University College Cork, Cork, Ireland; Women's College Hospital Research Institute (Thompson), Toronto, Ont.; Department of Anesthesiology, Pharmacology, and Therapeutics (Thompson), Faculty of Medicine, University of British Columbia, Vancouver, BC; Departments of Internal Medicine and Pharmacology-Toxicology (Kool, Kramers), Radboud University Medical Center, Radboud University Nijmegen, Nijmegen, the Netherlands; Department of Geriatric Medicine and Expertise Centre Pharmacotherapy in Old Persons (Knol), University Medical Centre Utrecht, University of Utrecht, the Netherlands
| | - Denis O'Mahony
- Department of General Internal Medicine (Aubert, Blum, Aujesky, Rodondi), Inselspital, Bern University Hospital, University of Bern; Institute of Primary Health Care (Aubert, Blum, Gastens, Rodondi), University of Bern, Bern, Switzerland; Clinical Pharmacy Research Group (Dalleur), Université Catholique de Louvain, Louvain Drug Research Institute; Pharmacy Department (Dalleur, Vaillant), Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Department of Medicine (Geriatrics) (Jennings, O'Mahony), Cork University Hospital, University College Cork, Cork, Ireland; Women's College Hospital Research Institute (Thompson), Toronto, Ont.; Department of Anesthesiology, Pharmacology, and Therapeutics (Thompson), Faculty of Medicine, University of British Columbia, Vancouver, BC; Departments of Internal Medicine and Pharmacology-Toxicology (Kool, Kramers), Radboud University Medical Center, Radboud University Nijmegen, Nijmegen, the Netherlands; Department of Geriatric Medicine and Expertise Centre Pharmacotherapy in Old Persons (Knol), University Medical Centre Utrecht, University of Utrecht, the Netherlands
| | - Nicolas Rodondi
- Department of General Internal Medicine (Aubert, Blum, Aujesky, Rodondi), Inselspital, Bern University Hospital, University of Bern; Institute of Primary Health Care (Aubert, Blum, Gastens, Rodondi), University of Bern, Bern, Switzerland; Clinical Pharmacy Research Group (Dalleur), Université Catholique de Louvain, Louvain Drug Research Institute; Pharmacy Department (Dalleur, Vaillant), Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Department of Medicine (Geriatrics) (Jennings, O'Mahony), Cork University Hospital, University College Cork, Cork, Ireland; Women's College Hospital Research Institute (Thompson), Toronto, Ont.; Department of Anesthesiology, Pharmacology, and Therapeutics (Thompson), Faculty of Medicine, University of British Columbia, Vancouver, BC; Departments of Internal Medicine and Pharmacology-Toxicology (Kool, Kramers), Radboud University Medical Center, Radboud University Nijmegen, Nijmegen, the Netherlands; Department of Geriatric Medicine and Expertise Centre Pharmacotherapy in Old Persons (Knol), University Medical Centre Utrecht, University of Utrecht, the Netherlands
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4
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Müskens JL, van Dulmen SA, Wiersma T, Burgers JS, Hek K, Westert GP, Kool RB. Low-value pharmaceutical care among Dutch GPs: a retrospective cohort study. Br J Gen Pract 2022; 72:e369-e377. [PMID: 35314429 PMCID: PMC8966784 DOI: 10.3399/bjgp.2021.0625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/31/2022] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Low-value pharmaceutical care exists in general practice. However, the extent among Dutch GPs remains unknown. AIM To assess the prevalence of low-value pharmaceutical care among Dutch GPs. DESIGN AND SETTING Retrospective cohort study using data from patient records. METHOD The prevalence of three types of pharmaceutical care prescribed by GPs between 2016 and 2019 were examined: topical antibiotics for conjunctivitis, benzodiazepines for non-specific lower back pain, and chronic acid-reducing medication (ARM) prescriptions. Multilevel logistic regression analysis was performed to assess prescribing variation and the influence of patient characteristics on receiving a low-value prescription. RESULTS Large variation in prevalence as well as practice variation was observed among the types of low-value pharmaceutical GP care examined. Between 53% and 61% of patients received an inappropriate antibiotics prescription for conjunctivitis, around 3% of patients with lower back pain received an inappropriate benzodiazepine prescription, and 88% received an inappropriate chronic ARM prescription during the years examined. The odds of receiving an inappropriate antibiotic or benzodiazepine prescription increased with age (P<0.001), but decreased for chronic inappropriate ARM prescriptions (P<0.001). Sex affected only the odds of receiving a non-indicated chronic ARM, with males being at higher risk (P<0.001). The odds of receiving an inappropriate ARM increased with increasing neighbourhood socioeconomic status (P<0.05). Increasing practice size decreased the odds of inappropriate antibiotic and benzodiazepine prescriptions (P<0.001). CONCLUSION The results show that the prevalence of low-value pharmaceutical GP care varies among these three clinical problems. Significant variation in inappropriate prescribing exists between different types of pharmaceutical care - and GP practices.
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Affiliation(s)
- Joris Ljm Müskens
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Centre, Nijmegen
| | - Simone A van Dulmen
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Centre, Nijmegen
| | | | - Jako S Burgers
- Department of General Practice, School CAPHRI, Maastricht University, Maastricht; senior consultant, Dutch College of General Practitioners, Utrecht
| | - Karin Hek
- Nivel, Netherlands Institute for Health Services Research, Utrecht
| | - Gert P Westert
- 'Doen of laten?', IQ Healthcare, Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Centre, Nijmegen
| | - Rudolf B Kool
- 'Doen of laten?', IQ Healthcare, Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Centre, Nijmegen
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5
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Clarke K, Adler N, Agrawal D, Bhakta D, Sata SS, Singh S, Gupta A, Pahwa A, Pherson E, Sun A, Volpicelli F, Cho HJ. Indications for the Use of Proton Pump Inhibitors for Stress Ulcer Prophylaxis and Peptic Ulcer Bleeding in Hospitalized Patients. Am J Med 2022; 135:313-317. [PMID: 34655535 DOI: 10.1016/j.amjmed.2021.09.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 12/11/2022]
Abstract
Proton pump inhibitors are widely used throughout the world for the treatment of gastrointestinal disorders that are related to acid secretion, such as peptic ulcer disease and dyspepsia. Another common indication for proton pump inhibitors is stress ulcer prophylaxis. Proton pump inhibitors have proven efficacy for the treatment of acid-related gastrointestinal disorders, but there is concern that their use may be associated with the development of significant complications, such as fractures, Clostridium difficile infection, acute kidney injury, chronic kidney disease, and hypomagnesemia. Proton pump inhibitors are overused in the hospital setting, both for stress ulcer prophylaxis and gastrointestinal bleeding, and then they are often inappropriately continued after discharge from the hospital. This narrative review article outlines the evidence surrounding appropriate proton pump inhibitor use for stress ulcer prophylaxis and peptic ulcer bleeding.
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Affiliation(s)
- Karen Clarke
- Division of Hospital Medicine, Emory University School of Medicine, Atlanta, Ga.
| | - Nicole Adler
- Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Deepak Agrawal
- Division of Gastroenterology and Hepatology, Dell Seton Medical Center, Austin, Tex
| | - Dimpal Bhakta
- Division of Gastroenterology, New York University School of Medicine, New York, NY
| | - Suchita Shah Sata
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Sarguni Singh
- Division of Hospital Medicine, University of Colorado, Aurora
| | - Arjun Gupta
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Amit Pahwa
- Division of General Internal Medicine, Division of General Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Emily Pherson
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Md
| | - Alexander Sun
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Frank Volpicelli
- Department of Medicine, New York University Grossman School of Medicine, New York, NY; Division of Hospital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hyung J Cho
- Division of Hospital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; New York City Health and Hospitals, New York, NY
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Yailian AL, Huet E, Charpiat B, Conort O, Juste M, Roubille R, Bourdelin M, Gravoulet J, Mongaret C, Vermorel C, Bedouch P, Janoly-Duménil A. Characteristics of Pharmacists' Interventions Related to Proton-Pump Inhibitors in French Hospitals: An Observational Study. Int J Clin Pract 2022; 2022:9619699. [PMID: 35846437 PMCID: PMC9256420 DOI: 10.1155/2022/9619699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 06/03/2022] [Indexed: 12/31/2022] Open
Abstract
METHODS The study was based on a retrospective analysis of pharmacist interventions for DRPs detected during the medication order review and documented into the French Act-IP© database over a 12-year period. DRPs and PIs were analyzed, and independent factors of physician acceptance were assessed via multiple logistic regression. RESULTS Out of the 620,620 PIs registered, 29,694 targeted a PPI (4.8%). PPI's DRPs were mostly related to the prescription of a "drug not available at the hospital" (26.1%) and a "drug use without indication" (18.3%); PIs were mostly "drug switch" (35.9%) and "drug discontinuation" (26.1%). In all, 18,919 PIs were accepted by physicians (63.7%). Acceptance was significantly associated with patient age: less accepted for the 18-75 years group (OR = 0.59, 95 CI [0.46-0.76]), and the >75 years group (OR = 0.57, 95 CI [0.44-0.73]) vs. <18 years group; for the type of DRP, "drug use without indication" was the less accepted (OR = 0.73, 95 CI [0.63-0.85]); for the type of PI, "dose adjustment" was the less accepted (OR = 0.32, 95 CI [0.23-0.45]). CONCLUSION Pharmacists contribute to preventing DRPs associated with PPI prescriptions during the medication order review process. Moreover, they often detect PPIs used without indication and they propose drug discontinuation, which contributes to the PPI deprescribing process. PIs should be further developed in the future to reduce PPI overprescription.
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Affiliation(s)
- AL Yailian
- Pharmacy Department, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- Université Claude Bernard Lyon 1, Université de Lyon, UR 4129 Parcours Santé Systémique, Lyon, France
| | - E. Huet
- Pharmacy Department, Dieppe Hospital, Dieppe, France
| | - B. Charpiat
- Pharmacy Department, Croix Rousse Hospital, Hospices Civils de Lyon, Lyon 69004, France
- Université Grenoble Alpes, CNRS/TIMC UMR5525, F-38041, Grenoble, France
- Working Group ‘Valorization of Pharmaceutical Interventions/Valorisation des Interventions Pharmaceutiques – Act-IP©' of the French Society for Clinical Pharmacy, Marseille, France
| | - O. Conort
- Working Group ‘Valorization of Pharmaceutical Interventions/Valorisation des Interventions Pharmaceutiques – Act-IP©' of the French Society for Clinical Pharmacy, Marseille, France
- Clinical Pharmacy Department, Cochin Hospital, APHP Centre, Cochin, Université de Paris, Paris, France
| | - M. Juste
- Working Group ‘Valorization of Pharmaceutical Interventions/Valorisation des Interventions Pharmaceutiques – Act-IP©' of the French Society for Clinical Pharmacy, Marseille, France
- Pharmacy Department, Auban Mouet Hospital, Epernay, France
| | - R. Roubille
- Pharmacy Department, Lucien Hussel Hospital, Vienne, France
| | - M. Bourdelin
- Working Group ‘Valorization of Pharmaceutical Interventions/Valorisation des Interventions Pharmaceutiques – Act-IP©' of the French Society for Clinical Pharmacy, Marseille, France
- Pharmacy Department, Nord-Ouest Villefrance Hospital, Villefranche sur Saône, France
| | - J. Gravoulet
- Working Group ‘Valorization of Pharmaceutical Interventions/Valorisation des Interventions Pharmaceutiques – Act-IP©' of the French Society for Clinical Pharmacy, Marseille, France
- Regional Union of Healthcare Professionals Pharmacists of the Grand Est (URPS), Nancy 54000, France
- Lorraine University, Faculty of Pharmacy, Nancy 54000, France
| | - C. Mongaret
- Working Group ‘Valorization of Pharmaceutical Interventions/Valorisation des Interventions Pharmaceutiques – Act-IP©' of the French Society for Clinical Pharmacy, Marseille, France
- Pharmacy Department, Reims University Hospital, Reims, France
- Reims Champagne Ardennes, Faculty of Pharmacy, Reims, France
| | - C. Vermorel
- Université Grenoble Alpes, CNRS/TIMC UMR5525, F-38041, Grenoble, France
| | - P. Bedouch
- Université Grenoble Alpes, CNRS/TIMC UMR5525, F-38041, Grenoble, France
- Working Group ‘Valorization of Pharmaceutical Interventions/Valorisation des Interventions Pharmaceutiques – Act-IP©' of the French Society for Clinical Pharmacy, Marseille, France
- Pharmacy Department, Grenoble Alpes University Hospital, Grenoble 38043, France
| | - A. Janoly-Duménil
- Pharmacy Department, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- Université Claude Bernard Lyon 1, Université de Lyon, UR 4129 Parcours Santé Systémique, Lyon, France
- Working Group ‘Valorization of Pharmaceutical Interventions/Valorisation des Interventions Pharmaceutiques – Act-IP©' of the French Society for Clinical Pharmacy, Marseille, France
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7
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Okoro RN, Abdullahi K, Dayar DA. Assessment of proton-pump inhibitor use at a tertiary teaching hospital in Nigeria. MEDICINE ACCESS @ POINT OF CARE 2021; 5:23992026211062729. [PMID: 36204491 PMCID: PMC9413602 DOI: 10.1177/23992026211062729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/10/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Proton-pump inhibitor (PPI) is a widely used medication class globally. Because of its good safety profile, there is a huge likelihood of inappropriate use. Objectives: To determine the prevalence of PPI use and indications, describe its pattern of usage, and identify factors associated with inappropriate prescriptions at a federal tertiary teaching hospital in Maiduguri, Nigeria. Methods: PPI prescriptions were retrospectively assessed in the General Outpatients’ Department (GOPD) and Gastroenterology Unit (GITU) of a teaching hospital. Relevant data for the study were extracted from the patients’ medical records. Chi-square or Fisher’s exact tests where appropriate were used to identify factors associated with inappropriate PPI prescriptions. A p < 0.05 was considered to be significant. Results: PPIs were prescribed to 73.3% (220/300) of patients, while inappropriate prescriptions were noted in 91.4% (201/220) of these patients. Epigastric pain (49.5%) was the most common PPI indication, while omeprazole was the highest prescribed (53.4%). Nearly all inpatients (98.2%), those with epigastric pain (95.7%), and patients who were prescribed intravenous PPIs had more inappropriate PPI prescriptions compared to others. Conclusion: This study revealed a high prevalence of PPI use and inappropriate prescriptions at the study hospital. As a result, these findings highlight the importance PPI-based stewardship program at the study hospital.
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Affiliation(s)
- Roland Nnaemeka Okoro
- Department of Clinical Pharmacy and Pharmacy Administration, Faculty of Pharmacy, University of Maiduguri, Maiduguri, Nigeria
| | - Kasim Abdullahi
- Department of Clinical Pharmacy and Pharmacy Administration, Faculty of Pharmacy, University of Maiduguri, Maiduguri, Nigeria
| | - Dauda Ayuba Dayar
- Gastroenterology Unit, Department of Internal Medicine, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
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Clarke K, Adler N, Agrawal D, Bhakta D, Sata SS, Singh S, Gupta A, Pahwa A, Pherson E, Sun A, Volpicelli F, Sreenivasan A, Cho HJ. Reducing Overuse of Proton Pump Inhibitors for Stress Ulcer Prophylaxis and Nonvariceal Gastrointestinal Bleeding in the Hospital: A Narrative Review and Implementation Guide. J Hosp Med 2021; 16:417-423. [PMID: 34197307 DOI: 10.12788/jhm.3637] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 04/13/2021] [Indexed: 11/20/2022]
Abstract
Proton pump inhibitors (PPIs) are among the most commonly used medications in the world; however, these drugs carry the risk of patient harm, including acute and chronic kidney disease, Clostridium difficile infection, hypomagnesemia, and fractures. In the hospital setting, PPIs are overused for stress ulcer prophylaxis and gastrointestinal bleeding, and PPI use often continues after discharge. Numerous multifaceted interventions have demonstrated safe and effective reduction of PPI use in the inpatient setting. This narrative review and the resulting implementation guide summarize published interventions to reduce inappropriate PPI use and provide a strategy for quality improvement teams.
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Affiliation(s)
- Karen Clarke
- Division of Hospital Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Nicole Adler
- Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Deepak Agrawal
- Division of Gastroenterology and Hepatology, Dell Seton Medical Center, Austin, TX
| | - Dimpal Bhakta
- Division of Gastroenterology, New York University School of Medicine, New York, New York
| | - Suchita Shah Sata
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Sarguni Singh
- Division of Hospital Medicine, University of Colorado, Aurora, Colorado
| | - Arjun Gupta
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amit Pahwa
- Division of General Internal Medicine, Division of General Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Emily Pherson
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland
| | - Alexander Sun
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Frank Volpicelli
- Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Aditya Sreenivasan
- Division of Gastroenterology, Long Island Jewish Medical Center, Manhasset, New York
| | - Hyung J Cho
- Division of Hospital Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- New York City Health and Hospitals, New York, New York
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9
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D'Silva KM, Mehta R, Mitchell M, Lee TC, Singhal V, Wilson MG, McDonald EG. Proton pump inhibitor use and risk for recurrent Clostridioides difficile infection: a systematic review and meta-analysis. Clin Microbiol Infect 2021; 27:S1198-743X(21)00035-5. [PMID: 33465501 DOI: 10.1016/j.cmi.2021.01.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/04/2021] [Accepted: 01/09/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Proton pump inhibitor (PPI) therapy is a potentially modifiable risk factor for recurrent Clostridioides difficile infection (CDI). Citing an absence of clinical trials, many guidelines do not provide recommendations for addressing PPI management. Our aim was to perform an updated systematic review and meta-analysis evaluating the association between PPI use and recurrent CDI addressing prior methodological limitations. METHODS Data sources were MEDLINE and EMBASE. Eligible studies were cohort and case-control studies; there were no restrictions on study setting or duration of follow-up. Participants were adults with prior CDI who did or did not receive PPI therapy and were assessed for recurrent CDI. Summary (unadjusted) odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random effects model. Prespecified subgroup analyses were performed to explore heterogeneity including study design, study quality, duration of follow-up, adjustment for confounders, and outcome definition. RESULTS Sixteen studies were included in the meta-analysis, comprising 57 477 patients with CDI, of whom 6870 (12%) received PPIs. The rate of recurrent CDI was 24% in patients treated with PPIs versus 18% in those who were not. A meta-analysis that pooled unadjusted odds ratios demonstrated higher odds of recurrent CDI in patients who received PPIs (OR 1.69, 95%CI 1.46-1.96) versus those who did not. There was moderate heterogeneity between studies (I2 56%); however, a sensitivity analysis restricted to studies with 56 days of follow-up substantially reduced the heterogeneity (OR 1.59, 95%CI 1.36-1.85; I2 12%). An analysis restricted to multivariate studies that combined adjusted ORs also demonstrated higher odds of recurrent CDI in patients who received PPIs (OR 1.49, 95%CI 1.12-2.00). No publication bias was identified. CONCLUSIONS We found significantly higher odds of recurrent CDI among users of PPIs that persisted across multiple sensitivity analyses. These results support stronger recommendations for PPI stewardship at CDI diagnosis.
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Affiliation(s)
- Kristin M D'Silva
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA
| | - Raaj Mehta
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA
| | - Michael Mitchell
- Division of Respirology, Department of Medicine, Western University, London, Ontario, Canada
| | - Todd C Lee
- Clinical Practice Assessment Unit, McGill University Health Centre, Montreal, Canada; Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Vibha Singhal
- Division of Pediatric Endocrinology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Emily G McDonald
- Clinical Practice Assessment Unit, McGill University Health Centre, Montreal, Canada; Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada.
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10
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Using a Systems Engineering Framework to Evaluate Proton Pump Inhibitor Prescribing in Critically Ill Patients. J Healthc Qual 2021; 42:e39-e49. [PMID: 31157697 DOI: 10.1097/jhq.0000000000000209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Proton pump inhibitors (PPIs) are a risk factor for hospital-acquired Clostridium difficile infection (CDI). Much PPI use is inappropriate, and interventions to reduce PPI use, such as for stress ulcer prophylaxis in all critically ill patients, are essential to reduce CDI rates. This mixed-methods study in a combined medical-surgical intensive care unit at a tertiary academic medical center used a human factors engineering approach to understand barriers and facilitators to optimizing PPI prescribing in these patients. We performed chart review of patients for whom PPIs were prescribed to evaluate prescribing practices. Semistructured provider interviews were conducted to determine barriers and facilitators to reducing unnecessary PPI use. Emergent themes from provider interviews were classified according to the Systems Engineering Initiative for Patient Safety model. In our intensive care unit, 25% of PPI days were not clinically indicated. Barriers to optimizing PPI prescribing included inadequate provider education, lack of institutional guidelines for stress ulcer prophylaxis, and strong institutional culture favoring PPI use. Potential facilitators included increased pharmacy oversight, provider education, and embedded decision support in the electronic medical record. Interventions addressing barriers noted by front line providers are needed to reduce unnecessary PPI use, and future studies should assess the impact of such interventions on CDI rates.
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11
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Singh-Franco D, Mastropietro DR, Metzner M, Dressler MD, Fares A, Johnson M, De La Rosa D, Wolowich WR. Impact of pharmacy-supported interventions on proportion of patients receiving non-indicated acid suppressive therapy upon discharge: A systematic review and meta-analysis. PLoS One 2020; 15:e0243134. [PMID: 33270710 PMCID: PMC7714117 DOI: 10.1371/journal.pone.0243134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 11/16/2020] [Indexed: 12/13/2022] Open
Abstract
Objective Conduct a systematic review and meta-analysis to estimate the impact of pharmacy-supported interventions on the proportion of patients discharged from the hospital on inappropriate acid suppressive therapy (AST). Methods To identify studies, the following databases were systematically searched on October 14th, 2018 and repeated on September 12th, 2019: Ovid MEDLINE(R) and In-Process & Other Non-Indexed Citations and Daily, Embase.com, CINAHL, Web of Science, Cochrane CENTRAL (EBSCO), and ClinicalTrials.gov. Eligible studies consisted of adults, intervention and historical/usual care groups, description of active pharmacy-supported intervention, and proportion of patients discharged on inappropriate AST. Qualitative assessments and quantitative analyses were performed. Modified funnel plot analysis assessed heterogeneity. Preferred reporting items of systematic reviews and meta-analyses (PRISMA) methodology was used to evaluate studies in this review. Results Seventeen publications resulting in 16 studies were included in the review. Using random effects model, meta-analysis showed a significant reduction in the odds of being discharged on inappropriate AST from the hospital in the pharmacist-supported intervention arm versus comparator (Odds Ratio 0.33 [95%CI 0.20 to 0.53]), with significant heterogeneity (I2 = 86%). Eleven studies favored pharmacy-supported interventions, four were inconclusive and one favored usual care. Using modified funnel plot analysis, our final evaluation was distilled to 11 studies and revealed a similar outcome (OR 0.36 [95%CI 0.27 to 0.48]), but with less heterogeneity (I2 = 36%). Conclusion This systematic review and meta-analysis showed that pharmacy-supported interventions were associated with a significantly reduced probability of patients discharged on inappropriate AST. However, heterogeneity was high and may affect interpretation of results. Using funnel plot optimization method, three positive and two negative studies were objectively removed from analyses, resulting in a similar effect size, but with less heterogeneity. To improve study quality, future researchers should consider utilizing a pre-post, multi-arm, prospective design with sampling randomization, training of data extractors (preferably two extractors), re-evaluating a small dataset to check for agreement and providing a comprehensive methodology in subsequent publications.
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Affiliation(s)
- Devada Singh-Franco
- Department of Pharmacy Practice, Nova Southeastern University, College of Pharmacy, Fort Lauderdale, Florida, United States of America
- * E-mail:
| | - David R. Mastropietro
- Department of Pharmaceutical Sciences, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - Miriam Metzner
- Department of Pharmacy Practice, Nova Southeastern University, College of Pharmacy, Fort Lauderdale, Florida, United States of America
| | - Michael D. Dressler
- Department of Pharmaceutical Sciences, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - Amneh Fares
- Department of Pharmacy Practice, Nova Southeastern University, College of Pharmacy, Fort Lauderdale, Florida, United States of America
| | - Melinda Johnson
- Martin and Gail Press Health Professions Division Library, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - Daisy De La Rosa
- Martin and Gail Press Health Professions Division Library, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - William R. Wolowich
- Department of Pharmacy Practice, Nova Southeastern University, College of Pharmacy, Fort Lauderdale, Florida, United States of America
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Coe AB, Vincent BM, Iwashyna TJ. Statin discontinuation and new antipsychotic use after an acute hospital stay vary by hospital. PLoS One 2020; 15:e0232707. [PMID: 32384108 PMCID: PMC7209203 DOI: 10.1371/journal.pone.0232707] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 04/20/2020] [Indexed: 11/29/2022] Open
Abstract
Introduction Patients are at risk for medication problems after hospital admissions, particularly those with critical illness. Medication problems include continuation of acute medications and discontinuation of chronic medications after discharge. Little is known across a national integrated health care system about the extent of these two medication problems. Objective To examine the extent of statin medication discontinuation and new antipsychotic medication use after hospital discharge. Design Retrospective cohort study. Setting Veterans Affairs healthcare system. Participants Veterans with an inpatient hospitalization from January 1, 2014-December 31, 2016, survived at least 180 days post-discharge, and received at least one medication through the VA outpatient pharmacy within one year around admission were included. Hospitalizations were grouped into: 1) direct admission to the intensive care unit (ICU) and a diagnosis of sepsis, 2) direct admission to the ICU without sepsis diagnosis, and 3) no ICU stay during the hospitalization. Main outcome measures Statin medication discontinuation and new antipsychotic use at six months post-hospital discharge. Results A total of 520,187 participants were included in the statin medication and 910,629 in the antipsychotic medication cohorts. Statin discontinuation ranged from 10–15% and new antipsychotic prescription fills from 2–4% across the three hospitalization groups, with highest rates in the ICU admission and sepsis diagnosis group. Statin discontinuation and new antipsychotic use after a hospitalization varied by hospital, with worse performing hospitals having 11% higher odds of discontinuing a statin (median odds ratio at hospital-level, adjusted for patient differences, aMOR: 1.11 (95% CI: 1.09, 1.13)) and 29% higher odds of new antipsychotic use (aMOR, 1.29 (95% CI: 1.24, 1.34)). Risk-adjusted hospital rates of these two medication changes were not correlated (p = 0.49). Conclusions Systemic variation in the rates of statin medication continuation and new antipsychotic use were found.
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Affiliation(s)
- Antoinette B. Coe
- Department of Clinical Pharmacy, College of Pharmacy and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, United States of America
- * E-mail:
| | - Brenda M. Vincent
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, United States of America
| | - Theodore J. Iwashyna
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, United States of America
- Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, United States of America
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13
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Willis T, Duff E. Optimizing Prescribing and Deprescribing of Proton Pump Inhibitors. J Nurse Pract 2020. [DOI: 10.1016/j.nurpra.2020.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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14
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Coe AB, Bookstaver RE, Fritschle AC, Kenes MT, MacTavish P, Mohammad RA, Simonelli RJ, Whitten JA, Stollings JL. Pharmacists' Perceptions on Their Role, Activities, Facilitators, and Barriers to Practicing in a Post-Intensive Care Recovery Clinic. Hosp Pharm 2020; 55:119-125. [PMID: 32214446 PMCID: PMC7081480 DOI: 10.1177/0018578718823740] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background: Complex medication regimen changes burden intensive care unit (ICU) survivors and their caregivers during the transition to home. Intensive care unit recovery clinics are a prime setting for pharmacists to address patients' and their caregivers' medication-related needs. The purpose of this study was to describe ICU recovery clinic pharmacists' activities, roles, and perceived barriers and facilitators to practicing in ICU recovery clinics across different institutions. Methods: An expert panel of ICU recovery clinic pharmacists completed a 15-item survey. Survey items addressed the pharmacists' years in practice, education and training, activities performed, their perceptions of facilitators and barriers to practicing in an ICU recovery clinic setting, and general ICU recovery clinic characteristics. Descriptive statistics were used. Results: Nine ICU recovery clinic pharmacists participated. The average number of years in practice was 16.5 years (SD = 13.5, range = 2-38). All pharmacists practiced in an interprofessional ICU recovery clinic affiliated with an academic medical center. Seven (78%) pharmacists always performed medication reconciliation and a comprehensive medication review in each patient visit. Need for medication education was the most prevalent item found in patient comprehensive medication reviews. The main facilitators for pharmacists' successful participation in an ICU recovery clinic were incorporation into clinic workflow, support from other health care providers, and adequate space to see patients. The ICU recovery clinic pharmacists perceived the top barriers to be lack of dedicated time and inadequate billing for services. Conclusions: The ICU recovery clinic pharmacists address ICU survivors' medication needs by providing direct patient care in the clinic. Strategies to mitigate pharmacists' barriers to practicing in ICU recovery clinics, such as lack of dedicated time and adequate billing for pharmacist services, warrant a multifaceted solution, potentially including advocacy and policy work by national pharmacy professional organizations.
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Affiliation(s)
- Antoinette B. Coe
- University of Michigan College of Pharmacy, Ann Arbor MI, USA,Antoinette B. Coe, PharmD, PhD, Department of Clinical Pharmacy, College of Pharmacy, University of Michigan College of Pharmacy, 428 Church Street, Ann Arbor, MI 48109, USA.
| | | | | | | | | | - Rima A. Mohammad
- University of Michigan College of Pharmacy, Ann Arbor MI, USA,Michigan Medicine, Ann Arbor, MI, USA
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15
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Abstract
GOAL The goal of this study was to reduce the percentage of inappropriately prescribed proton pump inhibitors (PPIs) in patients aged 50 and older from 80% (baseline) to 60% within 12 months in an academic, internal medicine clinic. BACKGROUND The use of PPIs has increased drastically worldwide. Internal medicine clinic patients had inappropriate use of PPIs for an average of 4 to 5 years. STUDY A multidisciplinary quality improvement team used the Plan-Do-Study-Act Model of health care improvement and performed a root cause analysis to identify barriers to inappropriate use of PPIs. The outcome measure was the percentage of patients inappropriately prescribed PPI. Process measures were completion rates of PPI risk assessment and esophagogastroduodenoscopy. Interventions included the creation of customized electronic health record templates and education to providers and patients. Analysis was performed using monthly statistical process control charts. RESULTS The average rate of PPI discontinuation was 51.1% (n=92/180), which corresponds to 30.0% inappropriate PPI usage within 12 months. The mean PPI discontinuation rate in the 1-year prestudy, study and 6 months poststudy period was 2.0%, 32.0%, and 49.7%, respectively. The mean esophagogastroduodenoscopy completion rate was 49.8% from the baseline of <30%. CONCLUSIONS We achieved a statistically significant and sustainable reduction of inappropriate PPI use to 30% from the baseline rates of 80% and surpassed our goal within 12 months. This quality improvement was unique as no pharmacy personnel was utilized in this process. The multifaceted strategies in a safety-net internal medicine clinic resulted in successful deprescribing of PPI and can be replicated in other setting.
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16
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Appaneal HJ, Caffrey AR, Beganovic M, Avramovic S, LaPlante KL. Predictors of Clostridioides difficile recurrence across a national cohort of veterans in outpatient, acute, and long-term care settings. Am J Health Syst Pharm 2019; 76:581-590. [PMID: 31361830 DOI: 10.1093/ajhp/zxz032] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE The greatest challenge in treating Clostridioides difficile infection (CDI) is disease recurrence, which occurs in about 20% of patients, usually within 30 days of treatment cessation. We sought to identify independent predictors of first recurrence among a national cohort of veterans with CDI. METHODS We conducted a case-control study among acute and long-term care Veterans Affairs (VA) inpatients and outpatients with a first CDI episode (positive stool sample for C. difficile toxin[s] and receipt of at least 2 days of CDI treatment) between 2010 and 2014. Cases experienced first recurrence within 30 days from the end of treatment. Controls were those without first recurrence matched 4:1 to cases on year, facility, and severity. Multivariable conditional logistic regression was used to identify predictors of first recurrence. RESULTS We identified 32 predictors of first recurrence among 974 cases and 3,896 matched controls. Significant predictors included medication use prior to (probiotics, fluoroquinolones, laxatives, third- or fourth-generation cephalosporins), during (first- or second-generation cephalosporins, penicillin/amoxicillin/ampicillin, third- and fourth-generation cephalosporins), and after CDI treatment (probiotics, any antibiotic, proton pump inhibitors [PPIs], and immunosuppressants). Other predictors included current biliary tract disease, malaise/fatigue, cellulitis/abscess, solid organ cancer, medical history of HIV, multiple myeloma, abdominal pain, and ulcerative colitis. CONCLUSION In a large national cohort of outpatient and acute and long-term care inpatients, treatment with certain antibiotics, PPIs, immunosuppressants, and underlying disease were among the most important risk factors for first CDI recurrence.
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Affiliation(s)
- Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, and College of Pharmacy, University of Rhode Island, Kingston, RI
| | - Aisling R Caffrey
- Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, and College of Pharmacy, University of Rhode Island, Kingston, RI
| | - Maya Beganovic
- Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, and College of Pharmacy, University of Rhode Island, Kingston, RI
| | - Sanja Avramovic
- Health Administration and Policy, George Mason University, Fairfax, VA
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, and College of Pharmacy, University of Rhode Island, Kingston, RI
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McDonald EG, Wu PE, Rashidi B, Forster AJ, Huang A, Pilote L, Papillon‐Ferland L, Bonnici A, Tamblyn R, Whitty R, Porter S, Battu K, Downar J, Lee TC. The MedSafer Study: A Controlled Trial of an Electronic Decision Support Tool for Deprescribing in Acute Care. J Am Geriatr Soc 2019; 67:1843-1850. [DOI: 10.1111/jgs.16040] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/02/2019] [Accepted: 05/06/2019] [Indexed: 01/21/2023]
Affiliation(s)
- Emily G. McDonald
- Division of General Internal Medicine, Department of Medicine McGill University Montréal Québec Canada
- Clinical Practice Assessment Unit McGill University Health Centre Montréal Québec Canada
| | - Peter E. Wu
- Division of General Internal Medicine, Department of Medicine University of Toronto Toronto Ontario Canada
| | - Babak Rashidi
- Division of General Internal Medicine, Department of Medicine University of Ottawa Ottawa Ontario Canada
| | - Alan J. Forster
- Division of General Internal Medicine, Department of Medicine University of Ottawa Ottawa Ontario Canada
| | - Allen Huang
- Division of Geriatric Medicine, Department of Medicine University of Ottawa Ottawa Ontario Canada
| | - Louise Pilote
- Division of General Internal Medicine, Department of Medicine McGill University Montréal Québec Canada
| | | | - André Bonnici
- Department of Pharmacy McGill University Health Centre Montréal Québec Canada
| | - Robyn Tamblyn
- Department of Epidemiology, Biostatistics and Occupational Health McGill University Montréal Québec Canada
| | - Rachel Whitty
- Leslie L. Dan Faculty of Pharmacy University of Toronto Toronto Ontario Canada
| | - Sandra Porter
- Leslie L. Dan Faculty of Pharmacy University of Toronto Toronto Ontario Canada
| | - Kiran Battu
- Leslie L. Dan Faculty of Pharmacy University of Toronto Toronto Ontario Canada
| | - James Downar
- Division of Palliative Care, Department of Medicine University of Ottawa Ottawa Ontario Canada
| | - Todd C. Lee
- Division of General Internal Medicine, Department of Medicine McGill University Montréal Québec Canada
- Clinical Practice Assessment Unit McGill University Health Centre Montréal Québec Canada
- Department of Epidemiology, Biostatistics and Occupational Health McGill University Montréal Québec Canada
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AlMutairi H, O'Dwyer M, McCarron M, McCallion P, Henman MC. The use of proton pump inhibitors among older adults with intellectual disability: A cross sectional observational study. Saudi Pharm J 2018; 26:1012-1021. [PMID: 30416357 PMCID: PMC6218847 DOI: 10.1016/j.jsps.2018.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 05/21/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Older people with Intellectual Disability (ID) have a high prevalence of gastrointestinal conditions such as Gastro-Oesophageal Reflux Disease (GORD). However, despite this, information about treatment, in particular the use of Proton Pump Inhibitors (PPIs), in this population is sparse and limited. OBJECTIVE To investigate the prevalence and pattern of PPI use among older people with ID. METHOD Data on PPI use and key demographics was analysed from Wave 2 (2013/2014) of IDS-TILDA, a nationally representative longitudinal study of 677 participants aged 40 years and above in Ireland. Descriptive statistics, bivariate analyses and binary logistic regression were carried out. RESULTS Just over a quarter, 27.9% (n = 189), of participants reported use of PPIs, and 53.4% (n = 101) were female. The largest proportion of PPI users (53.4%) were aged between 50 and 64 yrs. Most of the PPIs were used in maximum doses (66.7%). However only 43.9% of PPI users had an indication for PPI use (GORD, stomach ulcer or/and an NSAID use), and further 13.2% were also taking an antiplatelet agent. Use among those in residential care homes (54.3%) was much higher than for those living independently or with family (7%). PPI use among those who have severe/profound ID was 25% higher than those with mild ID. Information about the length of PPI use was missing for 31.2%, but of those with data, just over half recorded using the PPIs for more than a year. Apart from an indication, the factors associated with PPI use were older ages (≥50 years), severe/profound level of ID. CONCLUSION PPI use among older people with intellectual disability is prevalent and frequently long term, often without a clear indication. PPI use especially among those with severe/profound ID and those who live in residential care homes, could predispose these individuals to additional comorbidities and in order to avoid inappropriate long term of use regular review is required.
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Affiliation(s)
- Hadiah AlMutairi
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - Máire O'Dwyer
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - Mary McCarron
- Faculty of Health Sciences, Trinity College Dublin, Dublin, Ireland
| | | | - Martin C. Henman
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
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A Multifaceted Intervention to Reduce Pediatric Acid-Suppressant Prescriptions for Gastroesophageal Reflux: What Have We Learned? J Pediatr Gastroenterol Nutr 2018; 67:605-609. [PMID: 29901547 DOI: 10.1097/mpg.0000000000002054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Acid-suppressant prescriptions for children have increased over past decades, despite guideline recommendations to prescribe prudently. Acid suppressants are often ineffective and may lead to side effects. We aimed to reduce inappropriate acid-suppressant prescriptions for gastroesophageal reflux in a tertiary care setting through active implementation of national guideline recommendations and to evaluate intervention effect. METHODS Implementation consisted of 2 steps. First, all pediatric clinicians in an academic hospital received information on appropriate acid-suppressant prescribing, a link to an online national guideline application and summary card with important evidence-based recommendations-Wise Choices. Hereafter, clinicians prescribing acid suppressants were contacted to provide feedback on indications and to assess their knowledge of the guideline and Wise Choices. The pharmacy database supplied prescription data before, during, and after this intervention. RESULTS During the study period prescriptions ranged from 115 to 201/month. Ten months postintervention, a nonsignificant decrease of 4 prescriptions/month was measured (95% confidence interval -49-41). Of the 78 prescribers 76 were successfully contacted: 63% were familiar with the guideline and 45% with Wise Choices. Thirty percent of prescriptions were for gastroesophageal reflux symptoms. CONCLUSION This multifaceted implementation strategy did not lead to a significant difference in acid-suppressant prescriptions by tertiary care clinicians of whom the majority was familiar with the gastroesophageal reflux disease guideline. Future studies should clarify, which implementation strategies are most effective in reducing inappropriate prescribing of acid suppressants for children. Uniform registration of prescriptions and indications in a national database will enable monitoring of the intervention effect.
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Wan A, Halpape K, Talkhi SC, Dixon C, Dossa H, Tabamo J, Roberts M, Dahri K. Evaluation of Prescribing Appropriateness and Initiatives to Improve Prescribing of Proton Pump Inhibitors at Vancouver General Hospital. Can J Hosp Pharm 2018; 71:308-315. [PMID: 30401997 PMCID: PMC6209498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) have proven clinical efficacy for a variety of indications. However, there is emerging evidence of adverse events associated with their long-term use. The emergence of these adverse events has reinforced the need to regularly evaluate the appropriateness of continuing PPI therapy, and to use only the lowest effective dose for the minimally indicated duration. OBJECTIVES To characterize the appropriateness of PPI orders continued or initiated in the internal medicine and family practice units of Vancouver General Hospital, to detect adverse events associated with PPI use, and to explore the impact of multidisciplinary teaching and provision of educational resources on health care practitioners' views about PPI use. METHODS A chart review was conducted for patients admitted (for at least 24 hours) between January 1 and December 31, 2015, for whom a hospital formulary PPI was prescribed. An educational initiative, which included interprofessional in-service sessions, a PPI prescribing infographic, a PPI prescribing card, and a patient counselling sheet, was implemented. The impact of these interventions was assessed using a qualitative survey of health care practitioners. RESULTS Of the 258 patients whose charts were reviewed, 175 had a PPI prescription before hospital admission, and 83 were initiated on PPI therapy during their hospital stay. Overall, 94 (36%) of the patients were receiving PPIs without an appropriate indication. Community-acquired pneumonia and Clostridium difficile infections were the most common adverse events potentially associated with PPI use. In-service sessions and educational resources on PPI prescribing were reported to affect the clinical practice of 24 (52%) of the 46 survey respondents. CONCLUSIONS The results of this study emphasize the need for ongoing re-evaluation of long-term PPI therapy at the time of admission, during the hospital stay, and upon discharge. Implementing multidisciplinary teaching and providing educational resources may encourage more appropriate prescribing.
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Affiliation(s)
- Andrea Wan
- , BSc(Pharm), ACPR, is with the Department of Pharmacy, St Paul's Hospital, Vancouver, British Columbia
| | - Katelyn Halpape
- , BSc(Pharm), ACPR, PharmD, is with the Department of Pharmacy, Vancouver General Hospital, Vancouver, British Columbia
| | - Shirin C Talkhi
- , BSc(Pharm), was, at the time of this study, an undergraduate student in the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Claire Dixon
- , BSc(Pharm), was, at the time of this study, an undergraduate student in the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Hafeez Dossa
- , BSc(Pharm), was, at the time of this study, an undergraduate student in the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Jenifer Tabamo
- , RN, is with the Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia
| | - Mark Roberts
- , MD, is with the Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia
| | - Karen Dahri
- , BSc, BSc(Pharm), ACPR, PharmD, is with the Faculty of Pharmaceutical Sciences, The University of British Columbia, and the Department of Pharmacy Vancouver General Hospital, Vancouver, British Columbia
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21
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Proton pump inhibitor use as a risk factor for Enterobacteriaceal infection: a case-control study. J Hosp Infect 2018; 100:60-64. [PMID: 29864485 DOI: 10.1016/j.jhin.2018.05.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 05/30/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Gastric acid suppressants increase the risk of gastroenteritis by allowing ingested pathogens to survive passage through the stomach. It is not known whether the same mechanism affects transmission of Enterobacteriaceae. A case-control study was undertaken to answer this question. AIM To determine whether use of proton pump inhibitors (PPIs) increases the risk of infection with Enterobacteriaceae in hospital patients. METHODS Retrospective case-control study in a teaching hospital in South West England. Cases were 126 patients infected with extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae between April 2014 and March 2015. Use of PPIs, H2 receptor antagonists or antacids at the time of admission or in the preceding six months was compared with 126 demographically matched controls infected with non-ESBL-producing Enterobacteriaceae and 126 uninfected controls, matched by primary diagnosis. FINDINGS Sixty-six of 126 ESBL cases, 62 of 126 non-ESBL controls and 34 of 126 uninfected controls were prescribed PPIs on or within six months of admission. Multi-variable logistic regression analysis gave an odds ratio of 3.37 [95% confidence interval (CI) 1.84-6.18] for PPI exposure vs uninfected controls and 1.15 (95% CI 0.68-1.95) for ESBL infection vs non-ESBL infection. H2 receptor antagonists and antacids were not significantly associated with infection. CONCLUSION PPI exposure within the previous six months is significantly associated with infection with both ESBL- and non-ESBL-producing bacteria. Reducing inappropriate use of PPIs may be a novel way to reduce transmission, which might reduce antibiotic use and help control antimicrobial resistance.
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Del Giorno R, Ceschi A, Pironi M, Zasa A, Greco A, Gabutti L. Multifaceted intervention to curb in-hospital over-prescription of proton pump inhibitors: A longitudinal multicenter quasi-experimental before-and-after study. Eur J Intern Med 2018; 50:52-59. [PMID: 29274884 DOI: 10.1016/j.ejim.2017.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 11/03/2017] [Accepted: 11/06/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are indicated for a restricted number of clinical conditions, and their misuse can lead to several adverse effects. Despite that, the proportion of overuse is alarmingly high. OBJECTIVE To test the efficacy of a multifaceted strategy in order to achieve a significant reduction of new PPI prescriptions at discharge in hospitalized patients. DESIGN Multicenter longitudinal quasi-experimental before-and-after study conducted from July 1st, 2014 to June 30th, 2017. PARTICIPANTS 44,973 admissions in a network of 5 public teaching hospitals of the Italian-speaking region of Switzerland. INTERVENTION Multifaceted strategy consisting in a continuous transparent monitoring-benchmarking and in capillary educational interventions applied in the internal medicine departments. To confirm the causality of the results we monitored the trend of new PPI prescriptions in the, not exposed to the intervention, surgery departments of the same hospital network. MAIN MEASURES New PPI prescriptions at hospital discharge. KEY RESULTS Over the 36month study period 44,973 patient files were analyzed. At admission, comparing internal medicine vs. surgery departments, 44.9% vs. 23.3% of patients were already being treated with a PPI. The annual rate of new PPI prescriptions, for internal medicine showed a decreasing trend: 19, 19, 18, 16% in years 2014, 2015, 2016, 2017, respectively (p<0.001, 2014 vs. 2017; p-for-trend <0.001), while an increasing rate was found in the surgery departments in the same years: 30, 29, 36, 36%, respectively (p<0.001, 2014 vs. 2017; p-for-trend <0.001). The case mix was significantly associated with the probability of new PPI prescriptions in both departments (OR1.35, 95% CI 1.26-1.44 for internal medicine and 1.24, 95% CI 1.19-1.30 for surgery). CONCLUSIONS The introduction of a multifaceted intervention significantly reduced the time trend of PPI prescriptions at hospital discharge in internal medicine departments. Further studies are needed to confirm whether the strategy proposed could contribute to optimize the in-hospital drug prescription behavior in other healthcare settings as well.
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Affiliation(s)
- Rosaria Del Giorno
- Department of Internal Medicine and Nephrology, Regional Hospital of Bellinzona and Valli, Bellinzona, Switzerland.
| | - Alessandro Ceschi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland; Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland.
| | - Michela Pironi
- Central Pharmacy Service, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland.
| | - Anna Zasa
- Quality and Patient Safety Service, La Carità Hospital, Locarno, Switzerland
| | - Angela Greco
- Quality and Patient Safety Service, La Carità Hospital, Locarno, Switzerland.
| | - Luca Gabutti
- Department of Internal Medicine and Nephrology, Regional Hospital of Bellinzona and Valli, Bellinzona, Switzerland; Institute of Biomedicine, University of Southern Switzerland, Lugano, Switzerland.
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Appropriate Use of Proton Pump Inhibitors: A Double-Edged Sword. Am J Med 2018; 131:218-219. [PMID: 29157650 DOI: 10.1016/j.amjmed.2017.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 11/08/2017] [Indexed: 11/22/2022]
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24
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Wilson MG, Lee TC, Hass A, Tannenbaum C, McDonald EG. EMPOWERing Hospitalized Older Adults to Deprescribe Sedative Hypnotics: A Pilot Study. J Am Geriatr Soc 2018; 66:1186-1189. [DOI: 10.1111/jgs.15300] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - Todd C. Lee
- Department of Medicine; McGill University; Montréal Quebec Canada
- Clinical Practice Assessment Unit; McGill University Health Centre; Montréal Quebec Canada
| | - Aaron Hass
- Clinical Practice Assessment Unit; McGill University Health Centre; Montréal Quebec Canada
| | - Cara Tannenbaum
- Division of Geriatrics, Department of Medicine; Université de Montréal; Montréal Quebec Canada
| | - Emily G. McDonald
- Department of Medicine; McGill University; Montréal Quebec Canada
- Clinical Practice Assessment Unit; McGill University Health Centre; Montréal Quebec Canada
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25
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Stollings JL, Bloom SL, Wang L, Ely EW, Jackson JC, Sevin CM. Critical Care Pharmacists and Medication Management in an ICU Recovery Center. Ann Pharmacother 2018; 52:713-723. [PMID: 29457491 DOI: 10.1177/1060028018759343] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Many patients experience complications following critical illness; these are now widely referred to as post-intensive care syndrome (PICS). An interprofessional intensive care unit (ICU) recovery center (ICU-RC), also known as a PICS clinic, is one potential approach to promoting patient and family recovery following critical illness. OBJECTIVES To describe the role of an ICU-RC critical care pharmacist in identifying and treating medication-related problems among ICU survivors. METHODS A prospective, observational cohort study was conducted of all outpatient appointments of a tertiary care hospital's ICU-RC between July 2012 and December 2015. The pharmacist completed a full medication review, including medication reconciliation, interview, counseling, and resultant interventions, during the ICU-RC appointment. RESULTS Data from all completed ICU-RC visits were analyzed (n = 62). A full medication review was performed in 56 (90%) of these patients by the pharmacist. The median number of pharmacy interventions per patient was 4 (interquartile range = 2, 5). All 56 patients had at least 1 pharmacy intervention; 22 (39%) patients had medication(s) stopped at the clinic appointment, and 18 (32%) patients had new medication(s) started. The pharmacist identified 9 (16%) patients who had an adverse drug event (ADE); 18 (32%) patients had ADE preventive measures instituted. An influenza vaccination was administered to 13 (23%) patients despite an inpatient protocol to ensure influenza vaccination prior to discharge. A pneumococcal vaccination was administered to 2 (4%) patients. CONCLUSIONS Use of a critical care pharmacist resulted in the identification and treatment of multiple medication-related problems in an ICU-RC as well as implementation of preventive measures.
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Affiliation(s)
| | - Sarah L Bloom
- 1 Vanderbilt University Medical Center, Nashville, TN, USA
| | - Li Wang
- 1 Vanderbilt University Medical Center, Nashville, TN, USA
| | - E Wesley Ely
- 1 Vanderbilt University Medical Center, Nashville, TN, USA.,2 Department of Veterans Affairs Medical Center Tennessee Valley Healthcare System, Nashville, TN, USA
| | - James C Jackson
- 2 Department of Veterans Affairs Medical Center Tennessee Valley Healthcare System, Nashville, TN, USA.,3 Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Carla M Sevin
- 1 Vanderbilt University Medical Center, Nashville, TN, USA
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26
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Wahking RA, Steele RL, Hanners RE, Lockwood SM, Davis KW. Outcomes From a Pharmacist - led Proton Pump Inhibitor Stewardship Program at a Single Institution. Hosp Pharm 2017; 53:59-67. [PMID: 29434389 DOI: 10.1177/0018578717747192] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
| | - Randal L Steele
- Lexington Veterans Affairs Medical Center, Lexington, KY, USA
| | | | - Sean M Lockwood
- Lexington Veterans Affairs Medical Center, Lexington, KY, USA.,University of Kentucky College of Medicine, Lexington, KY, USA
| | - Kelly W Davis
- Lexington Veterans Affairs Medical Center, Lexington, KY, USA
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Naunton M, Peterson GM, Deeks LS, Young H, Kosari S. We have had a gutful: The need for deprescribing proton pump inhibitors. J Clin Pharm Ther 2017; 43:65-72. [PMID: 28895169 DOI: 10.1111/jcpt.12613] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 08/03/2017] [Indexed: 12/14/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE 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. METHODS 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. RESULTS AND DISCUSSION 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. WHAT IS NEW AND CONCLUSION 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.
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Affiliation(s)
- M Naunton
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Canberra, ACT, Australia
| | - G M Peterson
- University of Tasmania, Faculty of Health, University of Tasmania, Hobart, Tas., Australia
| | - L S Deeks
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Canberra, ACT, Australia
| | - H Young
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Canberra, ACT, Australia
| | - S Kosari
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Canberra, ACT, Australia
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28
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Davis KW, Hanners RE, Lockwood SM. Implementation of a proton pump inhibitor stewardship program. Am J Health Syst Pharm 2017; 74:932-937. [DOI: 10.2146/ajhp160670] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Kelly W. Davis
- Lexington Veterans Affairs Medical Center, Lexington, KY
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29
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McDonald EG, Saleh RR, Lee TC. Mindfulness-Based Laboratory Reduction: Reducing Utilization Through Trainee-Led Daily 'Time Outs'. Am J Med 2017; 130:e241-e244. [PMID: 28161348 DOI: 10.1016/j.amjmed.2017.01.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 01/05/2017] [Accepted: 01/06/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Overuse of laboratory investigations is widely prevalent in hospitalized patients, leads to discomfort, and increases direct and indirect costs. OBJECTIVE We implemented a simple, inexpensive, mindfulness strategy on our inpatient medical clinical teaching unit to reduce unnecessary laboratory orders through education, a forcing function, and daily structured laboratory "time outs." METHODS On a 26-bed unit in an academic hospital center, the per-period laboratory costs per patient were compared pre- and postintervention using segmented regression analysis of an interrupted time series. RESULTS The average cost per admitted patient decreased from $117 to $66, with an estimated savings of $50,657 over 985 admissions. After adjusting for fiscal period and the presence of our intervention, there was a significant reduction in the per-patient number of total tests, complete blood counts, and electrolyte panels performed (P <.001 for all level and time trend changes). CONCLUSION This trainee-designed and -led intervention, centered around structured, mindfulness-based laboratory test ordering, was successful at decreasing the overuse of common daily blood work in hospitalized patients.
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Affiliation(s)
- Emily G McDonald
- Department of Medicine, McGill University, Montreal, Quebec, Canada; Clinical Practice Assessment Unit, McGill University Health Centre, Montreal, Quebec, Canada.
| | - Ramy R Saleh
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Todd C Lee
- Department of Medicine, McGill University, Montreal, Quebec, Canada; Clinical Practice Assessment Unit, McGill University Health Centre, Montreal, Quebec, Canada
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Koronkowski MJ, Semla TP, Schmader KE, Hanlon JT. Recent Literature Update on Medication Risk in Older Adults, 2015-2016. J Am Geriatr Soc 2017; 65:1401-1405. [PMID: 28369729 DOI: 10.1111/jgs.14887] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Medications can pose considerable risk in older adults. This article annotates four articles addressing this concern from 2016. The first provides national data on the use of specific prescription, over-the-counter and dietary supplements in older adults and their change over time. The second discusses the opportunity of deprescribing ineffective/unnecessary stool softeners (i.e., docusate) routinely given to older hospital patients. The third national study examines common adverse drug events in older emergency room patients. Finally, a study published demonstrating a potential association between melatonin and fractures is discussed. This manuscript is intended to provide a narrative review of key publications in medication safety for clinicians and researchers committed to improving medication safety in older adults.
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Affiliation(s)
- Michael J Koronkowski
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois, Chicago, Illinois
| | - Todd P Semla
- Department of Veterans Affairs, Pharmacy Benefits Management Services, Hines, Illinois.,Departments of Medicine and Psychiatry & Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Kenneth E Schmader
- Department of Medicine, School of Medicine, Duke University Medical Center, Durham, North Carolina.,Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Joseph T Hanlon
- Department of Medicine (Geriatrics), School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania.,Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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31
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Lei ZB. Adverse reactions and rational use of proton pump inhibitors. Shijie Huaren Xiaohua Zazhi 2016; 24:3468-3475. [DOI: 10.11569/wcjd.v24.i23.3468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Proton pump inhibitors (PPIs) are a class of important drugs for treating acid related diseases, such as gastroesophageal reflux diseases (GERD), peptic ulcer, Zollinger-Ellison syndrome, and upper gastrointestinal bleeding. When combined with other drugs, PPIs can be used for the eradication of Helicobacter pylori. Short-term use of PPIs can cause allergic reactions, adverse reactions of the hematologic system, the digestive system and the nervous system and so on. Long-term use of PPIs can cause a series of new safety issues, such as increased risk of infection, vitamin B12 deficiency caused by the lack of nutrients, fractures, hypomagnesemia, occurrence or development of atrophic gastritis, interstitial nephritis, microscopic colitis, increased risk of serious skin allergy and so on. However, inappropriate use and off-label use of PPIs, and even abuse of PPIs are very common worldwide. Therefore, clinical rational use of PPIs should be emphasized among the relevant national administration departments, clinicians and pharmacists.
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Benmassaoud A, McDonald EG, Lee TC. Potential harms of proton pump inhibitor therapy: rare adverse effects of commonly used drugs. CMAJ 2015; 188:657-662. [PMID: 26598371 DOI: 10.1503/cmaj.150570] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Amine Benmassaoud
- Division of General Internal Medicine (Benmassaoud, McDonald, Lee), Department of Medicine, McGill University Health Centre; McGill Centre for Quality Improvement (McDonald, Lee), Montréal, Que
| | - Emily G McDonald
- Division of General Internal Medicine (Benmassaoud, McDonald, Lee), Department of Medicine, McGill University Health Centre; McGill Centre for Quality Improvement (McDonald, Lee), Montréal, Que
| | - Todd C Lee
- Division of General Internal Medicine (Benmassaoud, McDonald, Lee), Department of Medicine, McGill University Health Centre; McGill Centre for Quality Improvement (McDonald, Lee), Montréal, Que.
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