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Zhang J, Crossley B, Sun A, Palchaudhuri S, Pahwa A, O’Rourke P, Ahmed N, Pherson E. Multimodal Intervention Assessing the Appropriateness of Acid Suppression Therapy is Associated With Reduced Prescriptions at the Time of Discharge for Hospitalized Inpatients. Hosp Pharm 2023; 58:171-177. [PMID: 36890948 PMCID: PMC9986565 DOI: 10.1177/00185787221123212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Acid suppression therapy (AST), including proton pump inhibitors and histamine 2 receptor antagonists, are an overused class of medications. When used inappropriately, AST leads to polypharmacy, increased healthcare costs, and possible negative health consequences. Objective To assess whether an intervention including prescriber education combined with a pharmacist-driven protocol was effective in reducing the percentage of patients who were discharged with inappropriate AST. Methods This was a prospective pre-post study of adult patients who were prescribed AST before or during their admission to an internal medicine teaching service. All internal medicine resident physicians received education on appropriate AST prescribing. During the 4-week intervention period, dedicated pharmacists assessed the appropriateness of AST and made recommendations regarding deprescribing if no appropriate indication was identified. Results During the study period, there were 14 166 admissions during which patients were prescribed AST. Out of the 1143 admissions during the intervention period, appropriateness of AST was assessed by a pharmacist for 163 patients. AST was determined to be inappropriate for 52.8% (n = 86) of patients and discontinuation or de-escalate of therapy occurred in 79.1% (n = 68) of these cases. The percentage of patients discharged on AST decreased from 42.5% before the intervention to 39.9% after the intervention (P = .007). Conclusion This study suggests that a multimodal deprescribing intervention reduced prescriptions for AST without an appropriate indication at the time of discharge. To increase the efficiency of the pharmacist assessment several workflow improvements were identified. Further study is necessary to understand the long-term outcomes of this intervention.
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Affiliation(s)
- Jenny Zhang
- The Johns Hopkins Hospital, Baltimore,
MD, USA
| | | | | | | | - Amit Pahwa
- The Johns Hopkins Hospital, Baltimore,
MD, USA
| | - Paul O’Rourke
- Johns Hopkins Bayview Medical Center,
Baltimore, MD, USA
| | - Nazeer Ahmed
- Johns Hopkins Bayview Medical Center,
Baltimore, MD, USA
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Lazaridis LD, Rizos E, Bounou L, Theodorou-Kanakari A, Kalousios S, Mavroeidi EA, Roma M, Chatzidakis A, Vlachonicolou G, Miltiadou K, Gkolfakis P, Tziatzios G, Triantafyllou K. An educational intervention to optimize use of proton pump inhibitors in a Greek university hospital. Ann Gastroenterol 2021; 34:781-787. [PMID: 34815643 PMCID: PMC8596207 DOI: 10.20524/aog.2021.0654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/20/2021] [Indexed: 11/11/2022] Open
Abstract
Background Misuse of proton pump inhibitors (PPIs) is an alarming issue for patients and healthcare systems. Methods We conducted a 3-phase interventional, prospective study in a Greek university hospital. During Phase I, we collected data from patients' records to evaluate the appropriate use of PPIs. During Phase II, educational seminars about the proper use of PPIs were offered to the medical staff. In Phase III we collected data from the records of patients admitted to the hospital department with the highest rate of inappropriate PPI administration during Phase I, to evaluate the efficacy of the intervention. Inappropriate use was defined as either PPI administration without indication, or lack of use despite adequate indication. Appropriateness of PPI use was measured at admission, during hospitalization and at discharge. Results The rate of inappropriate PPI use was higher (51.7% and 48.6%) during hospitalization than at admission (34.9% and 21.9%), but at discharge was similar to pre-hospitalization levels (26.9% and 23.6%), in Phases I and III, respectively. At discharge during Phase I, the inappropriate use of PPIs was significantly higher (odds ratio 3.79, 95% confidence interval 1.98-7.19) for internal medicine patients than for surgical patients. The educational intervention failed to reduce the inappropriate use of PPIs during hospitalization (51.7% vs. 48.6%, P=0.478) or at discharge (26.9% vs. 23.6%, P=0.391) in the internal medicine patients. Conclusions The rate of inappropriate PPI use is almost double during hospitalization compared to the rates at admission and at discharge. Implementation of an educational intervention failed to reduce the inappropriate use of PPIs in internal medicine patients.
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Affiliation(s)
- Lazaros-Dimitrios Lazaridis
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Evripidis Rizos
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Lamprini Bounou
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Anna Theodorou-Kanakari
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Sotirios Kalousios
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Electra-Antonia Mavroeidi
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Maria Roma
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Alexandros Chatzidakis
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Georgia Vlachonicolou
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Konstantinos Miltiadou
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Paraskevas Gkolfakis
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Georgios Tziatzios
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
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Chen C, Liu H, Duan R, Wang F, Duan L. The efficacy and safety of acid suppressants for gastrointestinal bleeding prophylaxis in cardiac care unit patients. J Gastroenterol Hepatol 2021; 36:2131-2140. [PMID: 33586808 PMCID: PMC8451749 DOI: 10.1111/jgh.15432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/17/2020] [Accepted: 01/31/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIM Concerns regarding adverse events associated with proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) for gastrointestinal bleeding (GIB) prophylaxis in the intensive care unit have increased in recent years. Few studies have focused on acid suppressant use in the cardiac care unit (CCU) setting exclusively. We performed a cohort study to determine the efficacy and safety of acid suppressants for GIB prophylaxis in CCU patients. METHODS This retrospective cohort study included adults who were admitted directly to the CCU for more than 2 days from January 1, 2014, to April 30, 2019. The Crusade score was calculated to evaluate the risk of GIB. The primary outcomes were clinically important gastrointestinal bleeding (CIGIB), hospital-acquired pneumonia (HAP), and in-hospital mortality. RESULTS Of the 3318 patients enrolled, 2284 (68.8%) patients received PPIs, 515 (15.5%) received H2RAs, and 519 (15.7%) received no acid suppressants. After adjusting for potential confounders, utilization of PPIs (2.69, 95% confidence interval [0.62-11.73]) and H2RAs (1.41, 95% confidence interval [0.19-10.36]) were not associated with a lower risk of CIGIB than the control. Sensitivity analyses revealed that PPI use was an independent risk factor for in-hospital mortality in patients over 75 years old, with an adjusted odds ratio of 4.08 (1.14-14.63). PPIs increased the risk of HAP in patients over 75 years old and in those with heart failure, with adjusted odds ratios of 2.38 (1.06-5.34) and 2.88 (1.34-7.28), respectively. CONCLUSIONS Proton pump inhibitors and H2RAs for GIB prophylaxis in CCU patients were not associated with a lower risk of CIGIB than the controls. PPI therapy is associated with increased risks of HAP and in-hospital mortality in patients over 75 years old. PPIs may increase the risk of HAP in patients with heart failure.
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Affiliation(s)
- Chen Chen
- Department of GastroenterologyPeking University Third HospitalBeijingChina
| | - Hui Liu
- Department of Medical Informatics CenterPeking UniversityBeijingChina
| | - Ruqiao Duan
- Department of GastroenterologyPeking University Third HospitalBeijingChina
| | - Fangfang Wang
- Department of Cardiology and Institute of Vascular MedicinePeking University Third Hospital, NHC Key Laboratory of Cardiovascular Molecular Biology and Regulatory, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Peptides, Beijing Key Laboratory of Cardiovascular Receptors ResearchBeijingChina
| | - Liping Duan
- Department of GastroenterologyPeking University Third HospitalBeijingChina
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Augustsson H, Ingvarsson S, Nilsen P, von Thiele Schwarz U, Muli I, Dervish J, Hasson H. Determinants for the use and de-implementation of low-value care in health care: a scoping review. Implement Sci Commun 2021; 2:13. [PMID: 33541443 PMCID: PMC7860215 DOI: 10.1186/s43058-021-00110-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 01/14/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND A considerable proportion of interventions provided to patients lack evidence of their effectiveness. This implies that patients may receive ineffective, unnecessary or even harmful care. However, despite some empirical studies in the field, there has been no synthesis of determinants impacting the use of low-value care (LVC) and the process of de-implementing LVC. AIM The aim was to identify determinants influencing the use of LVC, as well as determinants for de-implementation of LVC practices in health care. METHODS A scoping review was performed based on the framework by Arksey and O'Malley. We searched four scientific databases, conducted snowball searches of relevant articles and hand searched the journal Implementation Science for peer-reviewed journal articles in English. Articles were included if they were empirical studies reporting on determinants for the use of LVC or de-implementation of LVC. The abstract review and the full-text review were conducted in duplicate and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data charting form and the determinants were inductively coded and categorised in an iterative process conducted by the project group. RESULTS In total, 101 citations were included in the review. Of these, 92 reported on determinants for the use of LVC and nine on determinants for de-implementation. The studies were conducted in a range of health care settings and investigated a variety of LVC practices with LVC medication prescriptions, imaging and screening procedures being the most common. The identified determinants for the use of LVC as well as for de-implementation of LVC practices broadly concerned: patients, professionals, outer context, inner context, process and evidence and LVC practice. The results were discussed in relation to the Consolidated Framework for Implementation Research. CONCLUSION The identified determinants largely overlap with existing implementation frameworks, although patient expectations and professionals' fear of malpractice appear to be more prominent determinants for the use and de-implementation of LVC. Thus, existing implementation determinant frameworks may require adaptation to be transferable to de-implementation. Strategies to reduce the use of LVC should specifically consider determinants for the use and de-implementation of LVC. REGISTRATION The review has not been registered.
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Affiliation(s)
- Hanna Augustsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
| | - Sara Ingvarsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
| | - Per Nilsen
- Department of Health, Medical and Caring Sciences, Division of Society and Health, Linköping University, Linköping, Sweden
| | - Ulrica von Thiele Schwarz
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
- School of Health, Care and Social Welfare, Mälardalen University, Box 883, 721 23 Västerås, Sweden
| | - Irene Muli
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
| | - Jessica Dervish
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
| | - Henna Hasson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
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Ingvarsson S, Augustsson H, Hasson H, Nilsen P, von Thiele Schwarz U, von Knorring M. Why do they do it? A grounded theory study of the use of low-value care among primary health care physicians. Implement Sci 2020; 15:93. [PMID: 33087154 PMCID: PMC7579796 DOI: 10.1186/s13012-020-01052-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/09/2020] [Indexed: 12/01/2022] Open
Abstract
Background The use of low-value care (LVC) is widespread and has an impact on both the use of resources and the quality of care. However, few studies have thus far studied the factors influencing the use of LVC from the perspective of the practitioners themselves. The aim of this study is to understand why physicians within primary care use LVC. Methods Six primary health care centers in the Stockholm Region were purposively selected. Focus group discussions were conducted with physicians (n = 31) working in the centers. The discussions were coded inductively using a grounded theory approach. Results Three main reasons for performing LVC were identified. Uncertainty and disagreement about what not to do was related to being unaware of the LVC status of a practice, guidelines perceived as conflicting, guidelines perceived to be irrelevant for the target patient population, or a lack of trust in the guidelines. Perceived pressure from others concerned patient pressure, pressure from other physicians, or pressure from the health care system. A desire to do something for the patients was associated with the fact that the visit in itself prompts action, symptoms to relieve, or that patients' emotions need to be reassured. The three reasons are interdependent. Uncertainty and disagreement about what not to do have made it more difficult to handle the pressure from others and to refrain from doing something for the patients. The pressure from others and the desire to do something for the patients enhanced the uncertainty and disagreement about what not to do. Furthermore, the pressure from others influenced the desire to do something for the patients. Conclusions Three reasons work together to explain primary care physicians’ use of LVC: uncertainty and disagreement about what not to do, perceived pressure from others, and the desire to do something for the patients. The reasons may, in turn, be influenced by the health care system, but the decision nevertheless seemed to be up to the individual physician. The findings suggest that the de-implementation of LVC needs to address the three reasons from a systems perspective.
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Affiliation(s)
- Sara Ingvarsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-171 77, Stockholm, Sweden.
| | - Hanna Augustsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-171 77, Stockholm, Sweden.,Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), SE-171 29, Stockholm, Stockholm Region, Sweden
| | - Henna Hasson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-171 77, Stockholm, Sweden.,Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), SE-171 29, Stockholm, Stockholm Region, Sweden
| | - Per Nilsen
- Department of Health, Medical and Caring Sciences, Linköping University, Linköping, Sweden
| | - Ulrica von Thiele Schwarz
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-171 77, Stockholm, Sweden.,School of Health, Care and Social Welfare, Mälardalen University, Box 883, 721 23, Västerås, Sweden
| | - Mia von Knorring
- Leadership in Healthcare and Academia Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-171 77, Stockholm, Sweden
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Dwivedi S, Edukulla J, Rajendra S, Murali S, Sorser SA, Piper MS, Piper M, Warren BJ, Ramchandani H. Educational intervention can improve appropriateness of acid suppression therapy in hospitalized geriatric patients. J Community Hosp Intern Med Perspect 2019; 9:5-8. [PMID: 30788067 PMCID: PMC6374937 DOI: 10.1080/20009666.2019.1571881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 01/08/2019] [Indexed: 11/20/2022] Open
Abstract
Background: Inappropriate use of acid suppression (AST) therapy may lead to unnecessary harms, especially in the geriatric population. Despite this, AST remains one of the most commonly prescribed medications in the hospital. Therefore, we aimed to assess its prevalence and create educational intervention to improve the appropriateness of inpatient acid suppression therapy. Methods: Using a time-series design, we established a historical control by performing a retrospective chart. Accepted indications for AST were based on those endorsed by the USA Food and Drug Administration and literature review. Inclusion criteria were: (1) age ≥ 65; (2) acid suppression therapy-initiated in the hospital; and (3) patients admitted to the medicine teaching services. We then created an educational intervention, which consisted of lectures and distribution of information pocket cards to residents. Data was collected for two months after the intervention. We used a two-tail fisher exact test and student’s t-test to analyze our results. Results: 65% of geriatric patients were inappropriately placed on acid suppression therapy, for which 13% were discharged without further indications. After the educational intervention, the inappropriate use of acid suppression therapy decreased to 45% (P < 0.05). Conclusion: There is a significant overuse of AST in hospitalized geriatric patients. Educational interventions are one potential method that may help improve the appropriateness of acid suppression therapy for elderly inpatients.
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Affiliation(s)
- Sankalp Dwivedi
- Department of Internal Medicine, St. Mary Mercy Hospital, Livonia, MI, USA.,Department of Gastroenterology, Providence - Providence Park Hospital, Michigan State University, Southfield, MI, USA
| | - Jaya Edukulla
- Department of Internal Medicine, St. Mary Mercy Hospital, Livonia, MI, USA
| | - Sindhu Rajendra
- Department of Internal Medicine, St. Mary Mercy Hospital, Livonia, MI, USA.,Department of Internal Medicine, Navicent Health Baldwin, Milledgeville, GA, USA
| | - Sandesh Murali
- Department of Internal Medicine, St. Mary Mercy Hospital, Livonia, MI, USA.,Department of Internal Medicine, Navicent Health Baldwin, Milledgeville, GA, USA
| | - Serge A Sorser
- Department of Gastroenterology, Providence - Providence Park Hospital, Michigan State University, Southfield, MI, USA
| | - Marc S Piper
- Department of Gastroenterology, Providence - Providence Park Hospital, Michigan State University, Southfield, MI, USA
| | - Michael Piper
- Department of Gastroenterology, Providence - Providence Park Hospital, Michigan State University, Southfield, MI, USA
| | - Bradley J Warren
- Department of Gastroenterology, Providence - Providence Park Hospital, Michigan State University, Southfield, MI, USA
| | - Harsha Ramchandani
- Department of Internal Medicine, St. Mary Mercy Hospital, Livonia, MI, USA.,Department of Internal Medicine, Tricity Health Center, Fremont, CA, USA
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Rodríguez-Poncelas A, Barceló MA, Saez M, Coll-de-Tuero G. Duration and dosing of Proton Pump Inhibitors associated with high incidence of chronic kidney disease in population-based cohort. PLoS One 2018; 13:e0204231. [PMID: 30332411 PMCID: PMC6192564 DOI: 10.1371/journal.pone.0204231] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 09/05/2018] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Proton Pump Inhibitors (PPIs) have been associated with chronic kidney disease (CKD). Our objective was to quantify the association between PPI use and incident CKD in a population-based cohort. METHODS AND FINDINGS We used a population-based retrospective cohort, including people aged 15 years or over, between January 1, 2005 and December 31, 2012. PPI use was measured in a follow-up session by recording prescriptions. Incident CKD was defined as an estimated glomerular filtration rate < 60 ml/ min/1.73 m2 and/or urinary albumin level to creatinine level ≥ 30 mg/g, in two or more determinations over a period of at least 3 months of the follow-up. Proton Pump Inhibitor use was associated with incident CKD in analysis adjusted for different clinical variables (Hazard Ratio (HR) 1.18; 95% CI 1.04-1.51) in individuals who used PPI in the basal visit (HR 1.37; 95% CI 1.25-1.50) and in those who started to use PPI during the follow-up. High doses of PPI increased the risk of incident CKD (HR 1.92; 95%CI 1.00-6.19) for any type of exposure to PPIs (HR 2.40; 95%CI 1.65-3.46) and for individuals who used high doses throughout the follow-up. This risk of incident CKD increased after three months' exposure to PPIs, (HR1.78; 95% CI 1.39-2.25) between the third and sixth months and (HR 1.30; 95%CI 1.07-1.72) after the sixth month. CONCLUSIONS PPI use is associated with a higher risk of incident CKD. This association is greater for high doses and becomes apparent after three months' exposure.
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Affiliation(s)
- Antonio Rodríguez-Poncelas
- Research Support Unit, University Institute of Research in Primary Care JordiGol (IdIAPGol), Girona, Spain
| | - Maria A. Barceló
- Research Group on Statistics, Econometrics and Health (GRECS), University of Girona, Girona, Spain
- CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Marc Saez
- Research Group on Statistics, Econometrics and Health (GRECS), University of Girona, Girona, Spain
- CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Gabriel Coll-de-Tuero
- Research Support Unit, University Institute of Research in Primary Care JordiGol (IdIAPGol), Girona, Spain
- CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Department of Medical Sciences, University of Girona, Girona, Spain
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