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

Multimodal Intervention Assessing the Appropriateness of Acid Suppression Therapy is Associated With Reduced Prescriptions at the Time of Discharge for Hospitalized Inpatients

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.

Randomised clinical trial: the use of alginates during preinvestigation proton pump inhibitor wash-out and their impact on compliance and symptom burden

BACKGROUND/AIMS

Investigation of gastro-oesophageal reflux disease is usually performed off proton pump inhibitors (PPIs). This can exacerbate symptoms, potentially impacting investigation accuracy if patients circumvent the preinvestigation instructions. There are no standard recommendations on how to manage PPI withdrawal. We aimed to assess the impact of structured alginate use on symptom burden.

METHODS

Participants were already established on ≥4 weeks of PPI therapy and being referred for manometry and 24-hour pH/impedance testing. Preinvestigation instructions involved stopping PPIs and H2 receptor antagonists for 1 week, but antacids and alginates were allowed until the night before. Participants were randomised to follow these standard instructions (control group), or the same instructions with the provision of Gaviscon Advance to be taken four times daily (treatment group). The primary outcome assessed change in Gastro-Oesophageal Reflux Disease Health-Related Quality of Life Score.

KEY RESULTS

Data for 48 patients were available for primary outcome assessment. While patients in the control group had a significant increase in symptoms (median difference 6.5, 95% CI (1 to 7), p=0.04), no change occurred in the treatment arm (median difference -1.5, 95% CI (-2, 3.5), p=0.54). There were no serious adverse events.

CONCLUSIONS

Structured alginate use prevents symptom exacerbation during preinvestigation PPI wash-out. These findings are limited to the 1-week wash-out period but can benefit thousands of patients undergoing investigation for gastro-oesophageal reflux each year. Further research is required to assess this effect in other settings, such as sustained PPI deprescription. The trial was funded by Reckitt Benckiser.

TRIAL REGISTRATION NUMBER

EudraCT registration 2019-004561-41.

Patients, Prescribers, and Institutional Factors Associated with Inappropriate Use of Acid Suppressive Therapy in Medical Wards: An Experience of a Single-Center in Saudi Arabia

PURPOSE

To identify factors associated with inappropriate acid-suppressive therapy (AST) use in hospitalized medical ward patients.

PATIENTS AND METHODS

This was a combined retrospective cohort study reviewing the electronic medical records of medical ward in a secondary university hospital between January 2018 and July 2019, in addition to prescriber surveys about AST knowledge. We included adult patients (≥18 years old) admitted to the medical ward who received at least one dose of AST during their hospitalization. Statistical analyses included descriptive statistics and logistic regression.

RESULTS

A total of 335 patients were included. Most of the patients were female (66.6%), with a mean age of 42.37 ± 17.72 years; 76% (n=256) of the study subjects were prescribed AST for an inappropriate indication. Patients who were not receiving any home medications associated with high bleeding risk had higher odds of being prescribed AST inappropriately (OR, 4.06; 95% CI, 1.09-13.8). A total of 27 physicians completed the prescriber survey, and the average prescriber's knowledge score was 46.8 ± 15.6%. This score did not differ by the prescriber's position.

CONCLUSION

This study demonstrated the overuse of AST in the medical ward. Therefore, improving providers' awareness about AST and implementing an AST stewardship program in institutions is necessary to limit this long-lasting issue.

Feasibility of a pharmacy-led intervention to de-implement non-guideline-concordant proton pump inhibitor use

Background

Proton pump inhibitors (PPIs) are among the most prescribed medications and are often used unnecessarily. PPIs are used for the treatment of heartburn and acid-related disorders. Emerging evidence indicates that PPIs are associated with serious adverse events, such as increased risk of Clostridioides difficile infection. In this study, we designed and piloted a PPI de-implementation intervention among hospitalized non-intensive care unit patients.

Methods

Using the Systems Engineering Initiative for Patient Safety (SEIPS) model as the framework, we developed an intervention with input from providers and patients. On a bi-weekly basis, a trainee pharmacist reviewed a random sample of eligible patients’ charts to assess if PPI prescriptions were guideline-concordant; a recommendation to de-implement non-guideline-concordant PPI therapy was sent when applicable. We used convergent parallel mixed-methods design to evaluate the feasibility and outcomes of the intervention.

Results

During the study period (September 2019 to August 2020), 2171 patients with an active PPI prescription were admitted. We randomly selected 155 patient charts for review. The mean age of patients was 70.9 ± 9 years, 97.4% were male, and 35% were on PPIs for ≥5 years. The average time (minutes) needed to complete the intervention was as follows: 5 to assess if the PPI was guideline-concordant, 5 to provide patient education, and 7 to follow-up with patients post-discharge. After intervention initiation, the week-to-week mean number of PPI prescriptions decreased by 0.5 (S<0.0001). Barriers and facilitators spanned the 5 elements of the SEIPS model and included factors such as providers’ perception that PPIs are low priority medications and patients’ willingness to make changes to their PPI therapy if needed, respectively. Ready access to pharmacists was another frequently reported facilitator to guideline-concordant PPI. Providers recommended a PPI de-implementation intervention that is specific and tells them exactly what they need to do with a PPI treatment.

Conclusion

In a busy inpatient setting, we developed a feasible way to assess PPI therapy, de-implement non-guideline-concordant PPI use, and provide follow-up to assess any unintended consequences. We documented barriers, facilitators, and provider recommendations that should be considered before implementing such an intervention on a large scale.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00161-6.

Opportunities for successful de-escalation of proton pump inhibitors at a federally qualified health center

Background

A Proton Pump Inhibitor (PPI) de-escalation initiative was piloted at a Family Medicine Federally Qualified Health Center (FQHC) after a needs assessment showed that PPIs were prescribed inappropriately. The objective was to evaluate implementation of a PPI de-escalation program for an urban, underinsured patient population at a (FQHC).

Methods

Patients receiving PPI with an upcoming appointment with their primary care provider (PCP) were evaluated by a pharmacist for the appropriateness of therapy. The pharmacist administered a questionnaire to patients to assess PPI usage patterns and then evaluated for appropriate PPI therapy which included diagnoses, risk factors for gastrointestinal bleed, symptom control, and duration of PPI therapy. For consenting patients, de-escalation was implemented per pharmacist protocol.

Results

A total of 36 patients were evaluated for appropriate PPI use, among those, 21 (58%) were eligible for de-escalation, and 19 agreed to de-escalation. Fifteen patients (15/19) had successful PPI de-escalation after 4 weeks without discomfort or symptoms which disrupted daily activities.

Conclusions

This pharmacist led initiative in collaboration with PCPs resulted in successful de-escalation of PPIs in an underserved primary care setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40360-021-00486-x.

Do the types and routes of proton pump inhibitor treatments affect clostridium difficile in ICU patients? A retrospective cohort study

Background: : Proton pump inhibitors (PPI) are associated with Clostridium difficile infection (CDI). Impact of the route of administration is unknown.Research Design and Methods: Patients in Multiparameter Intelligent Monitoring in Intensive Care II database (MIMIC-II) from 2001 to 2008, >18 years old, admitted to medical, surgical, or cardiac ICUs were included. PPI exposures were omeprazole, esomeprazole, lansoprazole, and pantoprazole. PPI administration routes were oral or intravenous. Patients who received histamine receptor antagonists (H2RA) were the control arm. CDI was identified using ICD-9 diagnostic code 008.45. Multiple logistic regression analysis was performed to calculate odds ratios (OR).Results: The study included 16,820 patients (57% male) with a mean age of 63 (SD±17) years and hospitalization duration of 10.2 days (SD±11). Pantoprazole was the most common PPI (94%). CDI occurred in 2.4% and more in patients receiving PPIs than H2RAs (3.0% vs. 0.8%, p < 0.001). CDI prevalence increased with intravenous (95%CI = 1.69-3.39, OR 2.4) and oral (95%CI = 1.59-3.27, OR 2.3) PPI use compared to H2RAs. CDI prevalence was not associated with PPI route in the multivariable model (OR 1.07, 95%CI 0.86-1.34).Conclusions: Both intravenous and oral PPI use in the ICU were independently associated with CDI.

“Get Me Off This Medication!”: A Comparison Between Gastroenterology and Primary Care Regarding Patient’s Perceptions of Proton Pump Inhibitor Therapy

Background

Not much is known about patient perceptions regarding proton pump inhibitor (PPI) de-escalation. We sought to determine the knowledge of adverse effects (AEs) and willingness to de-escalate therapy among patients presenting to primary care and subspecialty clinics.

Methods

We conducted an anonymous survey of patients presenting to family medicine, internal medicine, and gastroenterology clinics who use PPIs. Survey topics included awareness of and concern for AEs of PPIs, and willingness to de-escalate PPI therapy.

Results

The sample comprised 206 participants presenting to the gastroenterology (29.8%), internal medicine (32.2%), and family medicine clinics (38%). Of the participants, 16% were “extremely concerned” about AEs and 28.2% reported attempting to stop PPIs by themselves in the past. Many patients (54.9%) reported that providers had not discussed AEs before initiation. Patients visiting digestive disease clinics were no more likely to report discussions on AEs and de-escalation or discontinuation attempts compared to primary care patients (p-values > 0.05). On logistic regression analysis, concern for AEs and counseling regarding PPI discontinuation were found to be significantly associated with attempts to discontinue PPI.

Conclusions

Although many patients on PPIs are concerned about AEs, a low number of patients reported provider-initiated discussions on AEs of PPI at initiation.

Impact of interventions targeting the inappropriate use of proton-pump inhibitors by clinical pharmacists in a hepatobiliary surgery department

WHAT IS KNOWN AND OBJECTIVE

At present, studies on the usage of proton-pump inhibitors (PPIs) have universal significance. In clinical practice, PPIs are widely used to treat a variety of acid-related diseases, but they can be inappropriately prescribed, leading to increased medical costs and patient harm. The study comprehensively evaluated the clinical effects of a clinical pharmacist intervention on inappropriate PPI prescriptions in a tertiary general hospital hepatobiliary surgery ward.

METHODS

A retrospective, single-centre intervention study covering the periods of July-December 2018 and July-December 2019 was conducted. In the intervention group, clinical pharmaceutical care was initiated by a clinical pharmacist in the hepatobiliary surgery ward. Outcomes, including the clinical pattern of PPI utilization, the rate of inappropriate PPI use and safety outcomes, were compared between the two periods.

RESULTS AND DISCUSSION

In total, 1150 patients were admitted to the hepatobiliary surgery ward in our hospital in the study periods. Of these, 717 patients met the inclusion criteria for this study, and 420 and 297 patients were included in the preintervention and post-intervention groups, respectively. The PPI utilization rates before and after the intervention were 82.0% and 55.0%, respectively. The rates of inappropriate PPI use before and after the intervention were 48.9 and 22.7 per 100 patient-days, respectively. Clinical safety outcomes were nearly identical between before and after the intervention, but patients treated with PPIs were more likely to experience nosocomial pneumonia (2.4% vs. 0.6%).

WHAT IS NEW AND CONCLUSION

The implementation of a clinical pharmacist intervention for PPI use decreased inappropriate PPI use during hospitalization without sacrificing clinical safety outcomes.

Deprescribing in older people

Deprescribing is the process of discontinuing drugs that are either potentially harmful or no longer required. It can be achieved in older people and may be associated with improved health outcomes without long-term adverse effects. The risk of drug withdrawal effects can often be mitigated by carefully monitoring and gradually tapering the dose. Deprescribing should ideally be a shared decision-making process between the patient and the prescriber.

Guideline implementation is effective at reducing proton pump inhibitor use in hematology-oncology units: A multidisciplinary intervention for reducing Clostridioides difficile risk

We implemented a guideline for appropriate acid suppressant use in hematology-oncology patients. This intervention resulted in a sustained reduction in proton pump inhibitor (PPI) use without an increase in rates of gastrointestinal bleeding. Practice guidelines are effective in reducing PPI use, which is associated with risk of Clostridioides difficile infection.

Evaluation of a Pharmacist-Driven Protocol to Reduce Inappropriate Use of Acid-Suppressive Medications In the Non-ICU Setting

PURPOSE

Proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2 blockers) continue to be over utilized for stress ulcer prophylaxis (SUP). Our study aims to evaluate the effectiveness and feasibility of a pharmacist-driven termination protocol in a community teaching hospital to limit the inappropriate use of acid-suppressive medications in the non-intensive care unit (ICU) setting.

METHODS

Patient charts were evaluated for the appropriate use of PPIs or H2 blockers. A centralized pharmacist contacted healthcare providers for medication discontinuation if the acid suppressant use was deemed inappropriate. The primary outcome of the study was the number of patients who had acid-suppressive medication discontinued after the implementation of the pharmacist-driven termination protocol.

RESULTS

Acid-suppressive medication was inappropriately prescribed for nine patients. It was discontinued for eight of those patients based on the pharmacist-driven termination protocol; this was a statistically significant decrease (P < 0.001). The pharmacist spent, on average, less than one minute on each patient's chart.

CONCLUSION

Our study revealed that a pharmacist-driven termination protocol resulted in a 6% overall reduction rate in inappropriately used acid-suppressive medications, with little impact on pharmacist workflow. Implementing such a termination protocol could help to decrease the inappropriate use of acid-suppressive medications in an inpatient hospital service.