Patients' perspectives on a patient-oriented electronic decision support tool to reduce overuse of proton pump inhibitors (arriba-PPI): a qualitative study in primary care

Impact of pharmacist-evaluated clinical decision support system alerts on potentially missing or inappropriately prescribed proton pump inhibitors at hospital discharge: a retrospective cross-sectional study

BACKGROUND

Proton pump inhibitors (PPIs) are among the most prescribed drugs. A clinical decision support system (CDSS) could improve their rational use.

AIM

The impact of an electronic algorithm (e-algorithm) implemented in a CDSS on potentially missing or inappropriately prescribed PPIs at hospital discharge, its specificity and sensitivity, and the outcome of the alerts issued were analysed.

METHOD

An e-algorithm continuously monitored patients of a tertiary care hospital for missing or inappropriate PPIs. Following relevance assessment by a pharmacist, the alerts raised were either displayed in the patients' electronic record or dismissed. After a three-month period, all adult patients' records were retrospectively reviewed for missing or inappropriate PPIs at discharge. The results were compared with a corresponding period before CDSS introduction. Sensitivity, specificity and outcome of alerts were quantified.

RESULTS

In a 3-month period with 5018 patients, the CDSS created 158 alerts for missing PPIs and 464 alerts for inappropriate PPIs. PPI prescribing was proposed 81 times and PPI termination 122 times, with acceptance rates of 73% and 34%, respectively. A specificity of 99.4% and sensitivity of 92.0% for missing PPIs and a specificity of 97.1% and a sensitivity of 69.7% for inappropriate PPIs were calculated. The algorithm reduced incidents of missing PPIs by 63.4% (p < 0.001) and of inappropriate PPIs by 16.2% (p = 0.022).

CONCLUSION

The algorithm identified patients without necessary gastroprotection or inappropriate PPIs with high specificity and acceptable sensitivity. It positively impacted the rational use of PPIs by reducing incidents of missing and inappropriate PPIs.

Timely Cessation of Proton Pump Inhibitors in Critically Ill Patients Impacts Morbidity and Mortality: A Propensity Score-Matched Cohort Study

OBJECTIVE

Proton pump inhibitors (PPIs) are among the drugs most commonly used in critically ill patients. Although mainly applied temporarily for stress ulcer prophylaxis, their application is frequently not terminated. Potential adverse effects of PPI treatment could impact the outcome in case of unnecessary and, therefore, avoidable long-term continuation. We tested the hypotheses that nonindicated PPI therapy continued beyond hospital discharge is associated with increased morbidity, rehospitalization rate, and mortality.

DESIGN

Nationwide retrospective cohort study considering critically ill patients treated on German ICUs between January, 2017, and December, 2018 with a 2-year follow-up.

SETTING

A total of 591,207 patient datasets of a German healthcare insurer were screened.

PATIENTS

We identified 11,576 ICU patients who received PPI therapy for the first time during their index ICU stay without having an indication for its continuation.

INTERVENTIONS

The cohort was stratified into two groups: 1) patients without further PPI therapy and 2) patients with continuation of PPI therapy beyond 8 weeks after hospital discharge.

MEASUREMENTS AND MAIN RESULTS

Frequency of predescribed adverse events associated with PPI therapy, 1-year rehospitalization rate, and 2-year mortality were determined. The proportion of patients with continued PPI therapy without an objectifiable indication was 41.7% (4,825 of 11,576 patients). These patients had a 27% greater risk of pneumonia (odds ratio [OR] 1.27; 95% CI, 1.15-1.39; p < 0.001) and a 17% greater risk of cardiovascular events (OR 1.17; 95% CI, 1.08-1.26; p < 0.001). Continued PPI therapy was associated with a 34% greater risk of rehospitalization (OR 1.34; 95% CI, 1.23-1.47) and a nearly 20% greater 2-year mortality risk (hazard ratio 1.17; 95% CI, 1.08-1.27; p = 0.006).

CONCLUSIONS

These data demonstrate that an unnecessary continuation of PPI therapy after hospital discharge may significantly impact morbidity and mortality. To avoid potentially harmful overuse of a PPIs, intensivists should ensure timely cessation of a temporarily indicated PPI therapy.

Efficacy of a computer based discontinuation strategy to reduce PPI prescriptions: a multicenter cluster-randomized controlled trial

Deprescribing of inappropriate long-term proton pump inhibitors (PPI) is challenging and there is a lack of useful methods for general practitioners to tackle this. The objective of this randomized controlled trial was to evaluate the effectiveness of the electronic decision aid tool arriba-PPI on reduction of long-term PPI intake. Participants (64.5 ± 12.9 years; 54.4% women) with a PPI intake of at least 6 months were randomized to receive either consultation with arriba-PPI from their general practitioner (n = 1256) or treatment as usual (n = 1131). PPI prescriptions were monitored 6 months before, 6 and 12 months after study initiation. In 49.2% of the consultations with arriba-PPI, the general practitioners and their patients made the decision to reduce or discontinue PPI intake. At 6 months, there was a significant reduction by 22.3% (95% CI 18.55 to 25.98; p < 0.0001) of defined daily doses (DDD) of PPI. A reduction of 3.3% (95% CI - 7.18 to + 0.62) was observed in the control group. At 12 months, the reduction of DDD-PPI remained stable in intervention patients (+ 3.5%, 95% CI - 0.99 to + 8.03), whereas control patients showed a reduction of DDD-PPI (- 10.2%, 95% CI - 6.01 to - 14.33). Consultation with arriba-PPI led to reduced prescription rates of PPI in primary care practices. Arriba-PPI can be a helpful tool for general practitioners to start a conversation with their patients about risks of long-term PPI intake, reduction or deprescribing unnecessary PPI medication.