1
|
Fan X, Chen D, Bao S, Dong X, Fang F, Bai R, Zhang Y, Zhang X, Tang W, Ma Y, Zhai X. Prospective prescription review system correlated with more rational PPI medication use, better clinical outcomes and reduced PPI costs: experience from a retrospective cohort study. BMC Health Serv Res 2023; 23:1014. [PMID: 37730673 PMCID: PMC10512621 DOI: 10.1186/s12913-023-09931-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 08/16/2023] [Indexed: 09/22/2023] Open
Abstract
INTRODUCTION Proton pump inhibitor (PPI) abuse poses an overwhelming threat to the allocation of medical resources and places a heavy burden on global medical expenses. In this study, we put forward our prospective prescription review system and evaluated the effects of this system on clinical outcomes, rational medication use and costs related to PPIs. METHODS A retrospective cohort study was conducted in which the included patients were divided into a preintervention group (2019.10-2020.09) and a postintervention group (2020.10-2021.09). To reduce the bias of patients' baseline characteristics, the propensity score matching (PSM) method was employed. The primary endpoints were the incidence of stress ulcers (SUs), the improvement and cure rates of gastrointestinal haemorrhage, the defined daily dose (DDD), the drug utilization index (DUI) and the DDD/100 patient-days. The secondary endpoints included the types of unreasonable medication orders for PPIs, the PPI utilization rate and PPI costs. RESULTS A total of 53,870 patients were included to evaluate the secondary endpoints, and 46,922 patients were paired by PSM and assessed to evaluate the primary endpoints. The number of PPIs used and PPI costs were significantly lower in the postintervention group than in the preintervention group (P < 0.001). The rationality evaluation results showed that the frequency of PPI use and the number of drug interactions were significantly higher in the preintervention group than in the postintervention group (P < 0.01). The proportion of patients taking oral PPIs was significantly increased in the postintervention group (29.30% vs. 34.56%, p < 0.01). For the utilization of PPIs both for prevention and treatment, the DUI and DDD/100 patient-days were substantially decreased in the postintervention group (P < 0.001 and P < 0.05, respectively). The incidence of SUs in the postintervention group was 44.95%, and that in the preintervention group was 51.93% (p < 0.05). CONCLUSION The implementation of the prospective prescription review system on rational PPI use correlated with reduced PPI costs, more rational PPI medication use and better clinical outcomes, and this system is worthy of long-term implementation for further improvement of rational drug use.
Collapse
Affiliation(s)
- Xiucong Fan
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China
| | - Danxia Chen
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China
| | - Siwei Bao
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China
| | - Xiaohui Dong
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China
| | - Fang Fang
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China
| | - Rong Bai
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China
| | - Yuyi Zhang
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China
| | - Xiaogang Zhang
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China
| | - Weijun Tang
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China
| | - Yabin Ma
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China.
| | - Xiaobo Zhai
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China.
| |
Collapse
|
2
|
Bao J, Zhou L, Xu M, Ma J. The impact of pharmacist intervention on the intravenous-to-oral switch therapy of proton pump inhibitors in cardiovascular surgery. Expert Opin Drug Saf 2023; 22:611-619. [PMID: 36714924 DOI: 10.1080/14740338.2023.2172162] [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: 09/27/2022] [Accepted: 12/08/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND The prescriptions of proton pump inhibitors (PPIs) have been widely concerned due to both huge increase in medical costs and possible long-term adverse events (AEs) caused by the improper route of drug administration. The aim of this study was to assess the effectiveness of pharmacist interventions on the clinical outcome and safety of switching from intravenous (IV) to oral PPIs therapy. PATIENTS AND METHODS A retrospective, single-center, pre- intervention (early -stage)- and intervention (later -stage) study was performed in a Chinese hospital. RESULTS A total of 1736 patients were included in the study. After 12 months of interventions, significant improvements in the number of rational IV to oral switch in patients with oral switch indications were found. The median duration of oral therapy was increased, while the duration of PPIs therapy was decreased. Pharmacist interventions led to significant reductions in mean PPI costs, mean total drug costs, mean hospitalization costs, and the risk for long-term adverse events. CONCLUSION This study provides important evidence on the beneficial effect of pharmacist interventions on promoting an optimal IV to oral switch of PPIs and substantial cost saving by shortening the duration of IV PPIs therapy and reducing the risk for long-term AEs.
Collapse
Affiliation(s)
- Jianan Bao
- Department of Pharmacy, Medical Center of Soochow University, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, Jiangsu, China
| | - Ling Zhou
- Department of Pharmacy, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Mengying Xu
- Department of Pharmacy, Medical Center of Soochow University, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, Jiangsu, China
| | - Jingjing Ma
- Department of Pharmacy, Medical Center of Soochow University, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, Jiangsu, China
| |
Collapse
|
3
|
Dumlu HI, Sancar M, Ozdemir A, Okuyan B. Impact of a clinical pharmacist-led stewardship program for the appropriate use of acid suppression therapy in older hospitalized patients: a non-randomized controlled study. Int J Clin Pharm 2022; 44:914-921. [PMID: 35449351 DOI: 10.1007/s11096-022-01394-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 02/09/2022] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The potentially inappropriate use of the proton pump inhibitors is prevalent in older adults. AIM To evaluate the impact of a clinical pharmacist-led stewardship program for the appropriate use of acid suppression therapy in older hospitalized patients. METHOD This parallel nonrandomized controlled study was conducted at an internal medicine service of a tertiary training and research hospital between September 2019 and August 2021. Older patients (≥ 65 years old and received proton pump inhibitors within 48 h of admission) were allocated to two groups according to their number of medical file records, whether odd or even, two groups: control and clinical pharmacist-led stewardship program for the appropriate use of acid suppression therapy (including medication reconciliation and medication review) during the hospital stay. Primary outcome measures were the rate of appropriate use of proton pump inhibitors during hospitalization and potentially inappropriate proton pump inhibitor use at discharge. RESULTS The rate of appropriate proton pump inhibitor use during hospitalization was significantly higher in the clinical pharmacist-led program (n = 100) than in the control group (n = 97) (46.4% vs. 79.0%; P < 0.001). The rate of potentially inappropriate proton pump inhibitor use at discharge was significantly lower (61.7% vs. 35.1%; P < 0.05) in the clinical pharmacist-led program among the older patients discharged with a proton pump inhibitor prescription. CONCLUSION A clinical pharmacist-led stewardship program for the appropriate use of acid suppression therapy improved the rate of appropriate proton pump inhibitor use and reduced the potentially inappropriate proton pump inhibitor use during the hospital stay. TRIAL REGISTRATION NCT05113667 (17 October 2021-registered retrospectively).
Collapse
Affiliation(s)
- Hatice Ikra Dumlu
- Department of Clinical Pharmacy, Faculty of Pharmacy, Marmara University, Istanbul, Turkey
| | - Mesut Sancar
- Department of Clinical Pharmacy, Faculty of Pharmacy, Marmara University, Istanbul, Turkey
| | - Ali Ozdemir
- Department of Internal Medicine, Health Sciences University, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Betul Okuyan
- Department of Clinical Pharmacy, Faculty of Pharmacy, Marmara University, Istanbul, Turkey.
| |
Collapse
|
4
|
Chen Q, Wang Q, Zhang Y. Clinical Intervention Increases Rational Use of Proton Pump Inhibitors in the General Surgery Department. Front Pharmacol 2022; 13:864081. [PMID: 35548351 PMCID: PMC9083545 DOI: 10.3389/fphar.2022.864081] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/05/2022] [Indexed: 11/24/2022] Open
Abstract
This study aimed to evaluate the role of the clinical pharmacist in the rational use of proton pump inhibitors (PPIs) in a general surgery department. All enrolled patients had attended the general surgery department of a tertiary hospital. This single-center prospective study compared differences in the overall rate of rational PPI use, proportion of unindicated PPI use, utilization rate, average defined daily dose (DDD), drug costs, PPI costs, and cost-effectiveness of clinical pharmacist intervention between the intervention (538 cases) and control (536 cases) groups. In the intervention group, Pareto and fishbone diagram analyses were combined with the Plan-Do-Check-Act cycle; Statistical Package for the Social Sciences was used for analyzing all data. The overall rate of rational PPI use was significantly higher in the intervention group than in the control group (p < 0.01). The proportion of unindicated PPI use, utilization rate, average DDD, drug costs, and PPI costs were significantly lower in the intervention group than in the control group (p < 0.05). Cost-effectiveness analysis for the overall rate of rational PPI use indicated a positive impact of intervention, with economic benefits in the intervention group. Clinical pharmacist intervention for rational use of PPIs in general surgery departments could significantly increase the overall rate of rational PPI use; it could also reduce the proportion of unindicated PPI use, utilization rates, average DDDs, drug costs, and PPIs costs. Pharmacist intervention also offers economic benefits by improving the overall rate of rational PPI use.
Collapse
Affiliation(s)
- Qiying Chen
- Department of Pharmacy, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Qiaohong Wang
- Department of Pharmacy, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China.,Department of Pharmacy, QuanZhou Women's and Children's Hospital, Quanzhou, China
| | - Yin Zhang
- Department of Pharmacy, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| |
Collapse
|
5
|
Impact of proton pump inhibitor management committee's multifaceted interventions on acid suppressant prescribing patterns in outpatient and emergency departments. BMC Health Serv Res 2022; 22:417. [PMID: 35351121 PMCID: PMC8966235 DOI: 10.1186/s12913-022-07820-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 03/17/2022] [Indexed: 11/21/2022] Open
Abstract
Background A nationwide campaign for rational proton pump inhibitor (PPI) use launched in 2015 had a positive impact for hospitalized patients PPI use. But there were few studies focusing on the rational use of PPIs in outpatients. In 2018, the PPI management committee conducted a year-long intervention on the appropriate use of PPIs in outpatient and emergency departments, including clinical pharmacist interventions and stewardship interventions. The purpose of this study was to examine the impact of the PPI management committee’s multifaceted interventions by comparing the real-world acid suppressant prescribing patterns for outpatients before (2017) and after intervention (2019) at a Chinese tertiary teaching hospital. Methods Prescriptions containing any acid suppressant in outpatient and emergency departments in baseline (2017) and postintervention (2019) periods were extracted from the hospital information system and the prescription automatic screening system. Acid suppressant prescribing patterns were evaluated based on primary diagnoses and patient demographics. The prescribed acid suppressants stratified using age groups (< 7, 7–17, 18–45, 46–65, 66–85 and > 85 years) were also examined. Result The utilization rate of acid suppressant in 2017 and 2019 was 2.5% (41,165/1,619,366) and 2.2% (49,550/2,236,471), respectively (P < 0.0001). 60,135 acid suppressant prescriptions were obtained in 2017 and 73,275 in 2019. The rate of acid suppressant prescriptions for the approved indications significantly increased from 62.6% (2017) to 65.4% (2019) (P < 0.0001). Prescriptions diagnosed as abnormal symptoms, signs and clinical manifestations, decreased in 2019 (13.0% vs. 16.5%, P < 0.0001). The most frequently prescribed PPIs differed between 2017 and 2019 (rabeprazole 2017 vs. esomeprazole 2019). Omeprazole was the most common PPI and cimetidine was the most common H2RA prescribed to patients aged < 18 years in 2017 and 2019. A total of CNY11.83 million was spent on acid suppressants in 2019, accounting for about 48.7% of total medication cost, increased by 11.3% from 2017 (37.4%). Conclusion The proportion of acid suppressant prescriptions for approved indications was enhanced after the PPI management committee’s multifaceted interventions, but there were still some problems in the selection of acid suppressants.
Collapse
|
6
|
Wong SL, Sulaiman N, Ng KM, Lee ZY. Pharmacist-structured review of proton pump inhibitor utilisation in primary care: A nonrandomised control study. MALAYSIAN FAMILY PHYSICIAN : THE OFFICIAL JOURNAL OF THE ACADEMY OF FAMILY PHYSICIANS OF MALAYSIA 2021; 16:87-96. [PMID: 34938396 PMCID: PMC8680954 DOI: 10.51866/oa1153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION In the primary care setting, proton pump inhibitor (PPI) overutilisation often stems from the failure to discontinue prophylaxis treatment prior to tertiary care discharge and consider step-down therapy following discharge. Long-term PPI use can result in potential drug-related problems and unnecessary drug expenditure. This study aimed to evaluate the effectiveness of pharmacist-structured review in reducing inappropriate PPI prescriptions and estimate the potential cost saving. METHODS This non-randomised controlled study was conducted for 16 weeks at 17 government health clinics in Selangor, Malaysia. Eligible patients attending the outpatient pharmacies of intervention clinics were recruited consecutively and their consent was obtained. A structured review of PPIs was performed in which pharmacists identified patient demographics, indications and the length of PPI therapy using a PPI intervention form. Recommendations were discussed with physicians before prescription changes were made and documented. Moreover, standard management was conducted in the control clinics. RESULTS A total of 568 patients with prescriptions containing PPIs were sampled, with a total of 284 patients being placed into the control and intervention groups, respectively. Compared to the control group, inappropriate PPI utilisation in the intervention group significantly decreased from 79.9 to 30.4% (p<0.05). The changes to PPI prescriptions observed in the intervention group included: stop PPI therapy (30.8%), step-down therapy (22.9%), start substitution therapy (15.9%) and no change (30.4%). The physicians' acceptance rate for pharmacist intervention was 67.8%. A 66.1% reduction in monthly PPI pill count and a 72.0% reduction in monthly medication expenditure (RM44.85/patient/year) were observed. CONCLUSION The pharmacist-structured review was effective in increasing appropriate PPI utilisation and led to substantial cost savings.
Collapse
Affiliation(s)
- Su Li Wong
- Bachelor of Degree (Honours), Pharmacy (UCSI University) Department of Pharmacy, Pejabat Kesihatan Daerah Klang, Klang Selangor Darul Ehsan, Malaysia,
| | - Norharlina Sulaiman
- Master in Pharmacy Practice (UiTM Shah Alam), Bachelor of Degree Pharmacy (University Malaya), Department of Pharmacy, Pejabat Kesihatan Daerah Klang, Klang Selangor Darul Ehsan, Malaysia
| | - Kar Mun Ng
- Masters in Pharmacy Degree (University of Strathclyde), Department of Pharmacy, Pejabat Kesihatan Daerah Klang, Klang Selangor Darul Ehsan, Malaysia
| | - Zhe Yen Lee
- Bachelor of Pharmacy (Hons) AIMST University, Department of Pharmacy Pejabat Kesihatan Daerah Gombak Gombak, Selangor Darul Ehsan, Malaysia
| |
Collapse
|
7
|
Orelio CC, Heus P, Kroese-van Dieren JJ, Spijker R, van Munster BC, Hooft L. Reducing Inappropriate Proton Pump Inhibitors Use for Stress Ulcer Prophylaxis in Hospitalized Patients: Systematic Review of De-Implementation Studies. J Gen Intern Med 2021; 36:2065-2073. [PMID: 33532958 PMCID: PMC8298652 DOI: 10.1007/s11606-020-06425-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 12/08/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND A large proportion of proton pump inhibitor (PPI) prescriptions, including those for stress ulcer prophylaxis (SUP), are inappropriate. Our study purpose was to systematically review the effectiveness of de-implementation strategies aimed at reducing inappropriate PPI use for SUP in hospitalized, non-intensive care unit (non-ICU) patients. METHODS We searched MEDLINE and Embase databases (from inception to January 2020). Two authors independently screened references, performed data extraction, and critical appraisal. Randomized trials and comparative observational studies were eligible for inclusion. Criteria developed by the Cochrane Effective Practice and Organisation of Care (EPOC) group were used for critical appraisal. Besides the primary outcome (inappropriate PPI prescription or use), secondary outcomes included (adverse) pharmaceutical effects and healthcare use. RESULTS We included ten studies in this review. Most de-implementation strategies contained an educational component (meetings and/or materials), combined with either clinical guideline implementation (n = 5), audit feedback (n = 3), organizational culture (n = 4), or reminders (n = 1). One study evaluating the de-implementation strategy effectiveness showed a significant reduction (RR 0.14; 95% CI 0.03-0.55) of new inappropriate PPI prescriptions. Out of five studies evaluating the effectiveness of de-implementing inappropriate PPI use, four found a significant reduction (RR 0.21; 95% CI 0.18-0.26 to RR 0.76; 95% CI 0.68-0.86). No significant differences in the occurrence of pharmaceutical effects (n = 1) and in length of stay (n = 3) were observed. Adverse pharmaceutical effects were reported in two studies and five studies reported on PPI or total drug costs. No pooled effect estimates were calculated because of large statistical heterogeneity between studies. DISCUSSION All identified studies reported mainly educational interventions in combination with one or multiple other intervention strategies and all interventions were targeted at providers. Most studies found a small to moderate reduction of (inappropriate) PPI prescriptions or use.
Collapse
Affiliation(s)
- Claudia C Orelio
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands. .,Research Support, Diakonessenhuis Utrecht, Utrecht, The Netherlands.
| | - Pauline Heus
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Judith J Kroese-van Dieren
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - René Spijker
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Barbara C van Munster
- University Medical Center Groningen, University Center for Geriatric Medicine, University of Groningen, Groningen, The Netherlands
| | - Lotty Hooft
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
8
|
Lv X, Zhang J, Jiang M, Liu Y, Ren W, Fang Z. Clostridium difficile-associated diarrhea following the therapy with antibiotic and proton pump inhibitors in a 77-year-old man with several comorbidities: A case report. Medicine (Baltimore) 2019; 98:e15004. [PMID: 30921218 PMCID: PMC6455990 DOI: 10.1097/md.0000000000015004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
RATIONALE Clostridium difficile-associated diarrhea (CDAD) remains a persistent challenge, with substantially increased incidence and severity. The rising burden of CDAD requires urgent identification of preventable risk factors. PATIENTS CONCERNS A 77-year-old man with the symptoms of abdominal pain and watery diarrhea was readmitted to the hospital, who received cephalosporins and proton pump inhibitors (PPIs) during the initial hospitalization for 12 days until discharge. Antibiotic-associated diarrhea was seriously suspected. And the stool sample was immediately sent for inspection for C difficile. He had a history of chronic bronchitis, coronary heart disease, and osteonecrosis. DIAGNOSIS CDAD, renal insufficiency INTERVENTIONS:: Oral vancomycin was administered for 14 days. OUTCOMES On the third day after readmission, the stool sample turned out to be positive for both C difficile toxin and its antigen. After 10-day treatment with vancomycin, diarrhea symptoms disappeared and his stools became normal. LESSONS In elderly patients with multiple comorbidities, PPIs must be administered cautiously to minimize the risk for adverse effects including CDAD. It is important to identify the preventable risk factors of CDAD for clinicians and pharmacists. Oral vancomycin therapy seems to be effective in CDAD.
Collapse
Affiliation(s)
| | | | - Miao Jiang
- Department of Gastroenterology, Jinshan Hospital, Fudan University, Shanghai, China
| | | | | | | |
Collapse
|