Impact of Pharmacy Intervention on the Use of Proton-Pump Inhibitors in the Hospital Setting

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.

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

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).

An educational intervention to optimize use of proton pump inhibitors in a Greek university hospital

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.

Impact of pharmacy-supported interventions on proportion of patients receiving non-indicated acid suppressive therapy upon discharge: A systematic review and meta-analysis

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 14^th, 2018 and repeated on September 12^th, 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.

Appropriateness of the use of proton pump inhibitors in the Emergency Department of a Spanish university hospital

BACKGROUND

the use of proton pump inhibitors (PPI) has increased substantially during the last years, possibly due to a significant proportion of prescriptions that do not follow the approved indications.

OBJECTIVE

to assess the prevalence of PPI prescription and the appropriateness of the prescription within the Emergency Department (ED) of a Spanish university hospital.

MATERIALS AND METHODS

a cross-sectional, retrospective prescription-indication drug-use study was performed, which selected 384 patients that presented to the ED over two days in January 2016.

RESULTS

of the total cohort, 23.2% were taking PPI before their hospital visit and only 20.2% had a correct indication and dosage; 2.9% of the patient cohort had an indication for PPI treatment but had not been prescribed them. A drug other than omeprazole was used in 25% of cases; 30.47% of the patients were discharged with a PPI and only 28.2% of them had the correct indication and dosage. Finally, 5.7% were not prescribed PPI even though it was warranted. PPI prescription increased with age whereas the indication for the prescription decreased. Furthermore, the use of these drugs was higher in hospitalized patients compared to discharged patients.

CONCLUSIONS

these results are in line with similar studies, which demonstrate the existence of an over-prescription of PPI. PPI prescription needs to be improved, thereby reducing drug interactions, adverse effects and unnecessary economical expenses.

Effectiveness of Interventions to Deprescribe Inappropriate Proton Pump Inhibitors in Older Adults

BACKGROUND

The use of proton pump inhibitors (PPIs) in older adults is high, often inappropriate, and may cause harm. Deprescribing is defined as the reduction, withdrawal, or discontinuation of inappropriate medication.

OBJECTIVE

We conducted a systematic review to determine the effectiveness of interventions to deprescribe inappropriate PPIs in older adults.

METHODS

We searched MEDLINE, PubMed, Embase, the Cochrane Library, ProQuest Dissertations and Theses Global, and Google from inception to January 2017 for randomized and non-randomized studies describing the outcomes of interventions to deprescribe inappropriate PPIs in older adults (mean or median age of ≥65 years). Where available, clinically relevant outcomes were also assessed.

RESULTS

We included 21 articles in our review. Six studies demonstrated effective interventions, 11 were inconclusive, and four were ineffective. Effective interventions included a population-wide education and promotion strategy, academic detailing for general practitioners, and inpatient geriatrician-led deprescribing. Methodological issues limited the interpretation of several studies. Standardization in outcome reporting was lacking, and clinical outcome data were absent. A comparison of intervention effectiveness was not possible because of their heterogeneity, which precluded a meta-analysis.

CONCLUSION

The limited available evidence suggests that some strategies are more successful than others in effectively deprescribing inappropriate PPIs in older adults. However, whether PPI deprescribing translates into better clinical outcomes remains unclear.

Identifying Risk Factors Associated with Inappropriate Use of Acid Suppressive Therapy at a Community Hospital

Purpose. By examining the prescribing patterns and inappropriate use of acid suppressive therapy (AST) during hospitalization and at discharge we sought to identify the risk factors associated with such practices. Methods. In this retrospective observational study, inpatient records were reviewed from January 2011 to December 2013. Treatment with AST was considered appropriate if the patient had a known specific indication or met criteria for stress ulcer prophylaxis. Results. In 2011, out of 58 patients who were on AST on admission, 32 were newly started on it and 23 (72%) were inappropriate cases. In 2012, out of 97 patients on AST, 61 were newly started on it and 51 (84%) were inappropriate cases. In 2013, 99 patients were on AST, of which 48 were newly started on it and 36 (75%) were inappropriate cases. 19% of the patients inappropriately started on AST were discharged on it in three years. Younger age, female sex, and 1 or more handoffs between services were significantly associated with increased risk of inappropriate AST. Conclusion. Our findings reflect inappropriate prescription of AST which leads to increase in costs of care and unnecessarily puts the patient at risk for potential adverse events. The results of this study emphasize the importance of examining the patient's need for AST at each level of care especially when the identified risk factors are present.

Publications presenting negative impacts of pharmacists

OBJECTIVES

The main objective was to evaluate the rate of publications with at least one indicator of the negative impact of clinical pharmaceutics activity.

METHODS

This is a descriptive and retrospective literature review. A literature search was conducted using Pubmed. Articles published between 2009-2014 that described the role and impacts of pharmacists were included. We calculated the rate of publication containing at least one negative indicator. We collected the indicators with negative results.

RESULTS

A total of 203 articles were included. Nine articles (4%) that had at least one indicator of negative impact were identified. A total of 66% (6/9) were conducted in the United States. The study designs of the articles included were a meta-analysis (n=1), a systematic review (n=1), randomized studies (n=2), pre-post studies (n=3), a cohort study (n=1) and a survey (n=1). Nine indicators of negative impact were identified.

CONCLUSION

There were nine publications with at least one negative indicator of the impact of clinical pharmacy activity. While there are a large number of studies about the positive impact of clinical pharmacy activities; the publication of negative results should be encouraged.

Non-prescription treatment of NSAID induced GORD by Australian pharmacies: a national simulated patient study

BACKGROUND

Patients regularly present to community pharmacies for advice about and treatment for reflux symptoms and NSAIDs are a common cause of these symptoms. There is no published literature detailing the approach that pharmacies take to these enquiries, the pharmacotherapy they recommend or whether they contribute to the safe and effective use of reflux medicines.

OBJECTIVES

To assess in an observational study design the clinical history gathering, recommendations for GORD management and counselling provided by community pharmacies in a simulated patient scenario involving suspected NSAID induced reflux symptoms. Setting Australian community pharmacies.

METHOD

Simulated patients visited 223 community pharmacies to request treatment for reflux symptoms. The interaction was audiotaped and assessed against guidelines for the treatment of reflux symptoms.

MAIN OUTCOME MEASURES

Alignment of community pharmacies with international expert gastroenterologist guidance and national professional practice guidelines for the treatment of reflux symptoms by pharmacists including: consultation with a pharmacist; confirmation of reflux diagnosis based on symptoms; recommendation of short courses proton pump inhibitor (PPI) therapy; advice on the safe and effective use of reflux medicines and referral to a doctor for further assessment.

RESULTS

Pharmacists consulted with the simulated patient in 77% of cases. Symptoms were enquired about in 95% of cases and a medicines history taken in 69% of cases. Recommendations for treatment included: PPIs (18%), histamine H2 antagonists (57%) and antacids (19%). Advice on product use was given in 83% of cases. Referral to a doctor to discuss reflux symptoms was made in 63% of cases.

CONCLUSION

When assessing patients for the symptoms of GORD, Australian pharmacists and non-pharmacist support staff take a comprehensive history including symptomatology, duration of symptoms, concomitant medicines and medical conditions and any GORD treatments previously trialled. They provide comprehensive counselling on the use of antisecretory and antacid medicines. Counselling could involve more comprehensive information on lifestyle approaches for GORD management and side effects of antisecretory and antacid medicines. Further alignment with guidelines for the management of GORD would result in greater referral to a doctor for assessment of recurrent GORD and greater recommendation of PPIs for symptoms. However alignment with guidelines by all pharmacists is unrealistic if the guidelines are not universally available to them.