Does screening for PTSD lead to VA mental health care? Identifying the spectrum of initial VA screening actions

Despite the active posttraumatic stress disorder (PTSD) screening program in Department of Veterans Affairs (VA) primary care clinics and the availability of empirically supported treatments for PTSD at VA, many veterans for whom screening suggests treatment may be indicated do not gain access to VA-based mental health care. To determine where we may be losing veterans to follow-up, we need to begin by identifying the initial action taken in response to a positive PTSD screen in primary care. Using VA administrative data and chart review, we identified the spectrum of initial actions taken after veterans screened positive for PTSD in VA primary care clinics nationwide between October 2017 and September 2018 (N = 41,570). We collapsed actions into those that could lead to VA-based mental health care (e.g., consult placed to a VA mental health clinic) versus not (e.g., veteran declined care), and then examined the association between these categories of actions and contextual- and individual-level variables. More than 61% of veterans with positive PTSD screens had evidence that an initial action toward VA-based mental health care was taken. Urban-dwelling and female veterans were significantly more likely to have evidence of these initial actions, whereas White and Vietnam-era veterans were significantly less likely to have this evidence. Our findings suggest that most veterans screening positive for PTSD in VA primary care clinics have evidence of initial actions taken toward VA-based mental health care; however, a substantial minority do not, making them unlikely to receive follow-up care. Findings highlight the potential benefit of targeted primary care-based access interventions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Improving Medication Reconciliation with Comprehensive Evaluation at a Veterans Affairs Skilled Nursing Facility

BACKGROUND

Unintentional medication discrepancies due to inadequate medication reconciliation pose a threat to patient safety. Skilled nursing facilities (SNFs) are an important care setting where patients are vulnerable to unintentional medication discrepancies due to increased medical complexity and care transitions. This study describes a quality improvement (QI) approach to improve medication reconciliation in an SNF setting as part of the Multi-Center Medication Reconciliation Quality Improvement Study 2 (MARQUIS2).

METHODS

This study was conducted at a 112-bed US Department of Veterans Affairs SNF. The researchers used several QI methods, including data benchmarking, stakeholder surveys, process mapping, and a Healthcare Failure Mode and Effect Analysis (HFMEA) to complete comprehensive baseline assessments.

RESULTS

Baseline assessments revealed that medication reconciliation processes were error-prone, with high rates of medication discrepancies. Provider surveys and process mapping revealed extremely labor-intensive and highly complex processes lacking standardization. Factors contributing were polypharmacy, limited resources, electronic health record limitations, and patient exposure to multiple care transitions. HFMEA enabled a methodical approach to identify and address challenges. The team validated the best possible medication history (BPMH) process for hospital settings as outlined by MARQUIS2 for the SNF setting and found it necessary to use additional medication lists to account for multiple care transitions.

CONCLUSION

SNFs represent a critical setting for medication reconciliation efforts due to challenges completing the reconciliation process and the concomitant high risk of adverse drug events in this population. Initial baseline assessments effectively identified existing problems and can be used to guide targeted interventions.

Advancing the Science of Deprescribing: A Novel Comprehensive Conceptual Framework

Polypharmacy is common in older adults and associated with inappropriate medication use, adverse drug events, medication nonadherence, higher costs, and increased mortality compared with those without polypharmacy. Deprescribing, the clinically supervised process of stopping or reducing the dose of medications when they cause harm or no longer provide benefit, may improve outcomes. Although potentially beneficial, clinicians struggle to overcome structural, organizational, technological, and cognitive barriers to deprescribing, limiting its use in clinical practice. Deprescribing science would benefit from a unifying conceptual framework to prioritize research. Current deprescribing conceptual frameworks have made important contributions to the field but often with a focus on specific medication classes or aspects of deprescribing. To further this relatively nascent field, we developed a broader deprescribing conceptual framework that builds on prior frameworks and includes patient, prescriber, and system influences; the process of deprescribing; outcomes; and dissemination. Patient factors include patients' biology, experience, values, and preferences. Prescriber factors include rational (eg, based on explicit knowledge) and nonrational (eg, behavioral tendencies, biases, and heuristics) decision making. System factors include resources, incentives, goals, and culture that contribute to deprescribing. The framework separates the deprescribing decision from the deprescribing process. The framework captures the results of deprescribing by examining changes in clinical structures, performance processes, patient experience, health outcomes, and cost. Through testing and refinement, this novel, more comprehensive conceptual framework has the potential to advance deprescribing research by organizing the existing evidence, identifying evidence gaps, and categorizing deprescribing interventions and the settings in which they are applied. J Am Geriatr Soc 67:2018-2022, 2019.

Deprescribing in the context of multiple providers: understanding patient preferences

OBJECTIVES

Deprescribing could reduce the risk of harm from inappropriate medications. We characterized patients' acceptance of deprescribing recommendations from pharmacists, primary care providers (PCPs), and specialists relative to the original prescriber's professional background.

STUDY DESIGN

Secondary analysis of national Patient Perceptions of Discontinuation survey responses from Veterans Affairs (VA) primary care patients with 5 or more prescriptions.

METHODS

We created 4 relative deprescribing authority (RDA) outcome groups from responses to 2 yes/no (Y/N) items: (1) "Imagine…a specialist…prescribed a medicine. Would you be comfortable if your PCP told you to stop...it?" and (2) "Imagine…your VA PCP prescribed a medicine. Would you be comfortable if a VA clinical pharmacist [Pharm] told you to stop…it?" Multinomial regression associated patient factors with RDA.

RESULTS

Respondents (n = 803; adjusted response rate, 52%) were predominantly men (85%) and older than 65 years (60%). A total of 281 (38%) respondents said no to both questions (PCP-N/Pharm-N) and 146 (20%) said yes to both (PCP-Y/Pharm-Y). A total of 155 (21%) said no to a PCP stopping a specialist's medicine but yes to a pharmacist stopping a PCP's (PCP-N/Pharm-Y). A total of 153 (21%) said that a PCP could stop a specialist's medication but a pharmacist could not stop a PCP's (PCP-Y/Pharm-N). In adjusted models (reference, PCP-N/Pharm-N), those with greater medication concerns were more likely to respond PCP-Y/Pharm-Y (odds ratio [OR], 1.45; 95% CI, 1.09-1.92). Those with more interest in shared decision making were more likely to respond PCP-N/Pharm-Y (OR, 1.41; 95% CI, 1.04-1.92). Those with greater trust in their PCP were less likely to respond PCP-N/Pharm-Y (OR, 0.52; 95% CI, 0.34-0.81) but more likely to respond PCP-Y/Pharm-N (OR, 2.16; 95% CI, 1.31-3.56) or PCP-Y/Pharm-Y (OR, 1.83; 95% CI, 1.13-2.98).

CONCLUSIONS

Understanding patient preferences of RDA can facilitate effective design and implementation of deprescribing interventions.

External Determinants of Veterans' Utilization of VA Health Care

OBJECTIVE

Veterans' utilization of Veterans Affairs (VA) health care is likely influenced by community factors external to the VA, including Medicaid eligibility and unemployment, although such factors are rarely considered in models predicting such utilization. We measured the sensitivity of VA utilization to changes in such community factors (hereafter, "external determinants"), including the 2014 Medicaid expansion following the Affordable Care Act.

DATA SOURCES/STUDY SETTING

We merged VA health care enrollment and utilization data with area-level data on Medicaid policy, unemployment, employer-sponsored insurance, housing prices, and non-VA physician availability (2008-2014).

STUDY DESIGN

For veterans aged 18-64 and ≥65, we estimated the sensitivity of annual individual VA health care utilization, measured by the cost ($) of care received, to changes in external determinants using longitudinal regression models controlling for individual fixed effects.

PRINCIPAL FINDINGS

All external determinants were associated with small but significant changes in VA health care utilization. In states that expanded Medicaid in 2014, this expansion was associated with 9.1 percent ($826 million) reduction in VA utilization among those aged 18-64; sizable changes occurred in all services used (inpatient, outpatient, and prescription drugs).

CONCLUSIONS

Changes in alternative insurance coverage and other external determinants may affect VA health care spending. Policy makers should consider these factors in allocating VA resources to meet local demand.

Patient attitudes and experiences that predict medication discontinuation in the Veterans Health Administration

OBJECTIVES

Polypharmacy is associated with adverse medication effects. One potential solution is deprescribing, which is the intentional, proactive, rational discontinuation of a medication that is no longer indicated or for which the potential harms outweigh the potential benefits. We identified patient characteristics, attitudes, and health care experiences associated with medication discontinuation.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a national mail survey, with the use of the Patient Perceptions of Discontinuation (PPoD) instrument, of 1600 veterans receiving primary care at Veterans Affairs (VA) medical centers and prescribed 5 or more concurrent medications.

MAIN OUTCOME MEASURES

The primary outcome was the response to: "Have you ever stopped taking a medicine (with or without your doctor's knowledge)?" The primary predictors of interest were 8 validated attitudinal scales. Other predictors included demographics, health status, and health care experiences.

RESULTS

Respondents (n = 803; adjusted response rate 52%) were predominantly male (85%); non-Hispanic white (68%), 65 years of age or older (60%), and with poor (16%) or fair (45%) health. Participant attitudes toward medications and their providers were generally favorable. One in 3 patients (34%) reported having stopped a medicine in the past. In a multivariable logistic regression model (P < 0.001; pseudo-R² = 0.31; c-statistic = 0.82), factors associated with discontinuation included being told or asking to stop a medicine, greater interest in deprescribing and shared decision making, and higher education. Factors associated with decreased discontinuation were more prescriptions, higher trust in provider, and seeing a VA clinical pharmacist.

CONCLUSION

More highly educated patients with interest in deprescribing and shared decision making may be more receptive to discontinuation discussions. Future research evaluating how to incorporate this survey and these findings into clinical workflow through the design of clinical interventions may help to promote safe and rational medication use.

Supporting medication discontinuation: provider preferences for interventions to facilitate deprescribing

BACKGROUND

One approach to prevent adverse drug events is to discontinue ("deprescribe") medications that are outdated, not indicated, or of limited benefit relative to risk for a particular patient. However, there is little guidance to clinicians about how to integrate the process of deprescribing into the workflow of clinical practice. We sought to determine clinical prescribers' preferences for interventions that would improve their ability to appropriately and proactively discontinue medications.

METHODS

We conducted a national web-based survey of 2475 prescribers [physicians, nurse practitioners (NP), physician assistants (PA), and clinical pharmacy specialists] practicing in US Veterans Affairs (VA) primary care clinics. One survey question presented 15 potential changes to medication-related practices and respondents ranked their top three choices for changes that would "most improve [their] ability to discontinue medications." We summed the weighted rankings for each of the 15 response options. Preferences were determined for the whole sample and within subgroups of respondents defined by demographic and background characteristics, medication-relevant experience, and beliefs.

RESULTS

Among the 326 respondents who provided rankings, the top choice for a change that would help improve their ability to discontinue medications was "Requiring all medication prescriptions to have an associated 'indication for use.'" This preference was followed by "Assistance with follow-up of patients as they taper or discontinue medications is performed by another member of the Patient Aligned Care Team (PACT)" and "Increased patient involvement in prescribing decisions." This combination of options, albeit in varying rank order, was the most commonly selected, with 250 respondents (77%) who answered the question including at least one of these items in their three highest ranked choices, regardless of their demographics, experience, or beliefs.

CONCLUSIONS

Continued efforts to improve clinicians' ability to make prescribing decisions, especially around deprescribing, have many potential benefits, including decreased pharmaceutical and health care costs, fewer adverse drug events and complications, and improved patient involvement and satisfaction with their care. Future work, whether as research or quality improvement, should incorporate clinicians' preferences for interventions, as greater buy-in from front-line staff leads to better adoption of changes.

Prescribers' perceptions of medication discontinuation: survey instrument development and validation

OBJECTIVES

Primary care providers (PCPs) and clinical pharmacists have concerns about the adverse consequences of using medications inappropriately and generally support the notion of reducing unnecessary drugs. Despite this attitude, many factors impede clinicians' ability to discontinue medication in clinical settings. We sought to develop a survey instrument that assesses PCPs' and pharmacists' experiences, attitudes, and beliefs toward medication discontinuation.

STUDY DESIGN

Survey development and psychometric assessment.

METHODS

Based on a conceptual framework, we developed a questionnaire and surveyed a national sample of Department of Veterans Affairs PCPs with prescribing privileges, including physicians, nurse practitioners, physician assistants, and clinical pharmacy specialists. We randomly divided respondents into derivation and validation samples and used iterations of multi-trait analysis to assess the psychometric properties of the proposed measures. Multivariable regression models identified factors associated with the outcome of self-rated comfort with medication discontinuation.

RESULTS

Using established criteria for scale development, we identified 5 scales: Medication Characteristics, Current Patient Clinical Factors, Predictions of Future Health States, Patients' Resources to Manage Their Own Health, and Education and Experience. Three of these dimensions predicted providers' self-rated comfort with making decisions to discontinue medication (Current Patient Clinical Factors, Predictions of Future Health States, and Education and Experience).

CONCLUSIONS

We developed a psychometrically sound instrument to measure prescribers' attitudes toward, and experiences with, medication discontinuation. This survey will enable identification of perceived barriers to, and facilitators of, proactive discontinuation-an important step toward developing interventions that improve the quality and safety of care in medication use.

Medication Complexity, Medication Number, and Their Relationships to Medication Discrepancies

Background: Medication reconciliation to identify discrepancies is a National Patient Safety Goal. Increasing medication number and complex medication regimens are associated with discrepancies, nonadherence, and adverse events. The Medication Regimen Complexity Index (MRCI) integrates information about dosage form, dosing frequency, and additional directions. Objective: This study evaluates the association of MRCI scores and medication number with medication discrepancies and commissions, a discrepancy subtype. Methods: This was a retrospective cohort study of a convenience sample of 104 ambulatory care patients seen from April 2010 to July 2011 within the Department of Veterans Affairs. Primary outcomes included any medication discrepancy and commissions. Primary exposures included MRCI scores and medication number. Multivariable logistic regression models associated MRCI scores and medication number with discrepancies. Receiver operating characteristic (ROC) curves provided discrepancy thresholds. Results: For the 104 patients analyzed, the median MRCI score was 25 (interquartile range [IQR] = 14-43), and the median medication number was 8 (IQR = 5-13); 60% of patients had any discrepancy, whereas 36% had a commission. In adjusted analyses, patients with MRCI scores ≥25 or medication number ≥8 were more likely to have commissions (odds ratio [OR] = 3.64, 95% CI = 1.41-9.41; OR = 4.51, 95% CI = 1.73-11.73, respectively). The unadjusted ROC threshold for commissions was 36 for MRCI (sensitivity, 59%; specificity, 82%) and 9 for medication number (sensitivity 68%; specificity 67%). Conclusion: Patients with either MRCI scores ≥25 or ≥8 medications were more likely to have commissions. Given equal performance in predicting discrepancies, the efficiency and simplicity of medication number supports its use in identifying patients for intensive medication review beyond medication reconciliation.

Clinical provider perceptions of proactive medication discontinuation

OBJECTIVES

Polypharmacy and adverse drug events lead to considerable healthcare costs and morbidity, yet there is little to guide clinical providers in the area of discontinuing medications that may not be necessary. We sought to understand providers' beliefs and attitudes about polypharmacy and medication discontinuation.

STUDY DESIGN

Qualitative study using semi-structured interviews of 20 providers with prescribing privileges at 2 US Veterans Affairs Medical Centers, from April 2012 to October 2012.

METHODS

Transcribed interviews were analyzed using grounded thematic analysis, a systematic approach to deriving qualitative themes from textual data.

RESULTS

We identified 10 themes within 4 domains of medication discontinuation. Within the first domain (medication factors), we identified 2 themes: 1) medication characteristics, and 2) uncertainties of why a patient was taking a particular drug. Within the second domain (patient factors), we identified 3 themes: 3) clinical picture of the patient, 4) clinicians' understanding of the patients' knowledge and beliefs, and 5) patients' adherence. Within the third domain (clinical provider factors), we identified 2 themes: 6) professional identity, and 7) providers' decisions related to their own beliefs about medications. Within the fourth domain (system factors), we identified 3 themes: 8) multiple providers, 9) workload, and 10) external directives and policies such as structural components of a healthcare system.

CONCLUSIONS

Provider decisions to discontinue medications are affected by factors at all levels of the clinical encounter. Our findings have implications for development and implementation of interventions to improve appropriate medication discontinuation via enhanced medication reviews, enriched patient-provider communication, and better system-level structures. This, in turn, may reduce the continued prescribing of potentially inappropriate medications that can lead to adverse outcomes or increased healthcare costs.

Patient perceptions of proactive medication discontinuation

OBJECTIVE

While many patients prefer fewer medications, decisions about medication discontinuation involve collaboration between patients and providers. We sought to identify patient perspectives on intentional medication discontinuation in order to optimize medication use.

METHODS

We conducted 20 interviews and two focus groups with a convenience sample of patients (22 men, 5 women; mean age 66 years) at two US Veterans Affairs Medical Centers. We queried patients' experiences with and attitudes toward taking multiple medications, preferences about taking fewer medications, and communication with their providers about stopping a medicine. Transcripts were analyzed qualitatively.

RESULTS

Three main themes emerged to create a conceptual model of medication discontinuation from the patient perspective: (1) conflicting views of medication, encompassing the sub-themes of desire for fewer medications, adherence, and specific versus general; (2) importance of patient-provider relationships, encompassing the sub-themes of trust, relying on expertise, shared decision making, and balancing multiple providers; and (3) limited experience with medication discontinuation.

CONCLUSION

Many patients who have a preference to take fewer medicines do not share their beliefs with providers and recall few instances of provider-initiated medication discontinuation.

PRACTICE IMPLICATIONS

Strengthening patient-provider relationships and eliciting patient attitudes about taking fewer medications may enable appropriate discontinuation of unnecessary medications.

Patients' perceptions of their "most" and "least" important medications: a retrospective cohort study

Background

Despite benefits of adherence, little is known about the degree to which patients will express their perceptions of medications as more or less important to take as prescribed. We determined the frequency with which Veteran patients would explicitly identify one of their medications as “most important” or “least important.”

Findings

We conducted a retrospective cohort study of patients from ambulatory clinics at VA Boston from April 2010-July 2011. Patients answered two questions: “Which one of your medicines, if any, do you think is the most important? (if none, please write ‘none’)” and “Which one of your medicines, if any, do you think is the least important? (if none, please write ‘none’).” We determined the prevalence of response categories for each question. Our cohort of 104 patients was predominantly male (95%), with a mean of 9 medications (SD 5.7). Regarding their most important medication, 41 patients (39%) identified one specific medication; 26 (25%) selected more than one; 21 (20%) wrote “none”; and 16 (15%) did not answer the question. For their least important medication, 31 Veterans (30%) chose one specific medication; two (2%) chose more than one; 51 (49%) wrote “none”; and 20 (19%) did not directly answer the question.

Conclusions

Thirty-five percent of patients did not identify a most important medication, and 68% did not identify a least important medication. Better understanding of how patients prioritize medications and how best to elicit this information will improve patient-provider communication, which may in turn lead to better adherence.

Proton pump inhibitor discontinuation in long-term care

OBJECTIVES

To determine factors associated with proton pump inhibitor (PPI) discontinuation in long-term care.

DESIGN

Retrospective cohort analysis.

SETTING

Veterans Affairs (VA) long-term care facilities.

PARTICIPANTS

Veterans admitted for nonhospice care in 2005 with a length of stay of 7 days or more who were prescribed a PPI within 7 days of admission (N = 10,371).

MEASUREMENTS

Prescribed medications and comorbidities were determined from VA pharmacy and administrative databases and functional status from Minimum Data Set records. Associations between participant characteristics and PPI discontinuation were determined using Cox proportional hazard ratios (HRs), censoring at death, discharge, or 180 days after admission.

RESULTS

Participants were predominantly male (97%) and had a median age of 73 (interquartile range 60-81). There were 2,749 (27%) PPI discontinuations; 43% of these occurred within 28 days of admission. Hospitalizations (HR = 1.22, 95% confidence interval (CI) = 1.01-1.46), preadmission PPI use (HR = 1.35, 95% CI = 1.16-1.56), and lowest functional status (HR = 1.22, 95% CI = 1.03-1.45) were associated with early PPI discontinuation in adjusted models. Participants with gastric acid-related disease (HR = 0.53, 95% CI 0.46-0.61), diabetes mellitus (HR = 0.82, 95% CI 0.72-0.94), and those who were prescribed six or more medications (6-7 medications, HR = 0.78, 95% CI = 0.66-0.92; 8-10 medications, HR = 0.64, 95% CI = 0.54-0.76; ≥ 11 medications 0.51, 95% CI = 0.42-0.62) were less likely to have early discontinuation. No PPI discontinuer had PPIs resumed during the study, and few (9%) had histamine-2 receptor antagonist substitutions.

CONCLUSION

Although there may be clinical uncertainty regarding PPI discontinuation, more than one-quarter of participants prescribed a PPI upon admission to long-term care had it discontinued within 180 days. Targeting individuals prescribed PPIs for medication appropriateness review may reduce prescribing of potentially nonindicated medications.

Lifestyle behaviors in Massachusetts adult cancer survivors

INTRODUCTION

Adoption of healthy lifestyles in cancer survivors has potential to reduce subsequent adverse health. We sought to determine the prevalence of tobacco use, alcohol use, and physical inactivity among cancer survivors overall and site-specific survivors.

METHODS

We performed a cross-sectional analysis of the Massachusetts Behavioral Risk Factor Surveillance System, 2006-2008, and identified 1,670 survivors and 18,197 controls. Specific cancer sites included prostate, colorectal, female breast, and gynecologic (cervical, ovarian, uterine). Covariates included age, gender, race/ethnicity, education, income, marital status, health insurance, and physical and mental health. Gender stratified logistic regression models associated survivorship with each health behavior.

RESULTS

4.9% of men and 7.7% of women reported a cancer history. In adjusted regression models, male survivors were similar to gender matched controls, while female survivors had comparable tobacco and alcohol use but had more physical inactivity than controls (OR 1.5; 95% CI, 1.2-1.8). By site, breast cancer survivors were more likely to be physically inactive (OR 1.5; 95% CI, 1.1-2.0) and gynecologic cancer survivors were more likely to report current tobacco use (OR 1.8; 95% CI, 1.2-2.8).

CONCLUSIONS AND IMPLICATIONS FOR CANCER SURVIVORS

Specific subgroups of cancer survivors are more likely to engage in unhealthy behaviors. Accurate assessment of who may derive the most benefit will aid public health programs to effectively target limited resources.

A randomized-controlled trial of computerized alerts to reduce unapproved medication abbreviation use

Abbreviation use is a preventable cause of medication errors. The objective of this study was to test whether computerized alerts designed to reduce medication abbreviations and embedded within an electronic progress note program could reduce these abbreviations in the non-computer-assisted handwritten notes of physicians. Fifty-nine physicians were randomized to one of three groups: a forced correction alert group; an auto-correction alert group; or a group that received no alerts. Over time, physicians in all groups significantly reduced their use of these abbreviations in their handwritten notes. Physicians exposed to the forced correction alert showed the greatest reductions in use when compared to controls (p=0.02) and the auto-correction alert group (p=0.0005). Knowledge of unapproved abbreviations was measured before and after the intervention and did not improve (p=0.81). This work demonstrates the effects that alert systems can have on physician behavior in a non-computerized environment and in the absence of knowledge.

Proton pump inhibitors and risk for recurrent Clostridium difficile infection

BACKGROUND

Proton pump inhibitors (PPIs) are widely used gastric acid suppressants, but they are often prescribed without clear indications and may increase risk of Clostridium difficile infection (CDI). We sought to determine the association between PPI use and the risk of recurrent CDI.

METHODS

Retrospective, cohort study using administrative databases of the New England Veterans Healthcare System from October 1, 2003, through September 30, 2008. We identified 1166 inpatients and outpatients with metronidazole- or vancomycin hydrochloride-treated incident CDI, of whom 527 (45.2%) received oral PPIs within 14 days of diagnosis and 639 (54.8%) did not. We determined the hazard ratio (HR) for recurrent CDI, defined by a positive toxin finding in the 15 to 90 days after incident CDI.

RESULTS

Recurrent CDI was more common in those exposed to PPIs than in those not exposed (25.2% vs 18.5%). Using Cox proportional survival methods, we determined that the adjusted HR of recurrent CDI was greater in those exposed to PPIs during treatment (1.42; 95% confidence interval [CI], 1.11-1.82). Risks among exposed patients were highest among those older than 80 years (HR, 1.86; 95% CI, 1.15-3.01) and those receiving antibiotics not targeted to C difficile during follow-up (HR, 1.71; 95% CI, 1.11-2.64). [corrected]

CONCLUSIONS

Proton pump inhibitor use during incident CDI treatment was associated with a 42% increased risk of recurrence. Our findings warrant further studies to examine this association and careful consideration of the indications for prescribing PPIs during treatment of CDI.