Background: Proton pump inhibitors (PPIs) are commonly started inpatient for stress ulcer prophylaxis and wrongly continued on discharge. But in addition to polypharmacy and patient cost, there are significant adverse events associated with chronic use including increased risk of Clostridium difficile, community acquired pneumonia, hip and spine fractures, accelerated progression to chronic kidney disease, and dementia.
Methods: Starting with our first Plan-Do-Study-Act (PDSA) cycle, we educated a team of two internal medicine attendings and 15 residents regarding the harms of PPI overuse. Clinicians then received automatically generated electronic medical record messages with targeted patients discharged on PPIs, triggering an in-visit prompt designed to quickly and easily assess indications, medical necessity of PPI, and potential to deprescribe. After clinician feedback, the second PDSA cycle refined the required response to the prompt and provided monthly report cards giving feedback on the PPI patients per clinician.
Results: The electronic medical record tool identified 103 patients on PPIs appropriate for the intervention and the provider used the prompt in 70 of those visits, or 68% of the time. The prevalence of PPI use decreased from 14.8% to 12.5%, representing a 15.7% reduction. The total number of patients on PPIs decreased from 332 to 296, despite an increasing panel size over the six months of the intervention. The most commonly encountered indications for chronic PPI use were GERD (41.6%), Dyspepsia (19.8%), and continued in-hospital GI prophylaxis (13.9%).
Conclusions: An electronic medical record intervention was successful in identifying PPI overuse, reducing patients on non-indicated chronic PPI therapy, and improved our ability to provide high-value care and prevent potential medication related adverse events.