Background:
Acid suppressive medications, including histamine2‐receptor antagonists (H2RAs) and proton pump inhibitors (PPIs), are widely used to treat conditions associated with the overproduction of acid. Accepted indications include upper gastrointestinal bleeding, erosive esophagitis or gastritis, gastroesophageal reflux disease, ulcers, Helico‐bacter pylori eradication, Zollinger–Ellison syndrome, stress ulcer prophylaxis (SUP) in high‐risk patients, dyspepsia associated with nonsteroidal anti‐inflammatory drugs in high‐risk patients, and severe dyspepsia unresponsive to adequate trials of symptomatic drugs. Although PPIs are effective and well tolerated, there is growing concern about the overuse of PPIs in hospitalized patients. PPIs may increase the risk of nosocomial Clostridium difficile infections and hospital‐acquired pneumonia. The literature also suggests that patients frequently receive PPIs without a clear indication and that PPIs are often inadvertently continued on discharge. The purpose of this quality improvement project was to evaluate current prescribing practices for PPIs in hospitalized medical patients.
Methods:
This was a prospective observational study of adults admitted to general medicine (non‐ICU) services at a tertiary‐care medical center between February and May 2010. Patients were identified based on pharmacy order entry for esomeprazole, the PPI on formulary. The frequency of PPI use, indications, appropriateness of use, and discharge PPI orders were examined.
Results:
The overall frequency of PPI use was 45% in this study. Of 100 patients randomly selected for analysis, 69% were taking a PPI prior to hospitalization, whereas 31% were started on a PPI as an inpatient. Major indications for a new PPI during hospitalization included gastrointestinal bleeding (26%), followed by dyspepsia (23%) and SUP (23%). The new PPI was appropriate in 52% and inappropriate in 36% of patients; inappropriate indications included SUP in low‐risk patients and dyspepsia without a prior trial of calcium carbonate or H2RA. Overall, 83% of patients were continued on a PPI at discharge, including 52% (17 of 31) of those started on a PPI in the hospital. Of those patients discharged with a new PPI, the medication was likely unnecessary in 42% of cases.
Conclusions:
PPI use in hospitalized medical patients is common, with a high rate of inappropriate use both during hospitalization and at discharge. This increases the likelihood of adverse medication events as well as the cost of health care. Patients started on a new PPI during hospitalization represent the first target group for intervention. Adhering to approved indications for PPI use, discontinuing PPIs when no longer indicated, and considering alternative therapies such as H2RAs are areas for improvement. Strategies to improve prescribing practices may include implementing automatic stop orders on PPIs, reevaluating use of PPIs on standardized order sets, and integrating decisionmaking prompts into the electronic medical record.
Disclosures:
M. Anderson ‐ none; A. Go ‐ none; D. Levin ‐ none