Antiulcer drug prescribing in hospital successfully influenced by "immediate concurrent feedback"

Reducing Inappropriate Proton Pump Inhibitors Use for Stress Ulcer Prophylaxis in Hospitalized Patients: Systematic Review of De-Implementation Studies

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.

Development of a Patient-Centered Antipsychotic Medication Adherence Intervention

OBJECTIVE

A substantial gap exists between patients and their mental health providers about patient's perceived barriers, facilitators, and motivators (BFMs) for taking antipsychotic medications. This article describes how we used an intervention mapping (IM) framework coupled with qualitative and quantitative item-selection methods to develop an intervention to bridge this gap with the goal of improving antipsychotic medication adherence.

METHODS

IM is a stepwise method for developing and implementing health interventions. A previous study conducted in-depth qualitative interviews with patients diagnosed with schizophrenia and identified 477 BFMs associated with antipsychotic medication adherence. This article reports the results of using a variety of qualitative and quantitative item reduction and intervention development methods to transform the qualitative BFM data into a viable checklist and intervention.

RESULTS

The final BFM checklist included 76 items (28 barriers, 30 facilitators, and 18 motivators). An electronic and hard copy of the adherence progress note included a summary of current adherence, top three patient-identified barriers and top three facilitators and motivators, clarifying questions, and actionable adherence tips to address barriers during a typical clinical encounter.

DISCUSSION

The IM approach supplemented with qualitative and quantitative methods provided a useful framework for developing a practical and potentially sustainable antipsychotic medication adherence intervention. A similar approach to intervention development may be useful in other clinical situations where a substantial gap exists between patients and providers regarding medication adherence or other health behaviors.

The methodological quality of economic evaluations of guideline implementation into clinical practice: a systematic review of empiric studies

OBJECTIVES

Despite the emphasis on efficiency of health-care services delivery, there is an imperfect evidence base to inform decisions about whether and how to develop and implement guidelines into clinical practice. In general, studies evaluating the economics of guideline implementation lack methodological rigor. We conducted a systematic review of empiric studies to assess advances in the economic evaluations of guideline implementation.

METHODS

The Cochrane Effective Professional and Organisational Change Group specialized register and the MEDLINE database were searched for English publications between January 1998 and July 2004 that reported objective effect measures and implementation costs. We extracted data on study characteristics, quality of study design, and economic methodology. It was assessed whether the economic evaluations followed methodological guidance.

RESULTS

We included 24 economic evaluations, involving 21 controlled trials and three interrupted time series designs. The studies involved varying settings, targeted professionals, targeted behaviors, clinical guidelines, and implementation strategies. Overall, it was difficult to determine the quality of study designs owing to poor reporting. In addition, most economic evaluations were methodologically flawed: studies did not follow guidelines for evaluation design, data collection, and data analysis.

CONCLUSIONS

The increasing importance of the value for money of providing health care seems to be reflected by an increase in empiric economic evaluations of guideline implementation. Because of the heterogeneity and poor methodological quality of these studies, however, the resulting evidence is still of limited use in decision-making. There seems to be a need for more methodological guidance, especially in terms of data collection and data synthesis, to appropriately evaluate the economics of developing and implementing guidelines into clinical practice.

Potassium and phosphorus repletion in hospitalized patients: implications for clinical practice and the potential use of healthcare information technology to improve prescribing and patient safety

OBJECTIVES

Evaluate potassium and phosphorus repletion in hospitalized patients. Assess the potential role for use of various methods, including healthcare information technology, to improve prescribing and patient safety.

RESEARCH DESIGN AND METHODS

Inpatient medication profiles were screened to identify orders for potassium and phosphorus replacement products. Electronic laboratory and medical records were used to evaluate efficacy and safety. Eligibility for oral therapy was defined by the presence of other scheduled oral medications on the medication profile. Appropriateness of prescribing was based on adherence to the hospital guidelines for repletion.

RESULTS

Overall, 134 orders for potassium in 92 patients and 36 orders for phosphorus in 27 patients were evaluated over a 3-week data collection period. Intravenous (IV) potassium was prescribed in 73% of replacement episodes (46% as single doses and 54% within large volume IV fluids), with 85% for normokalemia or mild-to-moderate cases of hypokalemia. Phosphorus orders involved single doses of IV potassium phosphate (mean 13.1 mmol) in 75% of cases. Approximately 85% of doses were for mild or moderate hypophosphatemia. Eligibility for oral therapy was evident in 74% of normokalemic or mild hypokalemic cases receiving IV potassium products and in 33% of cases receiving IV phosphorus replacement. Six cases of mild hyperkalemia were observed. No hyperphosphatemia was documented. Study limitations include use of a retrospective design, inability to discern whether some electrolyte doses were given with a preventative intent, potential overestimation of the number of patients eligible for oral repletion, and lack of data on the accessibility of the laboratory serum concentrations or the awareness of serum values to the prescribers.

CONCLUSIONS

Intravenous potassium and phosphate products are commonly prescribed for mild or moderate cases of hypokalemia or hypophosphatemia. Many patients met eligibility for oral therapy. Efforts to enhance prescriber education and implement computerized prescribing and decision support systems have the potential to improve prescribing and reduce possibilities of adverse drug events and medication errors related to potassium and phosphate administration.

Proton pump inhibitors: a survey of prescribing in an Irish general hospital

Prescription rates and attendant costs of proton pump inhibitors (PPIs) continue to rise. The aim of this study was to assess the extent and appropriateness of PPI prescribing in an Irish general hospital. Using a structured pro forma, we conducted a 1-day comprehensive survey of the prescription charts of all inpatients. Of the 157 inpatients, 48 (30.6%) were on PPI therapy and omeprazole was the most widely prescribed PPI. Rabeprazole, the least expensive PPI, was the least prescribed. Prescription of PPI therapy was for an approved indication in 32 patients (66.6%) but was for an unapproved or unknown indication in 16 (33.3%). Prescribing had been initiated in hospital in 34 patients (70.8%) but only one-third of the patients on PPI therapy had undergone endoscopy. Over 90% of patients were on additional, often multiple, prescribed medications. Our results suggest that PPIs are overprescribed in hospital practice, and there is scope to improve the quality and cost-effectiveness of PPI prescribing.

Appropriateness of gastric antisecretory therapy in hospital practice

BACKGROUND

Recent data indicate an exponential increase in proton pump inhibitor (PPI) prescribing, and concerns are raised regarding the appropriateness of these prescriptions and the financial implications.

AIM

To survey the appropriateness of PPI prescription in a cohort of patients in a tertiary referral hospital.

METHODS

Prescription records of all inpatients on a randomly selected day were reviewed. The appropriateness of prescription and relevant investigations were identified by interview of patients, review of patient records and of a computerised endoscopy records system.

RESULTS

Thirty-two per cent (87 of 272) of all patients were on PPIs. A valid indication for therapy was not apparent in 63% of the patients on PPIs with the only predictive factor for inappropriate prescription being increasing age. Only 36 of the 87 patients on PPIs had undergone appropriate investigations for their gastrointestinal symptoms. Gender, age, speciality of admission or duration of hospital stay did not influence the appropriateness of prescription or performance of relevant investigations.

CONCLUSION

There appears to be a widespread and inappropriate use of PPIs in hospital practice.

Drug reimbursement: indicators of inappropriate resource allocation

AIMS

In many countries, governments and third parties find themselves paying for (reimbursing) unproven, inadequate products limiting their ability to invest in therapies with evidence of relevant patient benefit. We examined how three characteristics, level of therapeutic evidence, susceptibility of inappropriate prescribing, and intercountry variation can be used to identify inefficiencies in pharmaceutical reimbursement among four European Union countries, Austria, Belgium, the Netherlands and Sweden.

METHODS

Specific classes of medicines were chosen to provide useful examples of how healthcare resources could be reallocated. A high level of therapeutic evidence was defined as a substantial body of evidence in at least one indication with clear-cut support of relevant patient benefit. The susceptibility of inappropriate prescribing was defined as the likelihood of prescribing a drug outside the scenario for which clear-cut evidence (if any) has been documented to produce relevant benefit for the patient. The intercountry variation represents the variation in utilization of reimbursed drugs across the four countries.

RESULTS

The combination of these characteristics provides a useful tool for assessing appropriate reimbursement decisions. It would be beneficial to healthcare payers as well as patients to move resources from products that have a low level of therapeutic evidence and a high susceptibility of inappropriate prescribing to products with a high level of therapeutic evidence and low susceptibility of inappropriate prescribing, and to use intercountry variation as a signal of drug classes that should be subject to further scrutiny.

CONCLUSIONS

A method is presented to help policy-makers identify inefficiencies in the spending of limited health care resources, and to reallocate resources to products that have been shown to improve patient care through evidence-based medicine.

Drug dosage in patients with renal failure optimized by immediate concurrent feedback

OBJECTIVE

To examine the impact of immediate concurrent feedback on dose adjustment in patients with renal failure.

DESIGN

Prospective 12-month study in patients with various degrees of renal failure, with comparison to a retrospective control group.

SETTING

A 39-bed unit of a university hospital providing primary and tertiary care.

PATIENTS

Patients with renal failure (estimated creatinine clearance < or = 50 mL/min) receiving at least 1 pharmacologically active drug.

INTERVENTIONS

Education of physicians and immediate concurrent feedback on the ward giving estimated creatinine clearance and dose recommendations for renally eliminated drugs adjusted to individual renal function.

MEASUREMENTS AND MAIN RESULTS

The percentage of dosage regimens adjusted to renal function and cost assessment of drug therapy were calculated. Overall, 17% of the patients had at least 1 estimated creatinine clearance < or = 50 mL/min. In the intervention group, the dose of 81% of renally eliminated drugs was adjusted to renal function, compared with 33% in the control group ( P <.001). The mean difference in cost between standard and adjusted dose of renally eliminated drugs in the intervention and control groups was 5.3 +/- 12.3 and 0.75 +/- 2.8 Swiss francs (approximately US$3.5 and US$0.5), respectively ( P <.001), accounting for 16.5% and 2.8%, respectively, of daily medication costs of all drugs.

CONCLUSIONS

The proportion of doses of renally eliminated drugs adjusted to renal function can be substantially increased by immediate concurrent feedback. This saves drug costs and has the potential to prevent adverse drug reactions.

Overuse of proton pump inhibitors

BACKGROUND

There have been concerns raised about the potential adverse effects of proton pump inhibitors, especially with long-term use. In particular, their potent action can suppress the features and delay the diagnosis of gastric cancer, while prolonged exposure may hasten the development of gastric carcinoids.

AIM

To examine the use of proton pump inhibitors in patients at the major teaching hospital in Tasmania, Australia, principally to determine the appropriateness of the therapy according to published guidelines.

METHODS

A retrospective review of the medical records of all patients prescribed any of the proton pump inhibitors at the hospital over a 7-month period, was performed. An extensive range of demographic and clinical variables was recorded for each patient. The patients were also asked a series of questions during their hospitalization to extract some of the relevant information - in particular, if and when they had undergone endoscopy.

RESULTS

The 200 patients (52% males) had a mean age of 69 +/- 16.4 years. The most common indications for using proton pump inhibitors were acute gastrointestinal bleeding (20.9%), severe refractory ulcerating oesophagitis (17.3%), mild/moderate oesophageal reflux (17.3%) and refractory peptic ulcer (11.7%). A large number of patients were using a proton pump inhibitor for 'other' indications (39.6%). The prescribing of proton pump inhibitors satisfied the approved indications, as outlined in the Australian Schedule of Pharmaceutical Benefits, in only 37.1% of cases. Endoscopy had been performed in 54.1% of patients prior to commencing therapy with a proton pump inhibitor and within the next 7 days in another 12.8% of patients. Only 59% of patients had previously been treated with an H2-receptor antagonist before commencing therapy with a proton pump inhibitor. Even worse, only 58.5% of patients had used an H2-receptor antagonist before a proton pump inhibitor for mild/moderate oesophagitis. The median duration of proton pump inhibitor therapy for patients admitted to the hospital and already receiving one of the drugs was 450 days. Over half of the patients were being concurrently treated with other drugs which are known to cause or exacerbate gastro-oesophageal disease, and 18% were smokers.

CONCLUSION

Whereas the proton pump inhibitors are undoubtedly effective agents, studies of their prescribing in practice consistently suggest over-use prior to endoscopy, use in patients who do not fit the approved criteria, and prescribing for indications in which 'less powerful' agents should have been sufficiently effective for the patient's symptoms. This poses economic and safety concerns, particularly in light of the suggestion that these drugs could delay the diagnosis of gastric cancer.