1. Increase in Appropriate Prescribing of Proton Pump Inhibitors at Lincoln Medical and Mental Health Center Deliana Peykova MD, Kirill Rivkin PharmD, Alexandra Mamorska-Dyga MD, Anita Soni MD Department of Internal Medicine, Department of Pharmacy Lincoln Medical and Mental Health Center, Bronx, NY
Introduction
Overuse of Proton Pump Inhibitors (PPI’s) is a well-recognized problem. Approximately 50% of all PPI are prescribed inappropriately (1).
Reasons:
perceived to be safe
focus on acute issues
non-specific symptoms
patients’ reluctance to stop
lack of consensus on indications
lack of consensus on duration
Appropriate indications:
GERD Inappropriate PU
UGIB
Zollinger-Ellison
syndrome.
Purpose
Reduce inappropriate prescribing for inpatients in the department of Internal Medicine by 50%.
Improve documentation of indications.
Discontinuing inappropriately prescribed PPI’s.
Results
As a result of our intervention we are seeing progressively decreasing percentage of inappropriate prescriptions for PPI’s.
Continuation of inappropriate PPI’s despite team’s intervention: 6%.
Before Intervention
After Intervention
Appropriate
46%
68%
Inappropriate
54%
32%
Consequences:
↑ in C.difficile
Campylobacter infections
nosocomial PNA
unnecessary cost
pill burden to pts
management of potential complications
achlorhydria →impaired polyvalent cation absorption
Methods
Multidisciplinary team gave a presentation to Attending physicians and residents after beginning of academic year.
Put up posters in the internal medicine department.
Reviewed all inpatient PPI orders on daily basis for appropriateness.
Prescribers were contacted in cases without clear indication.
Attending physicians made the final decision whether to continue PPI therapy.
Background
References:
1. Eid SM, Boueiz A, Paranji S, Mativo C, Landis R, Abougergi MS. Patterns and predictors of proton pump inhibitor overuse among academic and non-academic hospitalists. Intern Med. 2010;49(23): Epub 2010 Dec 1.
2. Ramirez E, Lei SH, Borobia AM, Piñana E, Fudio S, Muñoz R, Campos A, Carcas AJ, Frias J. Overuse of PPIs in patients at admission, during treatment, and at discharge in a tertiary Spanish hospital. Curr Clin Pharmacol Nov;5(4):
3. Van Vliet EP, Otten HJ, Rudolphus A, Knoester PD, Hoogsteden HC, Kuipers EJ, Siersema PD. Inappropriate prescription of proton pump inhibitors on two pulmonary medicine wards. Eur J Gastroenterol Hepatol Jul;20(7): doi: /MEG.0b013e3282f52f95. 
4. Patel V, Fordtran JS. Hazards of PPI overuse and possible ways to curtail it. Nat Clin Pract Gastroenterol Hepatol May;4(5):246-7.
5. Choudhry MN, Soran H, Ziglam HM. Overuse and inappropriate prescribing of proton pump inhibitors in patients with Clostridium difficile-associated disease. QJM Jun;101(6): doi: /qjmed/hcn035. Epub 2008 Apr 14.
6. Pasina L, Nobili A, Tettamanti M, Salerno F, Corrao S, Marengoni A, Iorio A, Marcucci M, Mannucci PM; Prevalence and appropriateness of drug prescriptions for peptic ulcer and gastro-esophageal reflux disease in a cohort of hospitalized elderly. Eur J Intern Med Apr;22(2): doi: /j.ejim Epub 2010 Dec 21.
January
February
March
April
May
Overall
Total 44 19 55 80 62
265
Appropriate 20 10 39 50
168
Inappropriate 24 9 16 25 12 85
Inappropriate initiated by Lincoln 8 7 3 40
Inappropriate cntinued on discharge 6 5 28
February
March
April
Overall
Appropriate 24 61 80
165
Inappropriate 25 94 73
192
Total 49
155
153
357
Inappropriate