May Adra, PharmD

Prior studies have found that up to 70% of acid‐suppressive medication (ASM) use in the hospital is not indicated, most commonly for stress ulcer prophylaxis in patients outside of the intensive care unit (ICU).[1, 2, 3, 4, 5, 6, 7] Accordingly, reducing inappropriate use of ASM for stress ulcer prophylaxis in hospitalized patients is 1 of the 5 opportunities for improved healthcare value identified by the Society of Hospital Medicine as part of the American Board of Internal Medicine's Choosing Wisely campaign.[8]

We designed and tested a computerized clinical decision support (CDS) intervention with the goal of reducing use of ASM for stress ulcer prophylaxis in hospitalized patients outside the ICU at an academic medical center.

METHODS

Intervention

Our study was implemented in 2 phases (Figure 1).

Figure 1

Baseline Phase

The purpose of the first phase was to obtain baseline data on ASM use prior to implementing our CDS tool designed to influence prescribing. During this baseline phase, a computerized prompt was activated through our POE system whenever a clinician initiated an order for ASM (histamine 2 receptor antagonists or proton pump inhibitors), asking the clinician to select the reason/reasons for the order based on the following predefined response options: (1) active/recent upper gastrointestinal bleed, (2) continuing preadmission medication, (3) Helicobacter pylori treatment, (4) prophylaxis in patient on medications that increase bleeding risk, (5) stress ulcer prophylaxis, (6) suspected/known peptic ulcer disease, gastritis, esophagitis, gastroesophageal reflux disease, and (7) other, with a free‐text box to input the indication. This indications prompt was rolled out to the entire medical center on September 12, 2011 and remained active for the duration of the study period.

Intervention Phase

In the second phase of the study, if a clinician selected stress ulcer prophylaxis as the only indication for ordering ASM, a CDS prompt alerted the clinician that Stress ulcer prophylaxis is not recommended for patients outside of the intensive care unit (ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis. Am J Health‐Syst Pharm. 1999, 56:347‐79). The clinician could then select either, For use in ICUOrder Medication, Choose Other Indication, or Cancel Order. This CDS prompt was rolled out in a staggered manner to the East Campus on January 3, 2012, followed by the West Campus on April 3, 2012.

RESULTS

There were 26,400 adult admissions during the study period, and 22,330 discrete orders for ASM. Overall, 12,056 (46%) admissions had at least 1 charge for ASM. Admission characteristics were similar before and after the intervention on each campus (Table 1).

Table 2 shows the indications chosen each time ASM was ordered, stratified by campus and study phase. Although selection of stress ulcer prophylaxis decreased on both campuses during the intervention phase, selection of continuing preadmission medication increased.

Table 3 shows the unadjusted comparison of outcomes between baseline and intervention phases on each campus. Use of ASM with stress ulcer prophylaxis as the only indication decreased during the intervention phase on both campuses. There was a nonsignificant reduction in overall rates of use on both campuses, and use on discharge was unchanged. Figure 2 demonstrates the unadjusted and modeled monthly rates of admissions with at least 1 ASM order with stress ulcer prophylaxis selected as the only indication, stratified by campus. After adjusting for the admission characteristics in Table 1, during the intervention phase on both campuses there was a significant immediate reduction in the odds of receiving an ASM with stress ulcer prophylaxis selected as the only indication (East Campus odds ratio [OR]: 0.36, 95% confidence interval [CI]: 0.180.71; West Campus OR: 0.41, 95% CI: 0.280.60), and a significant change in trend compared to the baseline phase (East Campus 1.5% daily decrease in odds of receiving ASM solely for stress ulcer prophylaxis, P=0.002; West Campus 0.9% daily decrease in odds of receiving ASM solely for stress ulcer prophylaxis, P=0.02).

Figure 2

DISCUSSION

In this single‐center study, we found that a computerized CDS intervention resulted in a significant reduction in use of ASM for the sole purpose of stress ulcer prophylaxis in patients outside the ICU, a nonsignificant reduction in overall use, and no change in use on discharge. We found low rates of use for the isolated purpose of stress ulcer prophylaxis even before the intervention, and continuing preadmission medication was the most commonly selected indication throughout the study.

Although overall rates of ASM use declined after the intervention, the change was not statistically significant, and was not of the same magnitude as the decline in rates of use for the purpose of stress ulcer prophylaxis. This suggests that our intervention, in part, led to substitution of 1 indication for another. The indication that increased the most after rollout on both campuses was continuing preadmission medication. There are at least 2 possibilities for this finding: (1) the intervention prompted physicians to more accurately record the indication, or (2) physicians falsified the indication in order to execute the order. To explore these possibilities, we reviewed the charts of a random sample of 100 admissions during each of the baseline and intervention phases where continuing preadmission medication was selected as an indication for an ASM order. We found that 6/100 orders in the baseline phase and 7/100 orders in the intervention phase incorrectly indicated that the patient was on ASM prior to admission (P=0.77). This suggests that scenario 1 above is the more likely explanation for the increased use of this indication, and that the intervention, in part, simply unmasked the true rate of use at our medical center for the isolated purpose of stress ulcer prophylaxis.

These findings have implications for others attempting to use computerized CDS to better understand physician prescribing. They suggest that information collected through computer‐based interaction with clinicians at the point of care may not always be accurate or complete. As institutions increasingly use similar interventions to drive behavior, information obtained from such interaction should be validated, and when possible, patient outcomes should be measured.

Our findings suggest that rates of ASM use for the purpose of stress ulcer prophylaxis in the hospital may have declined over the last decade. Studies demonstrating that up to 70% of inpatient use of ASM was inappropriate were conducted 5 to 10 years ago.[1, 2, 3, 4, 5] Since then, studies have demonstrated risk of nosocomial infections in patients on ASM.[9, 10, 11] It is possible that the low rate of use for stress ulcer prophylaxis in our study is attributable to awareness of the risks of these medications, and limited our ability to detect differences in overall use. It is also possible, however, that a portion of the admissions with continuation of preadmission medication as the indication were started on these medications during a prior hospitalization. Thus, some portion of preadmission use is likely to represent failed medication reconciliation during a prior discharge. In this context, hospitalization may serve as an opportunity to evaluate the indication for ASM use even when these medications show up as preadmission medications.

There are additional limitations. First, the single‐center nature limits generalizability. Second, the first phase of our study, designed to obtain baseline data on ASM use, may have led to changes in prescribing prior to implementation of our CDS tool. Additionally, we did not validate the accuracy of each of the chosen indications, or the site of initial prescription in the case of preadmission exposure. Last, our study was not powered to investigate changes in rates of nosocomial gastrointestinal bleeding or nosocomial pneumonia owing to the infrequent nature of these complications.

In conclusion, we designed a simple computerized CDS intervention that was associated with a reduction in ASM use for stress ulcer prophylaxis in patients outside the ICU, a nonsignificant reduction in overall use, and no change in use on discharge. The majority of inpatient use represented continuation of preadmission medication, suggesting that interventions to improve the appropriateness of ASM prescribing should span the continuum of care. Future studies should investigate whether it is worthwhile and appropriate to reevaluate continued use of preadmission ASM during an inpatient stay.

Prior studies have found that up to 70% of acid‐suppressive medication (ASM) use in the hospital is not indicated, most commonly for stress ulcer prophylaxis in patients outside of the intensive care unit (ICU).[1, 2, 3, 4, 5, 6, 7] Accordingly, reducing inappropriate use of ASM for stress ulcer prophylaxis in hospitalized patients is 1 of the 5 opportunities for improved healthcare value identified by the Society of Hospital Medicine as part of the American Board of Internal Medicine's Choosing Wisely campaign.[8]

We designed and tested a computerized clinical decision support (CDS) intervention with the goal of reducing use of ASM for stress ulcer prophylaxis in hospitalized patients outside the ICU at an academic medical center.

METHODS

Intervention

Our study was implemented in 2 phases (Figure 1).

Figure 1

Baseline Phase

The purpose of the first phase was to obtain baseline data on ASM use prior to implementing our CDS tool designed to influence prescribing. During this baseline phase, a computerized prompt was activated through our POE system whenever a clinician initiated an order for ASM (histamine 2 receptor antagonists or proton pump inhibitors), asking the clinician to select the reason/reasons for the order based on the following predefined response options: (1) active/recent upper gastrointestinal bleed, (2) continuing preadmission medication, (3) Helicobacter pylori treatment, (4) prophylaxis in patient on medications that increase bleeding risk, (5) stress ulcer prophylaxis, (6) suspected/known peptic ulcer disease, gastritis, esophagitis, gastroesophageal reflux disease, and (7) other, with a free‐text box to input the indication. This indications prompt was rolled out to the entire medical center on September 12, 2011 and remained active for the duration of the study period.

Intervention Phase

In the second phase of the study, if a clinician selected stress ulcer prophylaxis as the only indication for ordering ASM, a CDS prompt alerted the clinician that Stress ulcer prophylaxis is not recommended for patients outside of the intensive care unit (ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis. Am J Health‐Syst Pharm. 1999, 56:347‐79). The clinician could then select either, For use in ICUOrder Medication, Choose Other Indication, or Cancel Order. This CDS prompt was rolled out in a staggered manner to the East Campus on January 3, 2012, followed by the West Campus on April 3, 2012.

RESULTS

There were 26,400 adult admissions during the study period, and 22,330 discrete orders for ASM. Overall, 12,056 (46%) admissions had at least 1 charge for ASM. Admission characteristics were similar before and after the intervention on each campus (Table 1).

Table 2 shows the indications chosen each time ASM was ordered, stratified by campus and study phase. Although selection of stress ulcer prophylaxis decreased on both campuses during the intervention phase, selection of continuing preadmission medication increased.

Table 3 shows the unadjusted comparison of outcomes between baseline and intervention phases on each campus. Use of ASM with stress ulcer prophylaxis as the only indication decreased during the intervention phase on both campuses. There was a nonsignificant reduction in overall rates of use on both campuses, and use on discharge was unchanged. Figure 2 demonstrates the unadjusted and modeled monthly rates of admissions with at least 1 ASM order with stress ulcer prophylaxis selected as the only indication, stratified by campus. After adjusting for the admission characteristics in Table 1, during the intervention phase on both campuses there was a significant immediate reduction in the odds of receiving an ASM with stress ulcer prophylaxis selected as the only indication (East Campus odds ratio [OR]: 0.36, 95% confidence interval [CI]: 0.180.71; West Campus OR: 0.41, 95% CI: 0.280.60), and a significant change in trend compared to the baseline phase (East Campus 1.5% daily decrease in odds of receiving ASM solely for stress ulcer prophylaxis, P=0.002; West Campus 0.9% daily decrease in odds of receiving ASM solely for stress ulcer prophylaxis, P=0.02).

Figure 2

DISCUSSION

In this single‐center study, we found that a computerized CDS intervention resulted in a significant reduction in use of ASM for the sole purpose of stress ulcer prophylaxis in patients outside the ICU, a nonsignificant reduction in overall use, and no change in use on discharge. We found low rates of use for the isolated purpose of stress ulcer prophylaxis even before the intervention, and continuing preadmission medication was the most commonly selected indication throughout the study.

Although overall rates of ASM use declined after the intervention, the change was not statistically significant, and was not of the same magnitude as the decline in rates of use for the purpose of stress ulcer prophylaxis. This suggests that our intervention, in part, led to substitution of 1 indication for another. The indication that increased the most after rollout on both campuses was continuing preadmission medication. There are at least 2 possibilities for this finding: (1) the intervention prompted physicians to more accurately record the indication, or (2) physicians falsified the indication in order to execute the order. To explore these possibilities, we reviewed the charts of a random sample of 100 admissions during each of the baseline and intervention phases where continuing preadmission medication was selected as an indication for an ASM order. We found that 6/100 orders in the baseline phase and 7/100 orders in the intervention phase incorrectly indicated that the patient was on ASM prior to admission (P=0.77). This suggests that scenario 1 above is the more likely explanation for the increased use of this indication, and that the intervention, in part, simply unmasked the true rate of use at our medical center for the isolated purpose of stress ulcer prophylaxis.

These findings have implications for others attempting to use computerized CDS to better understand physician prescribing. They suggest that information collected through computer‐based interaction with clinicians at the point of care may not always be accurate or complete. As institutions increasingly use similar interventions to drive behavior, information obtained from such interaction should be validated, and when possible, patient outcomes should be measured.

Our findings suggest that rates of ASM use for the purpose of stress ulcer prophylaxis in the hospital may have declined over the last decade. Studies demonstrating that up to 70% of inpatient use of ASM was inappropriate were conducted 5 to 10 years ago.[1, 2, 3, 4, 5] Since then, studies have demonstrated risk of nosocomial infections in patients on ASM.[9, 10, 11] It is possible that the low rate of use for stress ulcer prophylaxis in our study is attributable to awareness of the risks of these medications, and limited our ability to detect differences in overall use. It is also possible, however, that a portion of the admissions with continuation of preadmission medication as the indication were started on these medications during a prior hospitalization. Thus, some portion of preadmission use is likely to represent failed medication reconciliation during a prior discharge. In this context, hospitalization may serve as an opportunity to evaluate the indication for ASM use even when these medications show up as preadmission medications.

There are additional limitations. First, the single‐center nature limits generalizability. Second, the first phase of our study, designed to obtain baseline data on ASM use, may have led to changes in prescribing prior to implementation of our CDS tool. Additionally, we did not validate the accuracy of each of the chosen indications, or the site of initial prescription in the case of preadmission exposure. Last, our study was not powered to investigate changes in rates of nosocomial gastrointestinal bleeding or nosocomial pneumonia owing to the infrequent nature of these complications.

In conclusion, we designed a simple computerized CDS intervention that was associated with a reduction in ASM use for stress ulcer prophylaxis in patients outside the ICU, a nonsignificant reduction in overall use, and no change in use on discharge. The majority of inpatient use represented continuation of preadmission medication, suggesting that interventions to improve the appropriateness of ASM prescribing should span the continuum of care. Future studies should investigate whether it is worthwhile and appropriate to reevaluate continued use of preadmission ASM during an inpatient stay.

Prior studies have found that up to 70% of acid‐suppressive medication (ASM) use in the hospital is not indicated, most commonly for stress ulcer prophylaxis in patients outside of the intensive care unit (ICU).[1, 2, 3, 4, 5, 6, 7] Accordingly, reducing inappropriate use of ASM for stress ulcer prophylaxis in hospitalized patients is 1 of the 5 opportunities for improved healthcare value identified by the Society of Hospital Medicine as part of the American Board of Internal Medicine's Choosing Wisely campaign.[8]

We designed and tested a computerized clinical decision support (CDS) intervention with the goal of reducing use of ASM for stress ulcer prophylaxis in hospitalized patients outside the ICU at an academic medical center.

METHODS

Intervention

Our study was implemented in 2 phases (Figure 1).

Figure 1

Baseline Phase

The purpose of the first phase was to obtain baseline data on ASM use prior to implementing our CDS tool designed to influence prescribing. During this baseline phase, a computerized prompt was activated through our POE system whenever a clinician initiated an order for ASM (histamine 2 receptor antagonists or proton pump inhibitors), asking the clinician to select the reason/reasons for the order based on the following predefined response options: (1) active/recent upper gastrointestinal bleed, (2) continuing preadmission medication, (3) Helicobacter pylori treatment, (4) prophylaxis in patient on medications that increase bleeding risk, (5) stress ulcer prophylaxis, (6) suspected/known peptic ulcer disease, gastritis, esophagitis, gastroesophageal reflux disease, and (7) other, with a free‐text box to input the indication. This indications prompt was rolled out to the entire medical center on September 12, 2011 and remained active for the duration of the study period.

Intervention Phase

In the second phase of the study, if a clinician selected stress ulcer prophylaxis as the only indication for ordering ASM, a CDS prompt alerted the clinician that Stress ulcer prophylaxis is not recommended for patients outside of the intensive care unit (ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis. Am J Health‐Syst Pharm. 1999, 56:347‐79). The clinician could then select either, For use in ICUOrder Medication, Choose Other Indication, or Cancel Order. This CDS prompt was rolled out in a staggered manner to the East Campus on January 3, 2012, followed by the West Campus on April 3, 2012.

RESULTS

There were 26,400 adult admissions during the study period, and 22,330 discrete orders for ASM. Overall, 12,056 (46%) admissions had at least 1 charge for ASM. Admission characteristics were similar before and after the intervention on each campus (Table 1).

Table 2 shows the indications chosen each time ASM was ordered, stratified by campus and study phase. Although selection of stress ulcer prophylaxis decreased on both campuses during the intervention phase, selection of continuing preadmission medication increased.

Table 3 shows the unadjusted comparison of outcomes between baseline and intervention phases on each campus. Use of ASM with stress ulcer prophylaxis as the only indication decreased during the intervention phase on both campuses. There was a nonsignificant reduction in overall rates of use on both campuses, and use on discharge was unchanged. Figure 2 demonstrates the unadjusted and modeled monthly rates of admissions with at least 1 ASM order with stress ulcer prophylaxis selected as the only indication, stratified by campus. After adjusting for the admission characteristics in Table 1, during the intervention phase on both campuses there was a significant immediate reduction in the odds of receiving an ASM with stress ulcer prophylaxis selected as the only indication (East Campus odds ratio [OR]: 0.36, 95% confidence interval [CI]: 0.180.71; West Campus OR: 0.41, 95% CI: 0.280.60), and a significant change in trend compared to the baseline phase (East Campus 1.5% daily decrease in odds of receiving ASM solely for stress ulcer prophylaxis, P=0.002; West Campus 0.9% daily decrease in odds of receiving ASM solely for stress ulcer prophylaxis, P=0.02).

Figure 2

DISCUSSION

In this single‐center study, we found that a computerized CDS intervention resulted in a significant reduction in use of ASM for the sole purpose of stress ulcer prophylaxis in patients outside the ICU, a nonsignificant reduction in overall use, and no change in use on discharge. We found low rates of use for the isolated purpose of stress ulcer prophylaxis even before the intervention, and continuing preadmission medication was the most commonly selected indication throughout the study.

Although overall rates of ASM use declined after the intervention, the change was not statistically significant, and was not of the same magnitude as the decline in rates of use for the purpose of stress ulcer prophylaxis. This suggests that our intervention, in part, led to substitution of 1 indication for another. The indication that increased the most after rollout on both campuses was continuing preadmission medication. There are at least 2 possibilities for this finding: (1) the intervention prompted physicians to more accurately record the indication, or (2) physicians falsified the indication in order to execute the order. To explore these possibilities, we reviewed the charts of a random sample of 100 admissions during each of the baseline and intervention phases where continuing preadmission medication was selected as an indication for an ASM order. We found that 6/100 orders in the baseline phase and 7/100 orders in the intervention phase incorrectly indicated that the patient was on ASM prior to admission (P=0.77). This suggests that scenario 1 above is the more likely explanation for the increased use of this indication, and that the intervention, in part, simply unmasked the true rate of use at our medical center for the isolated purpose of stress ulcer prophylaxis.

These findings have implications for others attempting to use computerized CDS to better understand physician prescribing. They suggest that information collected through computer‐based interaction with clinicians at the point of care may not always be accurate or complete. As institutions increasingly use similar interventions to drive behavior, information obtained from such interaction should be validated, and when possible, patient outcomes should be measured.

Our findings suggest that rates of ASM use for the purpose of stress ulcer prophylaxis in the hospital may have declined over the last decade. Studies demonstrating that up to 70% of inpatient use of ASM was inappropriate were conducted 5 to 10 years ago.[1, 2, 3, 4, 5] Since then, studies have demonstrated risk of nosocomial infections in patients on ASM.[9, 10, 11] It is possible that the low rate of use for stress ulcer prophylaxis in our study is attributable to awareness of the risks of these medications, and limited our ability to detect differences in overall use. It is also possible, however, that a portion of the admissions with continuation of preadmission medication as the indication were started on these medications during a prior hospitalization. Thus, some portion of preadmission use is likely to represent failed medication reconciliation during a prior discharge. In this context, hospitalization may serve as an opportunity to evaluate the indication for ASM use even when these medications show up as preadmission medications.

There are additional limitations. First, the single‐center nature limits generalizability. Second, the first phase of our study, designed to obtain baseline data on ASM use, may have led to changes in prescribing prior to implementation of our CDS tool. Additionally, we did not validate the accuracy of each of the chosen indications, or the site of initial prescription in the case of preadmission exposure. Last, our study was not powered to investigate changes in rates of nosocomial gastrointestinal bleeding or nosocomial pneumonia owing to the infrequent nature of these complications.

In conclusion, we designed a simple computerized CDS intervention that was associated with a reduction in ASM use for stress ulcer prophylaxis in patients outside the ICU, a nonsignificant reduction in overall use, and no change in use on discharge. The majority of inpatient use represented continuation of preadmission medication, suggesting that interventions to improve the appropriateness of ASM prescribing should span the continuum of care. Future studies should investigate whether it is worthwhile and appropriate to reevaluate continued use of preadmission ASM during an inpatient stay.