A multidisciplinary, patient-centered approach can dramatically reduce inappropriate use of proton pump inhibitors (PPI), based on the success of a quality improvement study conducted at an academic, primary care clinic in New York.
In 1 year, the program reduced inappropriate PPI use from 80% to 30%, reported lead author Naren Nallapeta, MD, an internal medicine resident at the State University of New York at Buffalo, and colleagues.
According to the investigators, inappropriate use of PPIs is a common and growing concern. Recent patent expirations have led to wider availability of generic and over-the-counter options; and the consequences of unnecessary usage can be serious.
“PPI intake has been found to have a significant association with community-acquired pneumonia, Clostridium difficile associated diarrhea, impaired B12 absorption, hypomagnesemia, hip fractures, acute and chronic kidney disease, and spontaneous bacterial peritonitis in patients with cirrhotic ascites,” the investigators wrote in the Journal of Clinical Gastroenterology.
In 2017, the American Gastroenterological Association released guidelines that include indications for PPIs. But these guidelines often go unheeded, the investigators noted. Multiple studies have documented rates of inappropriate PPI use ranging from 54.1% to 82%. Previous studies have yielded mixed results: Simple physician education alone was found insufficient to reduce inappropriate prescriptions in a primary care setting, whereas studies involving pharmacy personnel have had positive results in various treatment centers.
In a survey of their own clinic, the Erie County Medical Center, an internal medicine service located in a tertiary care safety net hospital at the University at Buffalo, the investigators found that 80% of PPI prescriptions were inappropriate. This prompted a goal to reduce inappropriate use to less than 60% within 1 year.
To achieve this goal, the investigators started a quality improvement project based on the Plan-Do-Study-Act Cycle (PDSA) Model of health care improvement. The quality improvement team included internal medicine attending physicians and physician residents, gastroenterologists, patients, nurses, administrative and information technology staff, and a social worker.
After identifying root causes, the team deployed a variety of strategies to cut down on inappropriate PPI use. First, a new prompt in the electronic medical record reminded physicians to discuss PPI use with patients. Physicians were also given additional training concerning appropriate indications for PPIs, as well as a pocket guide and brochures that could be used for patient education. These efforts were supplemented by an enhanced nursing workflow, as well as continuous reinforcement with positive feedback for health care workers involved.
One year later, results exceeded expectations. Based on data from 180 patients, inappropriate use decreased from 80% to 30%, with a mean discontinuation rate of approximately 50%, an average that was maintained for 6 months beyond the end of the study. The annual, direct cost savings of the program totaled $13,992.
When indicated, patients on long-term PPIs were referred to the gastroenterology service for esophagogastroduodenoscopy. About half of the referred patients (49.8%) completed this procedure, which exceeded the baseline completion rate of less than 30%.
Dr. Smita Bakhai
According to principal author Smita Bakhai, MD, of the department of internal medicine at the University at Buffalo, and a physician with UBMB Internal Medicine, the strategies used in this study are broadly applicable.
“The multidisciplinary approach, including patient engagement, would work well in any setting, even with limited resources and without the use of pharmacy personnel,” Dr. Bakhai said in an interview. “We used a patient-centered approach and physicians used shared decision making with patients to taper and discontinue PPIs or switch them to an H2-blocking agent when [patients] did not need to be on chronic PPIs.”
Dr. Bakhai went on to highlight the importance of working with multiple stakeholders.
“This project is unique because it was a resident-led project,” she said. “As academicians, we should always engage the fellows and the residents in any quality improvement work that we do, because they are the doctors of the future.”
Beyond care providers and patients, Dr. Bakhai emphasized the need to involve administrative leadership who can guarantee long-term resources and cultivate the right culture.
“Without the resources, you can’t sustain the project,” Dr. Bakhai said. “You have to have allocated resources, and a culture of safety and quality in the environment that you are doing the project. It has to be a supportive environment. We had all of those things, and that’s why we succeeded.”
The study was funded by the National Institutes of Health. The investigators reported no conflicts of interest.
SOURCE: Nallapeta N et al. J Clin Gastroenterol. 2020 Feb 14. doi: 10.1097/MCG.0000000000001317.