Las Vegas—A San Antonio health care system markedly reduced unnecessary use of proton pump inhibitors (PPIs) for stress ulcer prophylaxis (SUP) in the ICU and ended up saving $80,000 annually. At a Boston-area hospital, researchers determined that reducing inappropriate PPI use among general medicine patients could lead to yearly cost avoidance in the neighborhood of $1 million.
Both initiatives, presented at the December 2012 Midyear Clinical Meeting of the American Society of Health-System Pharmacists (ASHP), were undertaken to address persistent inappropriate use of PPIs, which has been linked to higher hospital costs and an increased risk for Clostridium difficile infections (sidebar, page 30).
“Many of our general medicine patients were on PPIs or H2-receptor agonists constantly, and no one was following the ASHP 1999 stress ulcer prophylaxis guidelines,” said Paige Cuellar, PharmD, a critical care specialist with the five-hospital Baptist Health System, in San Antonio.
Because those patients often are not good candidates for SUP, Dr. Cuellar decided to shift use of SUP where it is needed most—in the ICU, where patients often are ventilated for more than 48 hours and thus face a heightened risk for gastrointestinal (GI) bleeding (poster 5-050). “Our goal was to reduce PPI overuse among patients who no longer needed mechanical ventilation and who had no other primary risk factors for GI bleeding,” she said.
The ICU proved an ideal venue for tracking and changing PPI prescribing habits, because all 134 of the system’s adult ICU beds are monitored around the clock by a tele-ICU, which augments observation and care by the on-site staff. Critical care physicians and nurses at a remotely located tele-health facility continuously track real-time patient information, including lab values, medications and vital signs. The system, called the eICU LifeGuard initiative, is supported by Philips Healthcare’s IntelliSpace eCareManager platform.
The remote staff, for example, alerts floor nurses to check daily if SUP is appropriate. “Without that electronic reminder, floor nurses could of course assess patients at the bedside every day,” Dr. Cuellar explained. “But with the tele-ICU assisting, our on-site nurses have become much more aware and involved with this aspect of care. They began approaching pharmacists and telling us when they thought SUP was no longer appropriate.”
Every evening during a two-month verification phase, tele-ICU nurses assessed the risk for GI bleeding for each patient in the 38-bed ICU at one of the system’s hospitals. The three-week intervention phase that followed involved all adult ICU beds. On-site nurses and pharmacists recommended 102 conversions from IV to oral PPIs; 86 (84.3%) were accepted. Discontinuation of SUP was recommended 173 times; prescribers accepted 91 (52.6%) of the recommendations. The cost of SUP treatment decreased from $1.06 per adjusted patient-day to 77 cents and the projected annual cost savings from decreased SUP amounted to $78,052.
“We were able to get nurses well educated about the appropriateness of SUP,” Dr. Cuellar said. “It was very important to start weaning patients from PPIs when they were sent to the floors, because after that there aren’t enough clinical pharmacists to cover all patients and check for appropriate PPI use.” Monitoring PPI use in the ICU is now standard practice.
“This study offers excellent findings and underscores the need to educate clinicians and patients that PPIs may be harmless in the short term, but that overuse can lead to unexpected problems,” said Chandra Sekar, RPh, PhD, an associate professor of pharmaceutical science at the University of findlay School of Pharmacy, in findlay, Ohio. “Physicians and other providers need to follow current guidelines for stress ulcer prophylaxis in hospitalized patients and use PPIs only for patients who really need them—which is less than 10% of the population—and not to prevent a bleed that’s never going to occur.”
When Is Use in Noncritical Patients OK?
At Northeastern University, Bouvé School of Health Sciences in Boston, researchers analyzed the economic effects of misusing PPIs for SUP in the general patient population (poster 3-097). “Our institution might save more than $1 million annually if PPIs—specifically, pantoprazole—were [prescribed] more appropriately and if institutional guidelines regulated their use,” said lead author Chau Chu, a PharmD candidate. An examination of the literature revealed that inappropriate PPI use for SUP occurred in 58% to 92% of cases. By extrapolating those best- and worst-case scenarios to a local 191-bed teaching hospital, Ms. Chu and her colleagues projected savings that ranged from $338,397 to $2,844,477 annually. Their calculations accounted not just for drug costs, but also for treating patients with C. difficile and community-acquired pneumonia that may have resulted from PPI use. The researchers determined the incidence of PPI-induced illness from previous research and concluded that strict enforcement of ASHP guidelines for SUP simultaneously promotes optimal patient care and reduces costs.
In a third investigation, researchers found that 163 of 744 patients (21.9%) were taking PPIs when they were admitted to Swedish Covenant Hospital, a 313-bed teaching facility in Chicago (poster 3-101). Of those 163 patients, 37 (22.7%) were admitted with pneumonia, and five (3.1%) were admitted with a fracture—rates comparable to those noted in other investigations of PPI risk, according to Zoon Park, PharmD, BCPS, an assistant director of pharmacy services. Documentation of any indication for PPI use was lacking in nearly half of the 163 patients using PPIs.
“PPI use prior to admission definitely increased the risk of community-acquired pneumonia,” Dr. Park said. “Overall, the high rate of PPI use is concerning and may place patients at risk for complications.”
These studies confirm previous findings about the overuse and risks associated with imprudent PPI use, said Dr. Sekar. “Reducing inappropriate prescribing for inpatients must be done one hospital at a time, and clinical pharmacists can play a big part in making that happen by encouraging new behaviors,” he said. “The beauty here is that all hospitals want to save money, and this is a very simple way to improve the bottom line while at the same time getting better patient outcomes.”
Drs. Sekar, Cuellar and Park, and Ms. Chu reported no relevant financial conflicts of interest.
Inappropriate—and potentially harmful—use of proton pump inhibitors (PPIs) for stress ulcer prophylaxis (SUP) is well documented in the scientific literature.
Which is not to say the drugs can’t be effective: PPIs clearly can reduce the incidence of gastric stress ulcers and resultant GI bleeding (Interact Cardiovasc Thorac Surg 2013;16:356-360). But as early as the mid-1990s, some researchers raised alarms that these drugs were prescribed too liberally for critically ill patients, few of whom develop clinically important GI bleeds (N Engl J Med 1994;330:377-381). More recently, concerns about PPI overuse have expanded to include indiscriminate prescribing among general hospital populations and outpatients. Many patients on general medicine floors, for example, receive PPIs whether or not they need them (Am J Health Syst Pharm 2007;64:1396-1400). One study that well represents the problem found that an intravenous PPI was prescribed for nearly 70% of inpatients who had no indications for the drug (J Clin Med Res 2010;2:215-219).
Moreover, many patients often are told to continue taking the medications when they return home from the hospital, despite no sound reasons for doing so. In one hospital, the cost of inappropriate SUP post-discharge was nearly $70,000 annually (Am J Gastroenterol 2006;101:2200-2205).
Beyond the financial burden, what worries a growing number of clinicians is the link between prolonged PPI use and potentially serious adverse events, such as rebound acid secretion, community-acquired pneumonia, bone fractures, hypergastrinemia, nutritional deficiencies and C. difficile infection (Proc Bayl Univ Med Cent 2009;22:373-376; Drugs 2012;72:437-445; Am J Gastroenterol 2012;107:1001-1010). In 2012, an FDA drug safety communication warned that PPIs “may be associated with an increased risk of [C. difficile]–associated diarrhea.”
Although the absolute risk for complications attributed to PPIs may be low, they’re real enough to prompt clinicians to step back and take a fresh look at PPI prescribing practices and ensure proper use. According to the ASHP’s Therapeutic Guidelines on Stress Ulcer Prophylaxis, “Prophylaxis is recommended in patients with coagulopathy or patients requiring mechanical ventilation for more than 48 hours. Prophylaxis is also recommended in patients with a history of GI ulceration or bleeding within one year before admission and in patients with at least two of the following risk factors: sepsis, ICU stay of more than one week, occult bleeding lasting six days or more, and use of high-dose corticosteroids” (Am J Health Syst Pharm 2007;64:1396).
“These are very effective drugs, but we use them too often, and extended use can lead to unexpected consequences,” said Chandra Sekar, RPh, PhD, an associate professor of pharmaceutical science at the University of findlay School of Pharmacy, in findlay, Ohio. “Many clinicians are still unaware of the risk.”