Use of Evidence-Based Guidelines May Reduce Proton Pump Inhibitor Prescriptions

Laurie Barclay, MD

May 11, 2010

May 11, 2010 — Implementing standardized, evidence-based guidelines for preventing nosocomial upper gastrointestinal tract bleeding appears to be associated with reductions in prescriptions for proton pump inhibitors (PPIs), according to the results of a single-center study reported in the May 10 issue of the Archives of Internal Medicine. The article describing this study is part of a series about PPIs in the Archives of Internal Medicine, titled "Less Is More."

"[PPIs] are frequently prescribed for prophylaxis of nosocomial upper gastrointestinal tract bleeding," write Patrick S. Yachimski, MD, MPH, formerly from Massachusetts General Hospital, Harvard Medical School, Boston, and colleagues. "Some inpatients receiving PPIs may have no risk factors for nosocomial upper gastrointestinal tract bleeding, and PPIs may be continued unnecessarily at hospital discharge. We aimed to assess the effect of standardized guidelines on PPI prescribing practices."

In the medical service of a tertiary academic medical center, PPI use among inpatient admissions was compared during the month before vs the month after implementation of PPI use guidelines.

Of 942 patients evaluated, 48% were prescribed PPIs while they were inpatients, and 41% were prescribed PPIs at hospital discharge. Factors associated with inpatient PPI use, based on univariate analysis, included age, duration of hospitalization, history of gastroesophageal reflux disease or upper gastrointestinal tract bleeding, and use of outpatient PPI, aspirin, or glucocorticoids.

Implementation of guidelines was associated with lower rates of inpatient PPI use (27% before vs 16% after; P = .001) and lower rates of PPI prescription at discharge (16% before vs 10% after; P = .03) in patients who at admission were not prescribed outpatient PPIs.

"Introduction of standardized guidelines resulted in lower rates of PPI use among a subset of inpatients and reduced the rate of PPI prescriptions at discharge," the study authors write.

Limitations of this study include that data were retrieved from medical record review, possible patient recall bias, possible confounding factors, and the inability of guidelines to address every clinical circumstance in which prophylactic PPI therapy might be considered.

In an accompanying editorial, Mitchell H. Katz, MD, from the San Francisco Department of Public Health, California, describes this study, as well as the others published in the series, "Less is More."

"In the drive to decrease harm due to PPI use, we can take some comfort in the study by Yachimski and colleagues," Dr. Katz writes. "They found that introduction of a standardized guideline on prescribing practice decreased inpatient use of PPI prescriptions, but only among patients not receiving PPIs at the time of hospital admission. This makes sense because the bulk of PPI prescribing occurs among outpatients."

The National Institutes of Health supported this study. The study authors have disclosed no relevant financial relationships. Dr. Katz is an independent consultant for Health Management Associates.

Arch Intern Med. 2010;170:779-783.