October 09, 2017
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Intervention reduces unnecessary PPI use in patients with upper GI bleeding

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Emmanuel Coronel
Emmanuel Coronel

A trainee-led intervention reduced unnecessary proton pump inhibitor infusions in patients hospitalized with upper GI bleeding, according to a research letter published in JAMA Internal Medicine.

The intervention, which was based on the “Culture, Oversight, Systems Change, Training framework,” cut inappropriate PPI infusions by 35% and resulted in significant cost savings.

“The use of continuous proton pump inhibitor (PPI) infusions are recommended for patients with upper gastrointestinal bleeding (UGIB) from peptic ulcer disease,” Emmanuel Coronel MD, of the section of gastroenterology in the department of medicine at University of Chicago, told Healio Gastroenterology and Liver Disease. “Before endoscopy, PPI infusions are given to assist with bleeding control. After endoscopy, continuous PPI infusions should only be used in patients who have an ulcer with high-risk features for bleeding.”

Gautham Reddy, MD
Gautham Reddy

Coronel and colleagues, including Gautham Reddy, MD, said they noticed overuse of PPI infusions in up to 50% of patients after endoscopy at their institution.

“Unfortunately, PPI infusions may be continued for 72 hours without indication,” they wrote. “Reducing the overuse of these infusions is important because, in addition to increasing the length of stay and cost, PPI overuse is associated with various complications.”

To reduce the inappropriate use of PPI infusions in these patients, fellows and residents at University of Chicago launched an intervention in 2015, which changed the EHR to prompt physicians to choose an appropriate indication for PPI infusions. Additionally, gastroenterology staff championed the initiative, pharmacists tracked monthly PPI infusions, and staff received training.

Investigators prospectively collected data on PPI infusions, indications, and endoscopic findings from July 2015 to April 2016, and compared them with historical control data from July 2014 to June 2015, before they implemented the intervention.

“The intervention significantly decreased the inappropriate use of PPI, resulting in substantial cost savings ($121,000 across 9-months),” Coronel said.

Inappropriate PPI infusions dropped significantly from an average of 50% (95% CI; 45.1%-54.7%) to 15% (95% CI; 10%-18.5%), an overall reduction of 35% (95% CI; −44.6% to −27.1%; P < .001).

PPI infusions were more frequently stopped after endoscopy once the intervention began, with 65.7% before (95% CI; 50%-81.4%) compared with 92.5% after (95% CI; 84.3%-100%; P = .004).

The intervention resulted in a daily cost savings of $277 per patient assuming all required PPIs twice per day — a single PPI infusion cost $378 per day, while twice daily PPIs cost $100.87.

Over the 9-month intervention, total estimated savings in pharmacy costs were at least $121,000.

“These changes were not observed for surgical services in which physicians had access to electronic health record changes but no education although a nonsignificant decrease in the percentage of inappropriate PPI infusions occurred 6 months after the intervention was launched,” investigators noted (32.3%; 95% CI, 23.1%-41.5% vs. 20.5%; 95% CI, 11.8%-29.2%; P = .08).

This showed that “access to the systems change alone did not result in significant changes, highlighting the importance of including all aspects of the framework in the intervention,” they added.

While further research is needed to assess the intervention’s durability and complications associated with overuse of PPI infusions, the investigators concluded that this intervention “resulted in high-value, guideline-based care for inpatients with UGIB.”

“This intervention demonstrates the utility of implementing education models within the EMR as a tool to promote evidence based care and ultimately resulting in decreasing costs,” Coronel said. – by Adam Leitenberger

Disclosures: The authors report no relevant financial disclosures.

Editor's note: This article was updated on October 13 with additional information from the study authors.