Highlights
- •More than 50/% of patients received PPIs before, during, or after hospitalization.
- •Hospital clinicians changed PPI therapy prescribed by GPs only rarely.
- •Appropriateness of PPI use/non-use was found in about 2/3 of cases.
- •The most common inappropriate behavior was over- rather than under-prescription.
Abstract
Introduction
Proton pump inhibitor (PPI) prescriptions have raised concern for both huge increase
of health expenditure and possible long-term adverse effects.
Objective
To evaluate appropriateness of PPI prescription in ambulatory and hospital care.
Design
Observational cohort study.
Patients
Patients admitted to the Internal Medicine Unit of Bologna S. Orsola Hospital between
15/09/2013 and 15/12/2013. Data on clinical condition and drug therapy were collected
at three time points: admission (reflecting GP's prescription), hospital stay and
discharge.
Main measures
Appropriateness of PPI use was evaluated as follows: (1) agreement between PPI use/non-use
and appropriate clinical condition; (2) in PPI users, assessment of Medication Appropriateness
Index (MAI). Differences in appropriateness among time points were analyzed by chi-square
test. Logistic regression model was used to identify possible determinants of PPI
appropriateness.
Key results
Among 280 patients, 56% received PPI at least once in the three time points. Appropriateness,
according to indication of use, was similar between admission and hospital stay (61%
vs. 62%; p = 0.82) and between hospital stay and discharge (62% vs. 59%; p = 0.94). MAI score showed important, although statistically non-significant, change
in appropriateness between admission and hospital stay (20% vs. 28%; p = 0.16). Age ≥ 65 was always associated with appropriate PPI use (up to OR = 4.37; p < 0.01), whereas cardiovascular comorbidity and conditions requiring analgesic treatment
influenced appropriateness only at admission (OR = 3.84; p < 0.01 and OR = 0.34; p < 0.01, respectively).
Conclusions
Hospital clinicians only rarely reconsidered GP's choice to prescribe PPI. Room for
improvement in PPI appropriateness is represented by (1) assessing gastrointestinal
risk in each patient under analgesics and anti-inflammatory drugs, and (2) short-term
re-evaluation of PPI prescription after discharge.
Abbreviations:
PPI (Proton pump inhibitor), GP (General practitioner), MAI (Medication Appropriateness Index), OR (Odds ratio), OTC (Over the counter), GERD (Gastroesophageal reflux disease), NSAID (Non-steroidal anti-inflammatory drug), ASA (Acetylsalicylic acid)Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to European Journal of Internal MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Overprescribing proton pump inhibitors.BMJ. 2008; 336: 2-3
- Aktuelle Daten KTuK: Arzneiverordnungs-Report.2010 ([article online], 2010. Available from) (Accessed 21 July 2015)
- IMS Health. [article online].2015 (Available from) (Accessed 21 July 2015)
- National Report on Medicines use in Italy. Year 2013. (English edition).in: The Medicines Utilisation Monitoring Centre. [article online]. 2014 (Available from http://www.agenziafarmaco.gov.it/sites/default/files/OsMed_Report13_Eng.pdf. Accessed 21 July 2015)
- Adverse effects of proton pump inhibitors.Best Pract Res Clin Gastroenterol. 2010; 24: 193-201
- Defining appropriate use of proton-pump inhibitors among medical inpatients.J Gen Intern Med. 2015;
- An evaluation of the use of proton pump inhibitors.Pharm World Sci. 2001; 23: 116-117
- Safety of proton pump inhibitors.Med Clin (Barc). 2006; 127: 790-795
- Vertebral fracture efficacy during risedronate therapy in patients using proton pump inhibitors.Osteoporos Int. 2012; 23: 277-284
- Proton pump inhibitor use and the antifracture efficacy of alendronate.Arch Intern Med. 2011; 171: 998-1004
- Thyroxine in goiter, Helicobacter pylori infection, and chronic gastritis.N Engl J Med. 2006; 354: 1787-1795
- Systematic review: impaired drug absorption related to the co-administration of antisecretory therapy.Aliment Pharmacol Ther. 2009; 29: 1219-1229
- Effect of the clopidogrel-proton pump inhibitor drug interaction on adverse cardiovascular events in patients with acute coronary syndrome.Pharmacotherapy. 2012; 32: 809-818
- Concomitant use of clopidogrel and proton pump inhibitors: impact on platelet function and clinical outcome—a systematic review.Heart. 2013; 99: 520-527
- Public statement on possible interaction between clopidogrel and proton pump inhibitors. [article online].2009 (Available from) (Accessed 21 July 2015)
- Early communication about an ongoing safety review of clopidogrel bisulfate (marketed as Plavix). [article online].2013 (Available from) (Accessed 21 July 2015)
- Overuse of PPIs in patients at admission, during treatment, and at discharge in a tertiary Spanish hospital.Curr Clin Pharmacol. 2010; 5: 288-297
- Long-term use of acid suppression started inappropriately during hospitalization.Aliment Pharmacol Ther. 2005; 21: 1203-1209
- A method for assessing drug therapy appropriateness.J Clin Epidemiol. 1992; 45: 1045-1051
- Functional evaluation: the BARTHEL index.Md State Med J. 1965; 14: 61-65
- Current concepts in the management of Helicobacter pylori infection: the Maastricht III consensus report.Gut. 2007; 56: 772-781
- Guidelines for prevention of NSAID-related ulcer complications.Am J Gastroenterol. 2009; 104: 728-738
- Proton pump inhibitor treatment for acute peptic ulcer bleeding.Cochrane Database Syst Rev. 2006; CD002094
- Treatment strategies for Zollinger–Ellison syndrome.Expert Opin Pharmacother. 2009; 10: 1145-1157
- American Gastroenterological Association Institute technical review on the management of gastroesophageal reflux disease.Gastroenterology. 2008; 135 (1413): 1392-1413
- Determining when quality improvement initiatives should be considered research: proposed criteria and potential implications.JAMA. 2000; 283: 2275-2280
- Appropriateness of proton pump inhibitor recommendations at hospital discharge and continuation in primary care.Int J Clin Pract. 2012; 66: 767-773
- Magnitude and economic effect of overuse of antisecretory therapy in the ambulatory care setting.Am J Manag Care. 2010; 16: e228-e234
- Proton pump inhibitors: a survey of prescribing in an Irish general hospital.Int J Clin Pract. 2005; 59: 31-34
- Continuation of proton pump inhibitors from hospital to community.Pharm World Sci. 2006; 28: 189-193
- Inappropriate prescribing of proton pump inhibitors in primary care.Postgrad Med J. 2007; 83: 66-68
- Discontinuation of proton pump inhibitors in patients on long-term therapy: a double-blind, placebo-controlled trial.Aliment Pharmacol Ther. 2006; 24: 945-954
- Why do physicians prescribe stress ulcer prophylaxis to general medicine patients?.South Med J. 2010; 103: 1103-1110
- Why do GPs continue inappropriate hospital prescriptions of proton pump inhibitors? A qualitative study.Eur J Gen Pract. 2014; 20: 174-180
- The role of food for the formation and prevention of gastrointestinal lesions induced by aspirin in cats.Dig Dis Sci. 2013; 58: 2840-2849
- Drug-disease and drug–drug interactions: systematic examination of recommendations in 12 UK national clinical guidelines.BMJ. 2015; 350: h949
- A therapeutic substitution policy for proton pump inhibitors: clinical and economic consequences.Clin Pharmacol Ther. 2006; 79: 379-388
- Proton pump inhibitors and hospital discharge rates for gastrointestinal events in Italy: a national ecological study.Clin Ther. 2007; 29: 751-758
Article info
Publication history
Published online: February 26, 2016
Accepted:
January 29,
2016
Received in revised form:
January 25,
2016
Received:
September 21,
2015
Identification
Copyright
© 2016 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
