Reducing Inappropriate Proton Pump Inhibitors Use for Stress Ulcer Prophylaxis in Hospitalized Patients: Systematic Review of De-Implementation Studies

Abstract

Background A large proportion of proton pump inhibitor (PPI) prescriptions, including those for stress ulcer prophylaxis (SUP), are inappropriate. Our study purpose was to systematically review the effectiveness of de-implementation strategies aimed at reducing inappropriate PPI use for SUP in hospitalized, non-intensive care unit (non-ICU) patients. Methods We searched MEDLINE and Embase databases (from inception to January 2020). Two authors independently screened references, performed data extraction, and critical appraisal. Randomized trials and comparative observational studies were eligible for inclusion. Criteria developed by the Cochrane Effective Practice and Organisation of Care (EPOC) group were used for critical appraisal. Besides the primary outcome (inappropriate PPI prescription or use), secondary outcomes included (adverse) pharmaceutical effects and healthcare use. Results We included ten studies in this review. Most de-implementation strategies contained an educational component (meetings and/or materials), combined with either clinical guideline implementation (n = 5), audit feedback (n = 3), organizational culture (n = 4), or reminders (n = 1). One study evaluating the de-implementation strategy effectiveness showed a significant reduction (RR 0.14; 95% CI 0.03–0.55) of new inappropriate PPI prescriptions. Out of five studies evaluating the effectiveness of de-implementing inappropriate PPI use, four found a significant reduction (RR 0.21; 95% CI 0.18–0.26 to RR 0.76; 95% CI 0.68–0.86). No significant differences in the occurrence of pharmaceutical effects (n = 1) and in length of stay (n = 3) were observed. Adverse pharmaceutical effects were reported in two studies and five studies reported on PPI or total drug costs. No pooled effect estimates were calculated because of large statistical heterogeneity between studies. Discussion All identified studies reported mainly educational interventions in combination with one or multiple other intervention strategies and all interventions were targeted at providers. Most studies found a small to moderate reduction of (inappropriate) PPI prescriptions or use.

Characterization of the gut microbiota among Veterans with unique military-related exposures and high prevalence of chronic health conditions: A United States-Veteran Microbiome Project (US-VMP) study

“…These alterations in the gut microbiota composition are likely not entirely benign, as use of PPIs is also associated with an increased risk of enteric infections, including C. difficile ( Janarthanan et al., 2012 ), which carries a high mortality risk ( Oake et al., 2010 ) and is known to respond well to restoration of a healthy microbiota composition through fecal microbiota transplant therapy ( Youngster et al., 2014 ). Moreover, these findings are particulary relevant in light of recent wide-spread PPI de-implementation strategies, based on findings suggesting that many PPI prescriptions are inappropriate ( Orelio et al., 2021 ).…”

Impact of Stress Ulcer Prophylaxis Discontinuation Guidance in Mechanically Ventilated, Critically Ill Patients: A Pre-Post Cohort Study

“…Prior reports have shown similar success in appropriate initiation or discontinuation of SUP in patients with major risk factors for stress ulcer development present or resolved. [19][20][21][22][23][24][25][26][27] The developed guideline for discontinuation of SUP considered not only available evidence, but also basic physiology, expert opinion, and practicality. Imploring these principles and education initiatives allowed study investigators to implement a successful quality improvement initiative in a short amount of time, and despite a global pandemic.…”

“…[11][12][13][14][15] Implications of inappropriate SUP include increased cost, polypharmacy, and medication adverse events (eg, pneumonia, myocardial ischemia, and Clostridioides difficile infection (CDI), antimicrobial resistance development), highlighting the need for acid suppression stewardship. [16][17][18][19] Various interventions including education, multidisciplinary rounds, clinical practice guidelines, audit-and-feedback, and pharmacist-based strategies in both ICU and non-ICU settings have shown variable results in improving SUP use. [19][20][21][22][23][24][25][26][27] These studies have often focused on discontinuation of SUP following resolution of major risk factors at different transitions/phases of care.…”

“…16-19 Various interventions including education, multidisciplinary rounds, clinical practice guidelines, audit-and-feedback, and pharmacist-based strategies in both ICU and non-ICU settings have shown variable results in improving SUP use. 19-27 These studies have often focused on discontinuation of SUP following resolution of major risk factors at different transitions/phases of care. While important, it may be reasonable to avoid use of SUP in some critically ill patients.…”

Pharmacist‐Led Intervention on the Inappropriate Use of Stress Ulcer Prophylaxis Pharmacotherapy in Intensive Care Units: A Systematic review

“…Compared with published reviews ( Singh-Franco et al, 2020 ; Orelio et al, 2021 ), we standardized the calculation process of the inappropriate rate so that the results of the studies were comparable. We also discussed the primary outcome at different time points including during ICU hospitalization, at ICU transfer and hospital discharge.…”