Lutheran Home/Lutheran Life Communities, Arlington Heights, IL, USA.
J Am Med Dir Assoc. 2013 Jun;14(6):429-32. doi: 10.1016/j.jamda.2013.01.021. Epub 2013 Apr 9.
The primary objective of this study was to identify proton pump inhibitor (PPI) prescribing patterns in a population of older adults admitted to 22 Midwestern skilled long term care facilities (LTCF) with medical coverage provided by the US Medicare Part A program. The relationship between PPI prescribing patterns and specific ICD-9 diagnostic codes and symptoms management was examined. The long-term objective is appropriate PPI prescription guidance through the development of evidence- and regulation-based pharmacy formulary and policy practices, as well as practical prescribing guidance for practitioners who are supported by this pharmacy.
An observational cohort study was conducted, using prospectively collected and de-identified prescribing and diagnostic data from a convenience sample of all Medicare A skilled nursing patients admitted between January 1, 2010, and May 31, 2011, to 22 urban, suburban, and rural Midwestern US LTCFs.
A common pharmacy service de-identified and aggregated PPI prescribing data and patient diagnostic information. These secondary data were analyzed for trends and patterns related to PPI use for all Medicare A patients admitted to these 22 facilities during a 17-month period in 2010 and 2011.
Rates of PPI use were determined and were compared with diagnostic codes. Of 1381 total admissions, 1100 patients (79.7%) were prescribed PPI. There was no appropriate diagnosis for PPI use in 718 patients (65.3%). Gastroesophageal reflux disease (GERD) tended to be the blanket diagnosis that was used most frequently for PPIs, but there was usually no follow-up or symptomatic evidence documented of active GERD. When long-term (current) use of nonsteroidal anti-inflammatory drugs (NSAIDs) (including aspirin) and/or anticoagulant therapy (warfarin) was considered as appropriate indications for 382 patients, 336 (24%) of all Medicare patients were still receiving PPIs with no relevant gastrointestinal ICD-9 diagnostic code. Total cost of PPIs prescribed from January 2010 to June 2011 was $348,414.
The examined PPI prescribing patterns show discordance between ICD-9 diagnostic code and prescribed use of PPIs in the study population. More than half (52%) of the total number of Medicare A patients were taking the medication without an indicated diagnosis. Even when NSAIDs and anticoagulant therapy were taken into consideration as valid reasons for PPI use, 24% of all patients admitted were still prescribed PPIs without a diagnosis that indicated the need for a PPI. Considering the economic cost, potential side effects, and CMS F329 regulations, which require that an LTCF resident's drug regimen be free from unnecessary medication, it is important that prescribers in LTCFs carefully consider use of PPIs in older adults in LTCFs and monitor the continued use of PPIs to prevent both the personal cost of physical side effects and drug-drug interactions, as well as the economic cost of unnecessary medication use.
本研究的主要目的是确定在 22 家中西部熟练护理长期护理机构（LTCF）中接受美国医疗保险 A 部分计划医疗覆盖的老年人群中质子泵抑制剂（PPI）的处方模式。研究考察了 PPI 处方模式与特定 ICD-9 诊断代码和症状管理之间的关系。长期目标是通过制定基于证据和法规的药房处方集和政策实践，以及为支持该药房的从业者提供实用的处方指导，来实现 PPI 的合理处方。
对 2010 年 1 月 1 日至 2011 年 5 月 31 日期间，22 家城市、郊区和农村中西部美国 LTCF 中所有 Medicare A 熟练护理患者入院的前瞻性收集和去识别处方和诊断数据进行了观察性队列研究。
一个共同的药房服务去识别和汇总了 PPI 处方数据和患者诊断信息。对 2010 年和 2011 年 17 个月期间这 22 家机构收治的所有 Medicare A 患者的 PPI 使用趋势和模式进行了分析。
确定了 PPI 的使用率，并与诊断代码进行了比较。在 1381 例总入院患者中，有 1100 例（79.7%）患者开具了 PPI。718 例患者（65.3%）没有适当的 PPI 使用诊断。胃食管反流病（GERD）往往是最常被用于开具 PPI 的通用诊断，但通常没有记录到 GERD 的后续或症状性证据。当考虑到长期（目前）使用非甾体抗炎药（包括阿司匹林）和/或抗凝剂治疗（华法林）是 382 例患者的适当指征时，所有 Medicare 患者中有 336 例（24%）仍在服用 PPI，而没有相关的胃肠道 ICD-9 诊断代码。2010 年 1 月至 2011 年 6 月期间开具的 PPI 总费用为 348414 美元。
研究人群中 PPI 处方模式与 ICD-9 诊断代码之间存在不一致。超过一半（52%）的 Medicare A 患者在没有指示性诊断的情况下服用了这种药物。即使考虑到 NSAIDs 和抗凝剂治疗作为 PPI 使用的有效原因，所有入院患者中仍有 24%的患者在没有指示需要 PPI 的诊断的情况下仍被开具了 PPI。考虑到经济成本、潜在的副作用以及 CMS F329 法规（要求 LTCF 居民的药物治疗方案中不包括不必要的药物），LTCF 中的处方者仔细考虑在 LTCF 中的老年人群中使用 PPI，并监测 PPI 的持续使用，以防止身体副作用和药物相互作用的个人成本以及不必要药物使用的经济成本。
