Boster Joshua, Lowry Lacy E, Bezzant Matthew L, Kuiper Brandon, Surry Luke
Internal Medicine, Brooke Army Medical Center, Fort Sam Houston, USA.
Internal Medicine, San Antonio Uniformed Services Health Education Consortium/Brooke Army Medical Center, San Antonio, USA.
Cureus. 2020 Jan 9;12(1):e6609. doi: 10.7759/cureus.6609.
Introduction Proton pump inhibitors (PPI) are commonly prescribed in the primary care setting. While generally considered to be safe, there is growing evidence suggesting that PPI misuse is associated with a variety of significant adverse outcomes and unnecessary cost. The goal of this quality improvement project was to identify patients with non-guideline recommended PPI prescriptions in our internal medicine residency clinics and implement a process to de-prescribe or reduce the dose of PPIs across this patient population. Methods PPI prescription rates, dosage, and indication were extracted from the medical records of all 854 patients empaneled to the internal medicine residency clinics at a multicenter closed referral military hospital system. Appropriate PPI indication was consensus based upon published guidelines, and patients without an appropriate indication were targeted for intervention. These patients were directly contacted by their primary care physicians, via phone or during a clinic visit, to discuss the risks and benefits of ongoing PPI use as well as alternative therapies or tapering regimens at the physician's discretion. For moderate to high dose PPI, the dose was decreased by 50% every week until the lowest tolerated dose was achieved or until discontinuation. For low dose PPI, discontinuation was recommended as the initial intervention. Six months following the intervention, the empanelment was reevaluated for ongoing PPI usage, tapered dosage, or discontinuation. Results Of a total of 854 patient records reviewed at the initiation of the project, 322 patients were noted to be prescribed PPIs. Of this subset, 66% (217/322) did not meet a guideline recommended indication for their use. At the completion of the six-month intervention period, 44% (96/217) of patients were successfully weaned to a reduced dose or were no longer using a PPI. Conclusions PPIs are widely used and generally considered to be a well-tolerated therapy for acid-secretion disorders. PPI overprescription and the associated adverse effects and economic burden are increasingly recognized. We show that a simple, focused, resident-driven quality improvement intervention can be effective in de-prescribing efforts to reduce inappropriate PPI use in the outpatient primary care setting.
引言 质子泵抑制剂（PPI）在基层医疗环境中是常用药物。虽然通常被认为是安全的，但越来越多的证据表明，PPI的不当使用与多种重大不良后果和不必要的费用相关。本质量改进项目的目标是在我们的内科住院医师诊所中识别出开具了非指南推荐的PPI处方的患者，并实施一个流程，在这一患者群体中停用或减少PPI的剂量。方法 从一个多中心封闭式转诊军事医院系统的内科住院医师诊所登记的所有854例患者的病历中提取PPI处方率、剂量和适应证。基于已发表的指南达成关于适当PPI适应证的共识，将没有适当适应证的患者作为干预对象。他们的初级保健医生通过电话或在门诊就诊时直接联系这些患者，讨论持续使用PPI的风险和益处以及由医生酌情决定的替代疗法或逐渐减量方案。对于中高剂量PPI，每周将剂量降低50%，直至达到最低耐受剂量或停药。对于低剂量PPI，建议将停药作为初始干预措施。干预6个月后，重新评估登记患者的PPI持续使用情况、逐渐减量的剂量或停药情况。结果 在项目启动时审查的总共854份患者记录中，有322例患者被记录开具了PPI。在这一子集中，66%（217/322）不符合指南推荐的使用适应证。在为期6个月的干预期结束时，44%（96/217）的患者成功减至较低剂量或不再使用PPI。结论 PPI被广泛使用，通常被认为是治疗胃酸分泌紊乱的耐受性良好的疗法。PPI的过度处方以及相关的不良反应和经济负担越来越受到认可。我们表明，一种简单、有针对性、由住院医师推动的质量改进干预措施在减少门诊基层医疗环境中不适当PPI使用的停药努力中可能是有效的。
