Musuuza Jackson S, Fong Emily, Lata Paul, Willenborg Katie, Knobloch Mary Jo, Hoernke Margaret J, Spiel Andrew R, Tischendorf Jessica S, Suda Katie J, Safdar Nasia
William S. Middleton Memorial Veterans Hospital, Madison, WI, USA.
Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.
Implement Sci Commun. 2021 Jun 1;2(1):59. doi: 10.1186/s43058-021-00161-6.
Proton pump inhibitors (PPIs) are among the most prescribed medications and are often used unnecessarily. PPIs are used for the treatment of heartburn and acid-related disorders. Emerging evidence indicates that PPIs are associated with serious adverse events, such as increased risk of Clostridioides difficile infection. In this study, we designed and piloted a PPI de-implementation intervention among hospitalized non-intensive care unit patients.
Using the Systems Engineering Initiative for Patient Safety (SEIPS) model as the framework, we developed an intervention with input from providers and patients. On a bi-weekly basis, a trainee pharmacist reviewed a random sample of eligible patients' charts to assess if PPI prescriptions were guideline-concordant; a recommendation to de-implement non-guideline-concordant PPI therapy was sent when applicable. We used convergent parallel mixed-methods design to evaluate the feasibility and outcomes of the intervention.
During the study period (September 2019 to August 2020), 2171 patients with an active PPI prescription were admitted. We randomly selected 155 patient charts for review. The mean age of patients was 70.9 ± 9 years, 97.4% were male, and 35% were on PPIs for ≥5 years. The average time (minutes) needed to complete the intervention was as follows: 5 to assess if the PPI was guideline-concordant, 5 to provide patient education, and 7 to follow-up with patients post-discharge. After intervention initiation, the week-to-week mean number of PPI prescriptions decreased by 0.5 (S<0.0001). Barriers and facilitators spanned the 5 elements of the SEIPS model and included factors such as providers' perception that PPIs are low priority medications and patients' willingness to make changes to their PPI therapy if needed, respectively. Ready access to pharmacists was another frequently reported facilitator to guideline-concordant PPI. Providers recommended a PPI de-implementation intervention that is specific and tells them exactly what they need to do with a PPI treatment.
In a busy inpatient setting, we developed a feasible way to assess PPI therapy, de-implement non-guideline-concordant PPI use, and provide follow-up to assess any unintended consequences. We documented barriers, facilitators, and provider recommendations that should be considered before implementing such an intervention on a large scale.
质子泵抑制剂（PPIs）是处方量最多的药物之一，且常被不必要地使用。PPIs用于治疗烧心和酸相关疾病。新出现的证据表明，PPIs与严重不良事件相关，如艰难梭菌感染风险增加。在本研究中，我们针对住院的非重症监护病房患者设计并试点了一项停用PPIs的干预措施。
以患者安全系统工程倡议（SEIPS）模型为框架，我们在医护人员和患者的参与下制定了一项干预措施。一名实习药剂师每两周对符合条件的患者病历进行随机抽样审查，以评估PPI处方是否符合指南；在适用时，会发出停用不符合指南的PPI治疗的建议。我们采用收敛平行混合方法设计来评估该干预措施的可行性和效果。
在研究期间（2019年9月至2020年8月），有2171名正在使用PPI的患者入院。我们随机抽取了155份患者病历进行审查。患者的平均年龄为70.9±9岁，97.4%为男性，35%使用PPIs≥5年。完成干预所需的平均时间（分钟）如下：评估PPI是否符合指南需5分钟，进行患者教育需5分钟，出院后随访患者需7分钟。干预开始后，每周PPI处方的平均数量减少了0.5（S<0.0001）。障碍和促进因素涵盖SEIPS模型的5个要素，分别包括医护人员认为PPIs是低优先级药物的观念以及患者在必要时愿意改变PPI治疗的意愿等因素。随时可咨询药剂师是另一个经常被提及的符合指南的PPI使用的促进因素。医护人员建议开展一项具体的停用PPIs干预措施，明确告知他们在PPI治疗方面需要做什么。
在繁忙的住院环境中，我们开发了一种可行的方法来评估PPI治疗、停用不符合指南的PPI使用，并进行随访以评估任何意外后果。我们记录了在大规模实施此类干预措施之前应考虑的障碍、促进因素和医护人员的建议。
