Reducing Inappropriate PPI Use Among the Veteran Population Using a Two-Step Process

Introduction: There is widespread use of proton pump inhibitors (PPI), but not always for clear indications or defined durations. Observational studies show that nearly 15% of hospitalized patients use PPIs at any given time, with the prevalence increasing in elderly patients. Twenty five percent of patients started on a PPI while inpatient will continue to use the PPI for at least one year, and nearly 70% of patients taking a PPI have no clear indication at all. PPI over-prescription creates unnecessary cost on the healthcare system and pill burden on patients. We identified that knowledge gap and deficiencies in the electronic medical record (EMR) are plausible causes for the mismanagement of PPIs. Methods: We conducted a quality improvement project at the Detroit Veteran Affairs Medical Center with two primary goals:1) Reduce inappropriate initiation of PPIs for gastrointestinal prophylaxis (GI PPX) during hospitalization and 2) Improve documentation on the indications for PPIs at discharge. The project was divided into 3 phases, each phase was 1 month long. In Phase 1, residents rotating on medicine wards received a 20 minute lecture on PPIs, and were instructed to document the indication for PPI prescriptions in discharge summaries. In Phase 2, residents received the lecture, and a reminder was integrated into the EMR, which prompted residents to document if a patient was being discharged on a PPI. In Phase 3, only the EMR tool was used. We reviewed 805 discharge summaries from the intervention (Aug-Oct 2022) and control groups (Aug-Oct 2021). Results: In all phases, we found a statistically significant decline in inappropriate PPI initiation for GI PPX (Figure 1). In all phases, there was a statistically significant improvement in documentation (Table 1). When phases 2 and 3 were compared to assess the value of the lecture, we found a significant decline in documentation in the phase 3 group (24/79= 30%) as compared to the phase 2 group (15/22=68%, p.0006). Conclusion: A lecture and an EMR tool effectively decreased PPI use for inappropriate GI PPX and improved documentation. However, residents were more likely to document indications for PPIs if they were provided a lecture that reviewed the statistics on mismanagement of PPIs and their appropriate indications. Our results suggest that topic-focused didactics and intentional utilization of the EMR can assist with improving resident knowledge and decreasing medication misuse.Figure 1.: Side-by-side comparison of veterans in the control vs. intervention groups who were started on proton pump inhibitors for inappropriate GI prophylaxis. Table 1. - Comparison of Phases 1, 2, and 3 Phase 1 Phase 2 Phase 3 Control Lecture only P-value Control Lecture + EMR Tool P-value Control EMR Tool only P-value Total patients 59 85 -- 76 69 -- 117 339 -- Inappropriate GI PPX 14 (24%) 3 (4%) 0.0002 17 (22%) 0 (0%) < .0001 89 (50%) 19 (6%) < .0001 Discharged on a PPI 16 (27%) 26 (31%) 0.652 28 (37%) 22 (32%) 0.530 81 (46%) 79 (23%) < 0.0001 Documented indication for PPI at discharge 1 (6%) 16 (62%) 0.0004 4 (14%) 15 (68%) < .0001 0 (0%) 24 (30%) < .0001 Lecture only, Lecture + EMR Tool, and EMR Tool only were all effective interventions in decreasing PPI use for inappropriate gastrointestinal prophylaxis and improving documentation (bolded P-values).