Inappropriate Use of Intravenous Pantoprazole: Extent of the Problem and Successful Solutions
2005; Elsevier BV; Volume: 3; Issue: 12 Linguagem: Inglês
10.1016/s1542-3565(05)00757-3
ISSN1542-7714
AutoresGilaad G. Kaplan, Duane Bates, Dawn McDonald, Remo Panaccione, Joseph Romagnuolo,
Tópico(s)Respiratory and Cough-Related Research
ResumoBackground & Aims: Indications for intravenous proton pump inhibitors (IV PPI) include upper gastrointestinal bleeding (UGIB) from peptic ulcer disease with high-risk stigmata and patients receiving nothing by mouth (NPO). The objectives were to assess the extent of errors in indications for IV PPI use and to determine whether multidisciplinary interventions could improve IV PPI use and costs. Methods: Part 1: Patients prescribed IV PPI during a period of 4 months were divided into 2 settings, UGIB or non-UGIB. The setting-specific appropriateness of the IV PPI indication and dosing regimen was determined. Part 2: Patients prescribed IV PPI before and after multidisciplinary interventions (educating physicians, a computerized dose template, pharmacists altering IV PPI orders in non-UGIB patients who were not NPO, and recommending a GI consult when a continuous infusion was ordered) were studied. Incidence of prescribing errors, IV PPI costs, and potential confounders were compared. Results: Part 1: Only 50% of UGIB (n = 145) patients received IV PPI for an appropriate indication. Both indication and dosing regimen were appropriate in 21%. In the non-UGIB group (n = 95), 33% were truly NPO; 51% had a correct dosing frequency. Part 2: The postintervention (n = 105) group (vs the preintervention group, n = 113) showed a significant absolute reduction in the degree of inappropriate indication in the UGIB (26%; 95% confidence interval [CI], 10%–42%; P < .0001) and in the non-UGIB (41%; 95% CI, 24%–58%; P < .0001) subgroups. However, a greater improvement in underspending than overspending meant that overall costs were unchanged. Conclusions: IV PPI was frequently prescribed inappropriately and incorrectly; simple maneuvers resulted in reductions in errors. Background & Aims: Indications for intravenous proton pump inhibitors (IV PPI) include upper gastrointestinal bleeding (UGIB) from peptic ulcer disease with high-risk stigmata and patients receiving nothing by mouth (NPO). The objectives were to assess the extent of errors in indications for IV PPI use and to determine whether multidisciplinary interventions could improve IV PPI use and costs. Methods: Part 1: Patients prescribed IV PPI during a period of 4 months were divided into 2 settings, UGIB or non-UGIB. The setting-specific appropriateness of the IV PPI indication and dosing regimen was determined. Part 2: Patients prescribed IV PPI before and after multidisciplinary interventions (educating physicians, a computerized dose template, pharmacists altering IV PPI orders in non-UGIB patients who were not NPO, and recommending a GI consult when a continuous infusion was ordered) were studied. Incidence of prescribing errors, IV PPI costs, and potential confounders were compared. Results: Part 1: Only 50% of UGIB (n = 145) patients received IV PPI for an appropriate indication. Both indication and dosing regimen were appropriate in 21%. In the non-UGIB group (n = 95), 33% were truly NPO; 51% had a correct dosing frequency. Part 2: The postintervention (n = 105) group (vs the preintervention group, n = 113) showed a significant absolute reduction in the degree of inappropriate indication in the UGIB (26%; 95% confidence interval [CI], 10%–42%; P < .0001) and in the non-UGIB (41%; 95% CI, 24%–58%; P < .0001) subgroups. However, a greater improvement in underspending than overspending meant that overall costs were unchanged. Conclusions: IV PPI was frequently prescribed inappropriately and incorrectly; simple maneuvers resulted in reductions in errors. Upper gastrointestinal bleeding (UGIB) is an important clinical problem accounting for 300,000 hospital admissions annually and an expenditure of 2.5 billion health care dollars per year in the United States.1Gilbert D.A. Epidemiology of upper gastrointestinal bleeding.Gastrointest Endosc. 1990; 36: S8-S13PubMed Google Scholar There is Level I evidence from randomized trials showing that patients with peptic ulcer disease (PUD) associated with high-risk stigmata (HRS) treated with high-dose bolus followed by continuous infusion of an IV proton pump inhibitor (PPI) have a reduced frequency of rebleeding.2Lau J.Y. Sung J.J. Lee K.K. et al.Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers.N Engl J Med. 2000; 343: 310-316Crossref PubMed Scopus (595) Google Scholar, 3Lin H.J. Lo W.C. Lee F.Y. et al.A prospective randomized comparative trial showing that omeprazole prevents rebleeding in patients with bleeding peptic ulcer after successful endoscopic therapy.Arch Intern Med. 1998; 158: 54-58Crossref PubMed Scopus (239) Google Scholar, 4Zed P.J. Lowewen P.S. Slavik R.S. et al.Meta-analysis of proton pump inhibitors in treatment of bleeding peptic ulcers.Ann Pharmacother. 2001; 35: 1528-1534Crossref PubMed Scopus (66) Google Scholar, 5Hasselgren G. Lind T. Lundell L. et al.Continuous intravenous infusion of omeprazole in elderly patients with peptic ulcer bleeding.Scand J Gastroenterol. 1997; 32: 328-333Crossref PubMed Scopus (147) Google Scholar, 6Schaffalitzky de Muckadell O.B. Havelund T. Harling H. et al.Effect of omeprazole on the outcome of endoscopically treated bleeding peptic ulcers randomized double-blind placebo-controlled multicentre study.Scand J Gastroenterol. 1997; 32: 320-327Crossref PubMed Scopus (167) Google Scholar A recent multivariate analysis of a large registry of UGIB patients suggested that IV PPI might also reduce mortality in UGIB.7Barkun A. Sabbah S. Enns R. et al.The Canadian Registry on Nonvariceal Upper Gastrointestinal Bleeding and Endoscopy (RUGBE) endoscopic hemostasis and proton pump inhibition are associated with improved outcomes in a real-life setting.Am J Gastroenterol. 2004; 99: 1238-1246Crossref PubMed Scopus (305) Google Scholar IV PPI has also been shown to be an effective substitute in patients who cannot tolerate oral medications but require a PPI for various reasons.8Paul J. Metz D. Maton P.A. Pantoprazole IV treatment decreases antacid usage in patients with gastroesophageal reflux disease.Gastroenterology. 1999; 116 (abstract): G1219Google Scholar, 9Metz D.C. Forsmark C. Lew E.A. et al.Replacement of oral proton pump inhibitors with intravenous pantoprazole to effectively control gastric acid hypersecretion in patients with Zollinger-Ellison syndrome.Am J Gastroenterol. 2001; 96: 3274-3280Crossref PubMed Google Scholar, 10Hartmann M. Ehrlich A. Fuder H. et al.Equipotent inhibition of gastric acid secretion by equal doses of oral or intravenous pantoprazole.Aliment Pharmacol Ther. 1998; 12: 1027-1032Crossref PubMed Scopus (56) Google Scholar IV pantoprazole was released on the Canadian market in 1999 and is currently the only approved IV PPI formulation in Canada. Since its addition to the Calgary Health Region adult acute care formulary in April 1999, annual IV PPI expenditures rose 4-fold between the first and third years to nearly half a million dollars (Canadian).11Kaplan G. Bates D. McDonald D. et al.Inappropriate prescribing leading to rapidly escalating costs of IV proton pump inhibitors in the Calgary Health Region.Pharma News. 2002; 26: 1-4Google Scholar In part this increase in spending is believed to be a result of inappropriate use of IV pantaprazole, because 3 North American institutions have shown misuse of this medication.12Cornish P. Papastergiou J. Saibil F. Audit of IV pantoprazole patterns of use and compliance with guidelines.Can J Hosp Pharm. 2002; 55: 20-26Google Scholar, 13Enns R. Andrews C.N. Fishman M. Hahn M. Atkinson K. Kwan P. Levy A. Description of prescribing practices in patients with upper gastrointestinal bleeding receiving intravenous proton pump inhibitors a multicentre evaluation.Can J Gastroenterol. 2004; 18: 567-571PubMed Google Scholar, 14Guda N.M. Noonan M. Kreiner M.J. et al.Use of intravenous proton pump inhibitors in community practice an explanation for the shortage?.Am J Gastroenterol. 2004; 99: 1233-1237Crossref PubMed Scopus (47) Google ScholarA retrospective study was conducted to assess adherence to published indications for the use of IV PPI, as well as appropriate dosing of the drug. Subsequently, a prospective study was carried out to determine whether simple institutional interventions could improve physician prescribing behavior and decrease drug costs.MethodsPart 1: Extent of the ProblemConsecutive inpatients receiving IV pantoprazole (bolus or infusion) during 4 selected months between 2001 and 2002 at the Foothills Medical Centre (University of Calgary, Alberta, Canada) were identified through the inpatient pharmacy computer database. Two summer months and 2 winter months were chosen without prior knowledge of their respective expenditures. The months were purposefully spaced to allow a determination of the presence of possible time trends in regional usage.Each chart was manually reviewed by one of the investigators by using an a priori developed data collection sheet. The following information was abstracted: indication for IV pantoprazole, dosing regimen and duration of IV pantoprazole, prescribing service, recent myocardial infarction or other significant comorbidity making endoscopy potentially unsafe, previous use of oral PPI, oral or nasogastric diet, medication orders during IV pantoprazole use, gastroenterology consultation, endoscopy results, and length of stay. Because the appropriateness criteria and dosing of IV PPI differ between UGIB patients and other patients given IV PPI, the patients were stratified into 2 subgroups, UGIB and non-UGIB (generally a patient who required a PPI but could not take it enterally). Institutional review board approval was granted through the Calgary Health Region Quality Improvement Health Information Group.Upper gastrointestinal bleeding subgroupDefinition of appropriate indication. In the study by Lau et al2Lau J.Y. Sung J.J. Lee K.K. et al.Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers.N Engl J Med. 2000; 343: 310-316Crossref PubMed Scopus (595) Google Scholar and in others, patients with an UGIB caused by PUD associated with HRS benefited from high-dose IV PPI infusion.3Lin H.J. Lo W.C. Lee F.Y. et al.A prospective randomized comparative trial showing that omeprazole prevents rebleeding in patients with bleeding peptic ulcer after successful endoscopic therapy.Arch Intern Med. 1998; 158: 54-58Crossref PubMed Scopus (239) Google Scholar, 5Hasselgren G. Lind T. Lundell L. et al.Continuous intravenous infusion of omeprazole in elderly patients with peptic ulcer bleeding.Scand J Gastroenterol. 1997; 32: 328-333Crossref PubMed Scopus (147) Google Scholar, 6Schaffalitzky de Muckadell O.B. Havelund T. Harling H. et al.Effect of omeprazole on the outcome of endoscopically treated bleeding peptic ulcers randomized double-blind placebo-controlled multicentre study.Scand J Gastroenterol. 1997; 32: 320-327Crossref PubMed Scopus (167) Google Scholar The presence of HRS was defined as arterial or venous bleeding, nonbleeding visible vessel, or adherent clot.2Lau J.Y. Sung J.J. Lee K.K. et al.Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers.N Engl J Med. 2000; 343: 310-316Crossref PubMed Scopus (595) Google Scholar, 15Johnston J.H. Endoscopic risk factors for bleeding peptic ulcer.Gastrointest Endosc. 1990; 36: S16-S20PubMed Google Scholar, 16Laine L. Peterson W.L. Bleeding peptic ulcer.N Engl J Med. 1994; 331: 717-728Crossref PubMed Scopus (659) Google Scholar Starting IV pantoprazole before endoscopy was considered acceptable, as long as it was discontinued within 12 hours of endoscopy when HRS were not confirmed. Empiric IV PPI (up to 72 hours) for patients with a suspected UGIB but determined by the consultant to be at high risk for endoscopy (eg, recent myocardial infarction) was considered acceptable. Furthermore, it was believed that when IV PPI was discontinued within 24 hours, it would not be labeled as inappropriate in this study, because brief diagnostic uncertainty regarding whether significant UGIB is indeed occurring is a real-life phenomenon that clinicians contend with.Definition of appropriate dosing regimenThe appropriate IV pantoprazole dosing regimen included an initial 80-mg bolus followed by an 8 mg/h infusion for 72 hours used by Lau et al2Lau J.Y. Sung J.J. Lee K.K. et al.Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers.N Engl J Med. 2000; 343: 310-316Crossref PubMed Scopus (595) Google Scholar; nearly identical regimens were used by other authors,2Lau J.Y. Sung J.J. Lee K.K. et al.Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers.N Engl J Med. 2000; 343: 310-316Crossref PubMed Scopus (595) Google Scholar, 3Lin H.J. Lo W.C. Lee F.Y. et al.A prospective randomized comparative trial showing that omeprazole prevents rebleeding in patients with bleeding peptic ulcer after successful endoscopic therapy.Arch Intern Med. 1998; 158: 54-58Crossref PubMed Scopus (239) Google Scholar, 5Hasselgren G. Lind T. Lundell L. et al.Continuous intravenous infusion of omeprazole in elderly patients with peptic ulcer bleeding.Scand J Gastroenterol. 1997; 32: 328-333Crossref PubMed Scopus (147) Google Scholar, 6Schaffalitzky de Muckadell O.B. Havelund T. Harling H. et al.Effect of omeprazole on the outcome of endoscopically treated bleeding peptic ulcers randomized double-blind placebo-controlled multicentre study.Scand J Gastroenterol. 1997; 32: 320-327Crossref PubMed Scopus (167) Google Scholar and this is the regimen supported by studies in healthy volunteers17Brunner G. Luna P. Hartmann M. et al.Optimizing the intragastric pH as a supportive therapy in upper GI bleeding.Yale J Biol Med. 1996; 69: 225-231PubMed Google Scholar and a recent consensus document.18Barkun A. Bardou M. Marshall J.K. et al.Nonvariceal upper GI bleeding consensus conference group consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding.Ann Intern Med. 2003; 139: 843-857Crossref PubMed Scopus (495) Google Scholar If rebleeding occurred, diagnosed on clinical and/or endoscopic grounds, the patient was allowed to receive IV PPI for an additional 72 hours.Non–bleeding subgroupDefinition of appropriate indication and dosing. In the non-UGIB subgroup, IV pantoprazole was considered to be indicated when a PPI was judged by the attending physician to be necessary, but the patient was unable to take an oral PPI preparation; the patient could not be concurrently receiving enteral (including oral or enteral tube routes) food or medications.8Paul J. Metz D. Maton P.A. Pantoprazole IV treatment decreases antacid usage in patients with gastroesophageal reflux disease.Gastroenterology. 1999; 116 (abstract): G1219Google Scholar, 19Freston J. Chiu Y.L. Pan W.J. et al.Effects on 24-hour intragastric pH a comparison of lansoprazole administered nasogastrically in apple juice and pantoprazole administered intravenously.Am J Gastroenterol. 2001; 96: 2058-2065Crossref PubMed Google Scholar, 20Taubel J.J. Sharma V.K. Chiu Y.L. et al.A comparison of simplified lansoprazole suspension administered nasogastrically and pantoprazole administered intravenously effects on 24 intragastric pH.Aliment Pharmacol Ther. 2001; 15: 1807-1817Crossref PubMed Scopus (23) Google Scholar The non-UGIB appropriate dose was defined as a 40-mg IV bolus once daily,8Paul J. Metz D. Maton P.A. Pantoprazole IV treatment decreases antacid usage in patients with gastroesophageal reflux disease.Gastroenterology. 1999; 116 (abstract): G1219Google Scholar unless the patient had an accepted indication for twice daily therapy (eg, failure on once daily therapy).Statistical analysisMultivariate analysis was used in each of the 2 groups (UGIB and non-UGIB) to determine predictors of inappropriate prescribing (logistic regression) within the inappropriate group, correcting for confounding by time period if needed. The variables included in this analysis were age, gender, month observed, prescribing service (modeled as several dummy variables; the reference category was gastroenterology), performance of an endoscopy, time to endoscopy, inpatient or outpatient status, nonsteroidal anti-inflammatory drug use, and time of day of first dose (daytime vs night-time). Transformations were used if indicated by residual plots. Likelihood ratio tests of nested models were used in model building. The trend in monthly costs was evaluated qualitatively and with linear regression to explore for any time trends.CostsThe pharmaceutical cost was based on the Calgary regional formulary cost of a 40-mg IV vial of pantoprazole being $13.70 (Canadian) compared with a 40-mg tablet being $0.45 (Canadian) in hospital patients. Costs were expressed in Canadian dollars. Costs were tabulated for the entire background period. Theoretical or ideal costs were calculated by using the rules in Table 1.Table 1Clinical Scenarios and Descriptions of How Corresponding Costs Were Calculated for the Ideal Model (Part 1 of the Study)Clinical scenarioCost calculation for ideal modelaFor each clinical scenario, the ideal cost model estimates the cost of IV PPI plus that of the oral PPI that would have been incurred if the physician had ordered the PPI appropriately with the correct dosing regimen.Patients with HRS or considered high risk for endoscopyCost of 80-mg bolus and 8 mg/h × 72 h + PO PPI thereafterNo HRS were identified and IV PPI discontinued within 12 h of endoscopyCost of 80-mg bolus and 8 mg/h for time prescribed as ordered + PO PPI thereafterIV PPI continued for >12 h after endoscopy when no HRS are identifiedCost of 80-mg bolus and 8 mg/h infusion before endoscopy + PO PPI thereafterIV PPI started for suspected UGIB, without endoscopy attempted, but discontinued within 24 hCost of IV PPI as orderedIV PPI started for suspected UGIB, without endoscopy, but continued for >24 hCost of PO PPIa For each clinical scenario, the ideal cost model estimates the cost of IV PPI plus that of the oral PPI that would have been incurred if the physician had ordered the PPI appropriately with the correct dosing regimen. Open table in a new tab Part 2: Effect of Multidisciplinary InterventionConsecutive inpatients prescribed IV pantoprazole (bolus or infusion) at any time during a 60-day period, before and after instituting interventions directed at improving prescribing behavior, were identified through the inpatient pharmacy computer database. The 2 periods were chosen without prior knowledge of their respective expenditures. The study period was separated by 3 months from the control period to allow time for interventions to work. Each chart was manually reviewed as outlined previously. Stratification of patients into UGIB and non-UGIB subgroups and the definitions for appropriateness criteria and dosing of IV PPI were identical to those described in Part 1 of the study. Baseline characteristics of the patients and balance measures, such as the total number of admissions to hospital, the number of UGIB cases presenting to the emergency department, and the total number of GI consults were compared between the 2 study periods to assess for potential confounders in the comparison of the 2 periods.InterventionsThe interventions conducted between the control and study periods were 4-fold: (1) a newsletter was sent out educating physicians on the appropriate indications and dosing of IV pantoprazole; (2) a dose template for ordering IV PPI that directed physicians to the correct indication and dosing of the drug was instituted in our computerized inpatient order system including an auto-stop requiring reordering after 72 hours; (3) autosubstitution of IV pantoprazole for the oral dose equivalent was performed by pharmacists if the patient was receiving IV pantoprazole for a "Non-UGIB" indication but was concurrently receiving either oral/nasogastric feeds or medications (ie, not truly nothing by mouth [NPO]); (4) a gastroenterology consult was recommended when physicians ordered continuous IV pantoprazole infusions, so that an endoscopy would be considered to confirm HRS and perform endoscopic therapy if present. With a phone call to pharmacy, the pharmacy suggestions could be readily overridden by the prescribing physician and the consult request easily cancelled if the referring service disagreed.CostsThe total pharmaceutical costs of administered IV pantoprazole in Canadian dollars were tabulated weekly by the pharmacy department for the preintervention and postintervention periods.Statistical analysisThe χ2 test was used to compare proportions with appropriate prescribing during the preintervention and postintervention periods. Differences in average weekly costs were compared with a Wilcoxon rank-sum test.ResultsPart 1: Extent of the ProblemA total of 240 patients were prescribed either a bolus or infusion of IV pantoprazole during the 4 months studied (January 2001, January 2002, July 2002, August 2002). One hundred forty-five (60.4%) were prescribed IV PPI for a suspected or confirmed UGIB, whereas 95 were prescribed PPI for other reasons (non-UGIB). The distribution of services (admitting service or consulting service) that initiated the order to prescribe IV pantoprazole in both the UGIB and non-UGIB subgroups was the following: (1) UGIB: medicine 28%, hospitalist 23%, critical care 13%, surgery 11%, gastroenterology 9%, cardiology 6%, and other services 10%; (2) non-UGIB: surgery 40%, hematology-oncology 26%, hospitalist 13%, cardiology 10%, critical care 6%, and other services 5%. Table 2 demonstrates the baseline characteristics of the patients assessed during the study period.Table 2Baseline Characteristics of the Patients Receiving IV Pantoprazole for the Indication of UGIB and non-UGIB subgroupsCharacteristicMean (standard deviation), median (range) or %UGIBAge (y)65 (17)Gender62% maleHistory of recent NSAID use34%Gastroenterology consult75%Endoscopy performed67%Inpatient when bleed commenced52%Length of stay (days)9 (1–93)Time to endoscopy (h)12.6 (2.5–80)Non-UGIBAge (y)57 (16)Gender59% maleGastroenterology consult14%History of oral PPI use33%Length of stay (days)14 (3–133) Open table in a new tab Upper gastrointestinal bleeding subgroupIV pantoprazole was withheld until endoscopy confirmed PUD with HRS in only 5.5% of cases. Of the 145 people who received the drug, 67% (97/145) underwent endoscopy. Of the 48 patients who did not undergo endoscopy, 54% (26/48) continued to receive the medication for more than 24 hours. Of note, in 78% of these 48 cases, a gastroenterologist was not consulted. Forty-seven percent (46/97) of those who underwent endoscopy continued to receive IV pantoprazole after the endoscopy, despite the absence of HRS. The remainder either had HRS (26%) or had IV pantoprazole discontinued appropriately after the endoscopy did not confirm HRS (27%). Overall, in 72 (50%) of the 145 cases, the IV PPI was determined to have been ordered for an inappropriate indication (Figure 1).When IV pantoprazole was used in the UGIB group, physicians correctly ordered the initial 80-mg bolus in only 44% of cases. The correct infusion (8 mg/h) was used in 67% of the cases. The remainder ordered pantoprazole 40 mg IV twice daily instead of a continuous infusion protocol, despite the fact that the indication for ordering the PPI was an UGIB. In only 30% of the cases was the duration of IV pantoprazole literature-based.2Lau J.Y. Sung J.J. Lee K.K. et al.Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers.N Engl J Med. 2000; 343: 310-316Crossref PubMed Scopus (595) Google Scholar, 3Lin H.J. Lo W.C. Lee F.Y. et al.A prospective randomized comparative trial showing that omeprazole prevents rebleeding in patients with bleeding peptic ulcer after successful endoscopic therapy.Arch Intern Med. 1998; 158: 54-58Crossref PubMed Scopus (239) Google Scholar, 5Hasselgren G. Lind T. Lundell L. et al.Continuous intravenous infusion of omeprazole in elderly patients with peptic ulcer bleeding.Scand J Gastroenterol. 1997; 32: 328-333Crossref PubMed Scopus (147) Google Scholar, 6Schaffalitzky de Muckadell O.B. Havelund T. Harling H. et al.Effect of omeprazole on the outcome of endoscopically treated bleeding peptic ulcers randomized double-blind placebo-controlled multicentre study.Scand J Gastroenterol. 1997; 32: 320-327Crossref PubMed Scopus (167) Google Scholar All 3 components (bolus, infusion, and duration) of the dosing regimen were correct in only 25% of the cases. The drug was ordered appropriately, in terms of indication and all 3 components of the correct dosing regimen, in only 21% (95% CI, 14%–27%) of the cases. During the time period studied, there was no significant time trend in the proportion of patients with an appropriate indication and/or dose.Non–bleeding subgroupOf the 95 patients who were prescribed IV pantoprazole because they required a PPI that they could not take orally, only 33% were truly NPO, and only half (51%) were prescribed the correct dosing frequency. Physicians prescribed IV pantoprazole for an appropriate indication and at the correct dosing frequency in only 14% (95% CI, 7%–22%) of these patients. The proportion of patients with an appropriate indication and/or dose did not significantly vary with time.Multivariate analysisNone of the variables significantly predicted inappropriate prescribing in either the UGIB or non-UGIB subgroups. In the UGIB group, within the subgroup that underwent an endoscopy, a model significantly explained variation in inappropriate prescribing (P = .0004). This model contained 2 significant variables, time delay to endoscopy (odds ratio per extra hour, 1.06 [95% CI, 1.0–1.1]; P = .006) and age (odds ratio per increased decade, 0.72 [95% CI, 0.5–0.99]; P = .02). Thus a longer time delay to endoscopy and younger patient age were independently associated with a higher chance of prescribing IV PPI inappropriately.Cost analysisThe costs of PPI therapy in all patients prescribed IV PPI during the background period were $33,164 compared with $14,566 in the ideal hypothetical model, with a potential cost savings of $18,598. For the UGIB subgroup these cost figures were $21,552 (actual) and $12,126 (ideal), respectively. The cost figures for non-UGIB subgroup were $11,612 and $2,440, respectively.Part 2: Effect of Multidisciplinary InterventionA total of 113 (68 for UGIB, 45 for non-UGIB) patients were prescribed and given a bolus and/or infusion of IV pantoprazole during the preintervention period and 105 (67 for UGIB, 38 for non-UGIB) patients during the postintervention period. An additional 30 patients were prescribed IV pantoprazole in the postintervention non-UGIB subgroup but had an oral PPI substituted by a pharmacist because they were not truly NPO.Upper gastrointestinal bleeding subgroupIn the UGIB subgroup, there was a significant absolute reduction in the proportion without an appropriate indication of 26% (95% CI, 10%–42%; P < .0001) during the postintervention period (Figure 2). Subgroup analysis explored which errors of inappropriate use of IV pantoprazole were most often corrected (Table 3, Table 4). Table 3 represents errors by physicians that resulted in overspending of IV pantoprazole, whereas Table 4 corresponds to underspending errors.Figure 2The proportion of physicians who prescribed IV pantoprazole appropriately for the UGIB and the non-UGIB subgroups in the preintervention (gray) and postintervention periods (black).View Large Image Figure ViewerDownload (PPT)Table 3Influence of the Intervention on Selected Physician Prescribing Errors That, When Corrected, Contributed to a Decrease in Drug Costs Between the Preintervention and Postintervention Periods (Part 2 of the Study)Control (n = 68), (%)Study (n = 67), (%)Difference (95% CI)P valueProportion of patients who continued to receive IV PZ despite no HRS seen on endoscopy21 (31)13 (19)12% (−3% to 26%).1Proportion of patients who received IV PZ for more than 24 h without confirming HRS15 (22)5 (8)14% (3% to 26%).02PZ, pantoprazole. Open table in a new tab Table 4Influence of the Intervention on Selected Physician Prescribing Errors That, When Corrected, Contributed to an Increase in Drug Costs Between the Preintervention and Postintervention Periods (Part 2 of the Study)Control (n = 68), (%)Study (n = 67), (%)Difference (95% CI)P valueUGIB treated appropriately with continuous infusion instead of intermittent bolus IV PZ44 (65)63 (94)29% (4% to 17%)<.001Appropriate 80-mg bolus used instead of 40-mg or no bolus31 (46)45 (67)21% (5% to 37%).01Continuous infusion ordered for ≤48 h when a 72-h infusion was indicated21 (31)13 (19)12% (−3% to 26%).1PZ, pantoprazole. Open table in a new tab Non–bleeding subgroupIn the non-UGIB subgroup, there was a significant absolute reduction in the proportion without an appropriate indication by 41% (95% CI, 24%–58%; P < .0001) during the postintervention period (Figure 2). As a secondary analysis, when the 30 patients with inappropriate IV pantoprazole that was corrected by the hospital pharmacist were considered "errors," there was still an absolute improvement of 22%.Cost analysisThere was no statistically significant pharmaceutical cost difference between the preintervention period and the postintervention period, with median weekly costs of $4188 and $4485, respectively.Baseline and balance measuresThe mean age of the patients in the 2 study periods was identical (62 years
Referência(s)