Juvelyn Palomique, DNP, MSN, ACNP-BC

Abstract:

Background: Inappropriate use of proton pump inhibitors (PPI) is common in patients with cirrhosis. PPIs are associated with deleterious effects in cirrhosis including increased risk for hepatic encephalopathy, spontaneous bacterial peritonitis, and liver-related mortality. Objectives: The aim was to decrease the incidence of low-value, non-guideline supported prescription of PPIs in the inpatient setting with a PPI Clinician Update education and a PPI stewardship by Hepatology. Methods: The study was implemented in a single inpatient transplant center. Key medical staff were identified to receive a PPI Clinician Update educational session, including Hospitalist, Gastroenterology fellows, Hepatology and Liver transplant advanced practice provider (APP). Patient data providing incidence of inappropriate PPI prescription was evaluated under a non-equivalent group pre-posttest design. The study used a one group pre-posttest design for assessing change in provider knowledge levels. A designated hepatology APP steward reviewed all PPI prescription appropriateness. Inappropriate PPI prescription was discontinued by the Hepatology APP who provided constructive feedback to the providers. The primary outcome measure was the incidence of inappropriate PPI prescription before and after the education session which were compared using a chi square test. Secondary outcome was percentage of correct responses (from a total of 10 questions), with before- and after-education measures compared using a paired t-test. Results: Twenty-six providers completed the educational session and pre-posttest. Lack of knowledge regarding outpatient PPI indication was reported as the main barrier to verifying PPI prescription. There was a statistically significant 20% increase in knowledge (p < .001) one month after receiving the educational intervention. There was a decrease in the incidence of inappropriate PPI use from 52% (23/44) to 25% (11/44) (p = .009) one month after receiving the educational intervention. The most common reason for inappropriate PPI prescription was continuation of the patient’s home medication without verifying the indication. The posttest survey showed that 46% of clinicians strongly agreed that their practice changed after the educational intervention and constructive feedback. Conclusion: The most common reason for inappropriate PPI prescription was due to a continuation of a home medication without verifying the indication. A multifaceted approach including an educational intervention and hepatology stewardship was effective in increasing knowledge and decreasing the inappropriate PPI prescriptions in the inpatient setting.

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