Deprescribing Unnecessary Pantoprazole Prescribed by Hospitalists on Parkland Hospital Non-ICU Inpatient Floors

BACKGROUND: Proton pump inhibitors are one of the most prescribed classes of drugs in the United States. Their efficacy and relatively low adverse event profile has resulted in their significant overuse both inpatient and at discharge. Long-term proton pump inhibitor use has been associated with many health consequences and any unnecessary prescribing leads to unnecessary expenses. OBJECTIVES: The primary aim of this project was to achieve a 25% relative reduction in inappropriate inpatient pantoprazole prescribing by the hospital medicine physicians and advanced practice providers who account for the majority of the unnecessary proton pump inhibitor prescribing in non-critical patients at Parkland during the period of January 2018-May 2020. METHODS: The baseline scope of the problem was determined using chart review and provider surveys. The chart review study population was any non-critical, medicine patient admitted to Parkland Memorial Hospital and prescribed inpatient pantoprazole by a hospitalist in June of 2017 (n=319 patients). This chart review helped quantify the pantoprazole use problem and identify the reasons for inappropriate prescription of inpatient pantoprazole. The hospitalists were surveyed to understand their prescribing practices and their perspective on the causes of unnecessary inpatient pantoprazole use. Using this information, a fishbone diagram outlining the causes of inappropriate inpatient pantoprazole use was created. Interventions addressing these causes were rated using a prioritization matrix and the best interventions were implemented. The interventions included removal of proton pump inhibitors from order sets, group and individual provider education, individual provider audit and feedback report cards, and changes to the proton pump inhibitor prescription auto-fill refill numbers in the electronic medical record. The 15 hospitalists accounting for 56% of the unnecessary prescribing at baseline were the study cohort. Prescribing data for these 15 hospitalists was then assessed post-intervention to determine the impact of the interventions. Chi squared analysis was performed. A p-value of <0.05 was considered significant. RESULTS: In June of 2017, in all non-critical patients cared for by hospitalists, 58.3% of pantoprazole prescriptions were unnecessary. Of the patients that were started on inpatient pantoprazole, 52.4% of the 66.5% of patients discharged on pantoprazole had no indication and, six months later, 46.8% of those patients continued to use pantoprazole. At baseline, the study cohort of 15 providers prescribed 45% of the total inpatient pantoprazole prescriptions and 71.7% of those prescriptions were inappropriate (n= 145 patients). After the interventions, the rate of their pantoprazole prescribing decreased from a mean of 145 prescriptions to 89 prescriptions per month. The proportion of inappropriate pantoprazole prescriptions decreased from 71.7% to 47.9% (n= 178 patients). Of those inappropriate prescriptions post-intervention, a majority were continuations of outpatient proton pump inhibitors; not new pantoprazole prescriptions as before. The percentage of the study cohort's patients inappropriately discharged on pantoprazole decreased from 62.9% to 50.8%. The percentage of their patients still on a proton pump inhibitor six months after discharge decreased from 32.4% to 26.4%. CONCLUSIONS: The interventions achieved a 33% relative reduction in inappropriate inpatient pantoprazole prescriptions in non-critical, medicine patients by the 15 worst prescribing hospitalists at Parkland. Further analysis will help elucidate if the audit and feedback received by these 15 hospitalists resulted in any additional benefit beyond the group education all the hospitalists received. Future directions would include continued re-education, audit and feedback and accountability for the proper utilization of proton pump inhibitors. As the opportunity for reducing unnecessary inpatient prescribing of proton pump inhibitors diminishes, resources may be redirected to decreasing inappropriate discharge prescriptions and improving outpatient prescribing practices.