Retrospective Study On The Use Of Proton Pump Inhibitors Over The Past Decade In A Tertiary Hospital And Cost-benefit Analysis Of Clinical Pharmacist Intervention

ObjectiveThis is to retrospectively study the trend in using proton pump inhibitors（PPIs）over the past decade at a tertiary hospital,to understand the rationality behind PPIs’clinical utilization,to analyze the effects and economic benefits of clinical pharmacists’interventions in key departments,and to explore the reasons of irrational utilization.Our goals are to provide the basis for establishing a long-term management plan for PPIs,analyze medical costs,and establish an appropriate utilization of PPIs.MethodIn the first part of this study,the hospital information system（HIS）and the prescription automatic screening system（PASS）were used to retrieve data from2007 to 2016 on PPIs use in outpatient and inpatient settings in a large tertiary hospital.Changes in PPIs’prescribing rate,expenditure,utilization（DDDs）,DDDs/HID,top ten departments with the highest PPI prescribing rate inpatient,and other indexes of PPIs both inpatient and outpatient were collected respectively.Analysis of these changes were traced over the past decade.The second part of the study uses the PASS system to extract gender,age,department,clinical diagnosis,type of drugs,expenditure of drugs,and other information regarding the patients from January 1,2017 to December 31,2017.Thirdly,a total of 500 medical records（50 copies per department）of patients who used PPIs and discharged from one of the top ten inpatient departments with the highest PPI prescribing rate from January to June of 2016 were randomly selected for special review.The rationalities behind these prescriptions were evaluated from the aspects of indication,dose,administration route,solvents,duration,etc.A selected clinical pharmacist in the hepatobiliary surgery ward implemented real-time interventions on the use of PPIs in the perioperative period According to retrospective-prospective studies,a pre-intervention group and a post-intervention group were divided for the cost-benefit analysis of these clinical pharmacist interventions.From the PASS system,250 patients with elective hepatobiliary surgery in the fourth quarter of 2015 were randomly selected as the pre-intervention group and 250patients with elective hepatobiliary surgery in the fourth quarter of 2016 were selected as the post-intervention group.From the two groups,information on general characteristics,surgical procedures,acid suppressant usage,and the cost of treatment were collected to analyze the effect of intervention and the economic benefits brought by the clinical pharmacist intervention.Finally,a survey was designed to study the awareness regarding PPIs among medical staff（doctors,nurses,and pharmacists）-including PPI knowledge,the general attitude on overusing PPIs,and the behavior behind PPI utilization-to analyze the possible reasons for inappropriate use of PPIs based on the result of the survey.Result1. Changes in PPI prescribing over the past decade:The prescribing rate of PPIs outpatient increased from 2.97%in 2007 to 4.90%in 2016 while inpatient the prescribing rate increased from 20.41%in 2007 to 37.21%in 2015 but then decreased to 32.14%in 2016.From 2013 to 2016,all top ten departments in prescribing PPIs exceeded 50%.Meanwhile,the top three departments were intervention,hepatological surgery,and cardiothoracic surgery.The utilization of PPIs in outpatient increased from 135,808 to 722,943 DDDs,mostly in oral dosage,with rabeprazole having the highest DDDs.The utilization of PPIs inpatient increased from 132,329 DDDs in 2007 to 827,747 DDDs in 2015,and decreased to 679,728 DDDs in 2016,mainly in injection dosage,with omeprazole being the highest.The DDDs/HID of PPIs inpatient increased from25.1 DDD in 2007 to 63.46 DDD in 2015,and decreased to 55.17 DDD in 2016.The average cost of PPIs outpatient increased from 102.88 RMB in 2007 to151.45 RMB in 2016,and increased from 316.22 RMB in 2007 to 609.37 RMB in 2016 inpatient.2. Survey of PPIs prescribing patterns for outpatient and emergency department:A total of 60,135 PPI-containing prescriptions for outpatient and emergency department were prescribed（55,611 outpatient versus 4,524emergency room prescriptions）in 2017.The age of patients using PPIs mainly distributed from 46 to 65 years old（49.65%）.The main departments were gastroenterology（63.58%）and cardiology（15.64%）.Of these PPI prescriptions,10,145 were prescribed for patients with abdominal pain,bloating,or other clinical manifestations（16.87%）,and 8,365（13.91%）were for non-acid secretion related diseases,such as biliary diseases,hypertension and rheumatic diseases.Rabeprazole（54.99%）and esomeprazole（17.39%）were prescribed commonly in all age groups.Omeprazole was most commonly prescribed to patients less than 18 years of age.3. Rationality evaluation of medical orders and cost-benefit analysis of clinical pharmacist interventions:Of the 500 sample medical orders,308 were considered to be irrational,at a rate of 61.60%.Of these,there were 125 with no indication（40.67%）.110 orders were for prevention,15 for treatment.Additionally,82 of the prescriptions（26.67%）had inappropriate routes,and 76were prescribed for an inappropriate duration（24.66%）.After given the real-time medication intervention by the clinical pharmacist on hepatobiliary surgery,the perioperative prophylactic use of acid inhibitors in the two groups before and after the intervention decreased from 100%to 73.80%（P<0.05）.The prescriptions without indication,inappropriate choice of prescription,inappropriate dosages and other situations were significantly improved（P<0.05）.The rate of complete correctness of five indicators（indication,choice of medication,dose,route,therapy duration）increased by 10.65%（P<0.01）,and the use of H₂RAs in the post-intervention group increased by 13.44%.The net cost benefit of pharmacist interventions（the difference between reduced costs of average acid inhibitors and average pharmacist cost）was 521.08 RMB,and the ratio of cost benefit（the average antacid cost reduction to the average pharmacist cost）was 13.61:1.4. Survey on the awareness of medical staff:The average score of medical staff’s recognition on the knowledge related to PPIs was 59.47±15.75.Of all medical personels,nurses received the lowest score,which was significantly lower than that of physicians（P<0.01）.Meanwhile,pharmacists scored significantly higher than doctors and nurses（P<0.01）.The score on awareness of PPI knowledge was related to gender,age,occupation,education,professional title,hospital nature,hospital grade and type of medical staff（P<0.05）.The score on pharmacists’attitude to the overuse of PPIs was significantly higher than that of doctors and nurses（P<0.01）.The score on nurses’behavior of toward PPIs use were lower than those of doctors and pharmacists（P<0.01）.ConclusionThe prescribing rate,utilization（DDDs）,DDDs/HID,and expenditures on PPIs in inpatient and outpatient settings in the past decade in the tertiary hospital have increased steadily.The most inappropriate utilization of PPIs is use with no indication,followed by the inappropriate route of prescription and extended duration of treatment.The reasons behind inappropriate PPI utilization are related to medical staffs’inadequate knowledge of PPIs and their inadequate awareness of the current situation such as harm from the overuse of PPIs.The rectification of PPI usage based on clinical pharmacist interventions can significantly reduce the prescribing rate,utilization（DDDs）,DDDs/HID of PPIs.Implementation of real-time intervention by clinical pharmacists improved the appropriate utilization of PPIs as well as resulted in favorable economic outcomes.Therefore,we recommend to strengthen clinical pharmacy skills and staff training,as well as prolong availability of clinical pharmacists or increase the clinical pharmacy staff.This is in hope to expand the scope of real-time interventions in playing a role to monitor prophylactic PPIs,using PPIs appropriately,and reduce medical cost.