Use of Intravenous Proton-Pump Inhibitors in a Teaching Hospital Practice

Objective To evaluate intravenous proton-pump inhibitor (IV PPI) prescribing in a single academic teaching hospital. Methods A retrospective pilot study of 107 patients in a single United States military teaching hospital was conducted over a 1-month period. Clinical data were collected and analyzed for demographic features, prior medication use, admission hemoglobin level, service prescribing the IV PPI, indication for IV PPI, IV PPI treatment duration, gastroenterology consultant use, endoscopic findings, and blood products given. Indications for use were compared with current established guidelines to determine appropriate usage. Results A total of 683 doses of IV pantoprazole were prescribed over a 1-month period. Seventy-six patients (71%; 95% confidence interval [CI], 62–79%) who received IV PPIs did not meet the criteria for an appropriate indication for use. Ninety-nine patients in the study (93%; 95% CI, 86–96%) met criteria for an acceptable dosage given. The most common appropriate indication given was stress ulcer prophylaxis in a high-risk setting (13%; 95% CI, 8–21%) with appropriate use of this indication 45% of the time (95% CI, 29–62%). IV PPIs were appropriately prescribed most often by the medical intensive care unit (66.7%; 95% CI, 43–84%) and least often by the surgical wards services (16%; 95% CI, 7–33%). No discernable indication was given in 52% of cases (95% CI, 43–62%), and patients were not actually nil per os in 46% of these instances (95% CI, 34–59%). Conclusions Intravenous PPI prescribing habits in this military hospital facility are poor. A multifaceted approach including physician/pharmacist education, IV PPI ordering templates, and a consensus medical position statement from a major gastroenterological or prominent medical association may lead to more appropriate use. Institution from which this work is originated: San Antonio Uniformed Services Health Education Consortium (SAUSHEC). Presented in part at the 2007 Combined Army/Air Force ACP Chapter Meeting.     

Substance Use Disorder Detection Rates Among Providers of General Medical Inpatients

BackgroundThe prevalence of substance use disorders is higher among medical inpatients than in the general population, placing inpatient providers in a prime position to detect these patients and intervene.ObjectiveTo assess provider detection rates of substance use disorders among medical inpatients and to identify patient characteristics associated with detection.DesignData drawn from a cluster randomized controlled trial that tested the effectiveness of three distinct implementation strategies for providers to screen patients for substance use disorders and deliver a brief intervention (Clinical Trials.gov: {"type":"clinical-trial","attrs":{"text":"NCT01825057","term_id":"NCT01825057"}}NCT01825057).ParticipantsA total of 1076 patients receiving care from 13 general medical inpatient units in a large teaching hospital participated in this study.Main MeasuresData sources included patient self-reported questionnaires, a diagnostic interview for substance use disorders, and patient medical records. Provider detection was determined by diagnoses documented in medical records.Key ResultsProvider detection rates were highest for nicotine use disorder (72.2%) and lowest for cannabis use disorder (26.4%). Detection of alcohol use disorder was more likely among male compared to female patients (OR (95% CI) = 4.0 (1.9, 4.8)). When compared to White patients, alcohol (OR (95% CI) = 0.4 (0.2, 0.6)) and opioid (OR (95% CI) = 0.2 (0.1, 0.7)) use disorders were less likely to be detected among Black patients, while alcohol (OR (95% CI) = 0.3 (0.0, 2.0)) and cocaine (OR (95% CI) = 0.3 (0.1, 0.9)) use disorders were less likely to be detected among Hispanic patients. Providers were more likely to detect nicotine, alcohol, opioid, and other drug use disorders among patients with higher addiction severity (OR (95% CI) = 1.20 (1.08–1.34), 1.62 (1.48, 1.78), 1.46 (1.07, 1.98), 1.38 (1.00, 1.90), respectively).ConclusionsFindings indicate patient characteristics, including gender, race, and addiction severity impact rates of provider detection. Instituting formal screening for all substances may increase provider detection and inform treatment decisions.KEY WORDS: substance use disorder, detection, hospitalization, diagnosis     

Alcohol Dependence Among General Medical Inpatients

Alcoholics identified on medical wards were found to be less severely dependent overall than comparative samples admitted to a psychiatric hospital for treatment. This was the case although typical alcohol consumption levels were reported to be the same. Few ‘medical’alcoholics conformed to Jellinek's beta subtype and few were severely dependent. There was, however, on the scale of severity of dependence a similar distribution of cases of ‘absent to minimal’—‘mild to moderate’dependence between ‘medical’ alcoholics and approximately half of ‘psychiatric’ alcoholics. The remaining ‘psychiatric’ alcoholics were more severely dependent. The development of dependence as judged by the temporal ordering of symptoms occurred according to a sequence which was similar to that identified in psychiatric treatment settings.     

Physical Health and Drinking Among Medical Inpatients With Unhealthy Alcohol Use: A Prospective Study1

Objective: Unhealthy alcohol use is common in medical inpatients, and hospitalization has been hypothesized to serve as a “teachable moment” that could motivate patients to decrease drinking, but studies of hospital‐based brief interventions have often not found decreases. Evaluating associations between physical health and subsequent drinking among medical inpatients with unhealthy alcohol use could inform refinement of hospital‐based brief interventions by identifying an important foundation on which to build them. We tested associations between poor physical health and drinking after hospitalization and whether associations varied by alcohol dependence status and readiness to change. Methods: Participants were medical inpatients who screened positive for unhealthy alcohol use and consented to participate in a randomized trial of brief intervention (n = 341). Five measures of physical health were independent variables. Outcomes were abstinence and the number of heavy drinking days (HDDs) reported in the 30 days prior to interviews 3 months after hospitalization. Separate regression models were fit to evaluate each independent variable controlling for age, gender, randomization group, and baseline alcohol use. Interactions between each independent variable and alcohol dependence and readiness to change were tested. Stratified models were fit when significant interactions were identified. Results: Among all participants, measures of physical health were not significantly associated with either abstinence or number of HDDs at 3 months. Having an alcohol‐attributable principal admitting diagnosis was significantly associated with fewer HDDs in patients who were nondependent [adjusted incidence rate ratio (aIRR) 0.10, 95% CI 0.03–0.32] or who had low alcohol problem perception (aIRR 0.36, 95% CI 0.13–0.99) at hospital admission. No significant association between alcohol‐attributable principal admitting diagnosis and number of HDDs was identified for participants with alcohol dependence or high problem perception. Conclusions: Among medical inpatients with nondependent unhealthy alcohol use and those who do not view their drinking as problematic, alcohol‐attributable illness may catalyze decreased drinking. Brief interventions that highlight alcohol‐related illness might be more successful.     

The Safety of Fetal Exposure to Proton-Pump Inhibitors During Pregnancy

Background  

Proton-pump inhibitors (PPIs) are often needed in pregnancy due to the high rates of acid reflux. Previous studies did not include medical pregnancy terminations data, which may cause a bias toward the null hypothesis. We assessed the fetal safety of PPIs following exposure during gestation including data from medical pregnancy terminations.     

Appropriate Use of Intravenous Proton Pump Inhibitors in the Management of Bleeding Peptic Ulcer

Rebleeding from peptic ulcers is a major unsolved problem in the management of acute upper gastrointestinal bleeding. Our goal was to review what is known and what remains to be learned about the effectiveness of antisecretory therapy for acute upper gastrointestinal bleeding. We reviewed the data regarding the effectiveness of endoscopic therapy, the prediction of those at increased risk for rebleeding, and the effectiveness of antisecretory drug therapy in preventing rebleeding with or without endoscopic hemostasis. Proton pump inhibitor therapy without endoscopic hemostasis is ineffective clinically for stopping bleeding or preventing rebleeding. Endoscopic hemostasis remains the cornerstone of therapy. The data are consistent with the notion that reliable maintenance of the intragastric pH at ≥6 after endoscopic hemostasis is associated with the lowest rebleeding rates. H₂-receptor antagonists are ineffective for achieving this goal. Intermittent bolus and oral administration of proton pump inhibitors are equivalent and fail to achieve this goal, which can only be accomplished by bolus administration of a proton pump inhibitor (e.g., 80 mg) followed by a constant infusion (e.g., 8 mg/hr). Whether the combination of endoscopic hemostasis and pH control is equal or superior to selected second-look endoscopy is unknown. A treatment algorithm is suggested.Conflict of interest statement: In the last 3 years, Dr. Graham has received recent research support or honoraria for speaking engagements from AstraZeneca, Jannsen, Bayer HealthCare, TAP, Pharmacia, Meretek, Otsuka, Prometheus, and EISAI.     

High-dose Proton-Pump Inhibitors as a Diagnostic Test of Gastro-oesophageal Reflux Disease in Endoscopic-negative Patients

Background: To evaluate a high dose of a proton-pump inhibitor as a diagnostic test in endoscopynegative patients presenting with symptoms indicating gastro-oesophageal reflux disease. Methods:     

Hazardous Alcohol Consumption Among Mexican Inpatients

To determine the prevalence of “hazardous drinkers,” 1,064 Mexican inpatients (ages 18–59 years) from nine general hospitals answered an Alcohol Use Disorders Identification Test (AUDIT) questionnaire, previously validated by the World Health Organization. When subjects scored positive, a clinical screening procedure and a serum gamma-glutamyl-trans-peptidase (GGT) test were carried out. An AUDIT score ≥ 8 (hazardous drinking) was found in 23.4% of the sample (43.2% in men vs. 3.6% in women). Patients' answers were positively correlated in 83.3% with those of their next of kin. The clinical screening procedure and serum GGT levels correlated with AUDIT scores ≥ 8 in 55%. Data support the recommendation of routine screening for alcohol consumption in a general hospital population and the usefulness of the AUDIT application as a screening instrument for early phases of hazardous use of alcohol.     

Screening for Alcoholism Among Medical Inpatients: How Important Is Corroboration of Patient Self-Report?

Little Is known about the utility of collateral reports in substantiating self-report for individuals assessed in nonalcoholism treatment contexts. This study examined the concordance of 581 pairs of medical patient and collateral responses to a commonly used alcohol screening instrument, the CAGE Questions, as well as to reports of the patient's drinking consequences and alcohol consumption. Results demonstrated that patient/collateral concordance was marginal, but acceptable, on CAGE cut-off scores and, that similar to reports from alcoholism treatment settings, patients generally reported more drinking consequences than collaterals. Patient and collateral reports of the patient's alcohol consumption did not differ significantly. This pattern of patient and collateral reporting of alcohol consequences and consumption was found for both men and women, as well as for patients with a DSM-III-R diagnosis of alcohol dependence. The findings support the validity of patient self-report on alcoholism screening measures in medical settings. Furthermore, results demonstrated that the addition of collateral reports to information directly obtained from patients only modestly improved the Identification of alcohol dependence. The overall findings indicate that alcohol screening can be done effectively and efficiently in medical settings.     

Incidence of Antireflux Surgery in Finland 1988-1993: Influence of Proton-Pump Inhibitors and Laparoscopic Technique

Background: The advent of proton-pump inhibitors, and subsequently of the laparoscopic technique, can be assumed to have influenced the use of antireflux surgery in gastro-oesophageal reflux disease. Methods: Data on antireflux operations carried out in Finland in 1988-93 were obtained from national statistics, and the number of operations performed laparoscopically in 1993 was ascertained by a questionnaire to all relevant units. The rates per 100,000 population in the catchment areas were calculated. Results: Antireflux surgery almost always implied fundoplication. During 1993, 784 fundoplications and 43 other antireflux procedures were performed in Finland (total population around 5 million). The fundoplication rate per 100,000 population rose from 8.8 to 15.4 between 1988 and 1993. The increase was minimal (8.1-8.2) in 1990-91 when the first proton-pump inhibitor, omeprazole, was introduced, but remarkably greater (12.8-15.4) in 1992-93, when the laparoscopic technique became popular. Differences in fundoplication rates were six to tenfold between health service districts and even larger between hospitals. Conclusions: The numbers of antireflux operations in Finland were almost static when proton-pump inhibitors were introduced, but rapidly increased after the advent of the laparoscopic technique. Remarkable discrepancies were found in the incidence of fundoplication between different areas and hospitals.     

Burden of 30-Day Readmissions Associated With Discharge Against Medical Advice Among Inpatients in the United States

BackgroundDischarges against medical advice are common among inpatients in the United States. The impact of discharge against medical advice on readmission rates and subsequent hospitalization outcomes is uncertain. We sought to ascertain the effect of discharge against medical advice on 30-day readmission rates and outcomes of readmission.MethodsWe used the 2014 Nationwide Readmissions Database to identify index hospitalizations among patients older than 18 years of age. The primary exposure variable was discharge against medical advice, and the primary outcome measure was all-cause unplanned 30-day readmission. We used multivariate hierarchical logistic regression modeling to ascertain the effect of discharge against medical advice on 30-day readmission rates.ResultsThere were an estimated 23,110,641 index hospitalizations nationwide with an overall unplanned 30-day readmission rate of 10.2%. 1.3% of index admissions resulted in a discharge against medical advice. Patients who were discharged against medical advice were younger (mean age 47.1 years vs 56.5 years, P < 0.001) with a higher proportion of males (61.1% vs 39.5%, P < 0.001) compared with patients with a routine discharge. Discharge against medical advice was associated with significantly higher odds of 30-day readmission (risk-adjusted odds ratio [OR] 2.06, 95% confidence interval [CI] 2.03-2.09, P < 0.001). Discharge against medical advice was associated with higher odds of readmission to a different hospital (OR 2.35, 95% CI 2.22-2.49, P < 0.001) and repeat discharge against medical advice after readmission (OR 18.41, 95% CI 17.46-19.41, P < 0.001). The most common cause of readmission after discharge against medical advice was alcohol-related disorders (9%). Hospital-level rates of discharge against medical advice ranged from 0% to 12.5%.ConclusionsDischarge against medical advice is associated with over twice the odds of all-cause unplanned 30-day readmission compared with routine discharge. There is large hospital-level variation in rates of discharge against medical advice. Interventions to reduce discharges against medical advice, particularly at hospitals with high rates of such discharges, may reduce the overall readmission burden in this challenging and high-risk patient population.     

Associations of Proton-Pump Inhibitors and H2 Receptor Antagonists with Chronic Kidney Disease: A Meta-Analysis

Background/Aims

The aim of this meta-analysis was to assess the risks of chronic kidney disease (CKD) and/or end-stage kidney disease (ESRD) in patients who are taking proton-pump inhibitors (PPIs) and/or H2 receptor antagonists (H2RAs).

Methods

Comprehensive literature review was conducted utilizing MEDLINE and EMBASE databases through April 2017 to identify all studies that investigated the risks of CKD or ESRD in patients taking PPIs/H2RAs versus those without PPIs/H2RAs. Pooled risk ratios (RR) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method of DerSimonian and Laird. The protocol for this study is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42017067252).

Results

Five studies with 536,902 participants were patients were identified and included in the data analysis. When compared with non-PPIs users, the pooled risk ratio (RR) of CKD or ESRD in patients with PPI use was 1.33 (95% CI 1.18–1.51). Pre-specified subgroup analysis (stratified by CKD or ESRD status) demonstrated pooled RRs of 1.22 (95% CI 1.14–1.30) for association between PPI use and CKD and 1.88 (95% CI 1.71–2.06) for association between PPI use and ESRD, respectively. However, there was no association between the use of H2RAs and CKD with a pooled RR of 1.02 (95% CI 0.83–1.25). When compared with the use of H2RAs, the pooled RR of CKD in patients with PPI use was 1.29 (95% CI 1.22–1.36).

Conclusions

Our study demonstrates statistically significant 1.3-fold increased risks of CKD and ESRD in patients using PPIs, but not in patients using H2RAs.