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Original research
Prevalence and factors associated with inappropriate continuation of stress ulcer prophylaxis at discharge
  1. Justine Chinnappan1,2,
  2. Rami Al-Handola1,2,
  3. Noyal M Joseph3,
  4. Ekwevugbe Ogbon1,2,
  5. Philip J McDonald1,2
  1. 1Internal Medicine, Michigan State University College of Human Medicine, East Lansing, Michigan, USA
  2. 2Internal Medicine, Hurley Medical Center, Flint, Michigan, USA
  3. 3Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
  1. Correspondence to Dr Justine Chinnappan; chinnapp{at}msu.edu

Abstract

Stress ulcer prophylaxis is started in the critical care unit to decrease the risk of upper gastrointestinal ulcers in critically ill persons and to decrease mortality caused by stress ulcer complications. Unfortunately, the drugs are often continued after recovery through discharge, paving the way for unnecessary polypharmacy.

Study design We conducted a retrospective cross-sectional study including patients admitted to the adult critical care unit and started on the stress ulcer prophylaxis with a proton pump inhibitor (PPI) or histamine receptor 2 blocker (H2 blocker) with an aim to determine the prevalence of inappropriate continuation at discharge and associated factors.

Result 3200 people were initiated on stress ulcer prophylaxis, and the medication was continued in 1666 patients upon discharge. Indication for long-term use was not found in 744 of 1666, with a 44% prevalence of inappropriate continuation. A statistically significant association was found with the following risk factors: discharge disposition (home vs other medical facilities, p=0.002), overall length of stay (more than 10 days vs less than or equal to 10 days, p<0.0001), mechanical ventilator use (p<0.001), number of days on a mechanical ventilator (more than 2 days vs less than or equal to 2 days, p<0.001) and class of stress ulcer prophylaxis drug used (H2 blocker vs PPI, p<0.001).

Conclusion The prevalence of inappropriate continuation was found to be higher than prior studies. Given the risk of unnecessary medication intake and the associated healthcare cost, a web-based quality improvement initiative is being considered.

  • Patient-centred care
  • Safety culture
  • Patient safety
  • Medication reconciliation

Data availability statement

All data relevant to the study are included in the article or uploaded as supplemental information.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjoq-2023-002678

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    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • Few studies in the literature aimed to determine the prevalence of inadvertent continuation of stress ulcer prophylaxis focused only on proton pump inhibitor (PPI) or histamine receptor 2 blocker (H2 blocker) or both. We aimed to identify the prevalence of injudicious continuation of stress ulcer prophylaxis, including both H2 blockers and PPIs for the first time, in addition to comparing the various factors influencing their inappropriate continuation.

    WHAT THIS STUDY ADDS

    • The prevalence of inappropriate continuation of stress ulcer prophylaxis was found to be higher than in prior studies. The prevalence of inappropriate continuation of stress ulcer prophylaxis at discharge was 44.7%, including both H2 blockers and PPIs. The individual prevalence of inappropriate continuation of PPI was 41.7% and H2 blocker was 51.2%, with a statistically significant increase in inappropriate continuation with H2 blockers compared with PPIs.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • Quality improvement projects can be initiated based on the principle of inappropriate continuation of many drugs, such as a project aiming at reducing the unnecessary continuation of stress ulcer prophylaxis.

    • A careful review of the appropriateness and indications of medications before proceeding with the transition of care.

    Introduction

    Stress ulcers, as the name indicates, are upper gastrointestinal (GI) ulcers caused in response to stress in critically ill persons, especially those who are hospitalised. Bleeding from stress ulcers can increase morbidity and mortality further in this group of patients.1 Thus, stress ulcer prophylaxis (SUP) was introduced. The agents often used as SUP are histamine 2 receptor blockers (H2 blockers) and proton pump inhibitors (PPIs).2 The most common indications for SUP in the intensive care unit (ICU) include bleeding diathesis, use of mechanical ventilation, history of peptic ulcer or GI bleeding within the past year, traumatic brain injury or burn injury, among others, as described in Box 1.3 4 There are no established safe criteria to discontinue SUP. Most experts consider discontinuing SUP after discharge from the ICU, as they are no longer critically ill unless risk factors prevail. This consensus is based on the rationale that the baseline risk of GI bleeding is low in non-critically ill hospitalised patients. However, SUP initiated in the ICU often continues during the hospital stay and discharge. Prior studies found that 27–39% of patients were inappropriately continued on PPI upon discharge.5–8 Though they are considered relatively safe medications, interactions along with healthcare costs add to unnecessary burdens.9 Given this background, with a future goal to reduce the inappropriate continuation of SUP as long term, our team decided to estimate the prevalence of inappropriate continuation of SUP at discharge in addition to identifying the risk factors associated with its continuation.

    Box 1

    Indications of stress ulcer prophylaxis

    • Bleeding diathesis

      • INR >1.5

      • PTT >2 times the control value

      • Platelet count <50 x109/L

    • Mechanical ventilation >48 hours

    • History of peptic ulcer or GI bleeding within the past year

    • Traumatic brain injury

    • Traumatic spinal cord injury

    • Burn injury

    • Two or more of the following minor criteria:

      • ICU stay more than 1 week

      • Sepsis

      • Occult GI bleeding for 6 or more days

      • NSAID therapy

      • Glucocorticoid therapy

      • Antiplatelets

    • GI, gastrointestinal; ICU, intensive care unit; INR, international normalised ratio; NSAID, non-steroidal anti-inflammatory drug; PTT, partial thromboplastin time.

    Materials and method

    Study design and participants

    This retrospective cross-sectional study was conducted at Hurley Medical Center (Flint, Michigan, USA) after obtaining approval from the Institutional Review Board. This study was conducted using the data collected from the Epic (Epic Systems Corporation, Verona, Wisconsin, USA) Electronic Medical Record (EMR) database. Patients aged 18 years or older admitted to the medical ICU (MICU) or coronary ICU (CICU) directly from the emergency department between 1 January 2018 and 30 April 2022 were screened for initiation of SUP while in the MICU or CICU. This was carried over by verifying if the patient was started on an H2 blocker or PPI while in the MICU or CICU and was not prior to admission medication. The pharmacy technician and the nurse verify the prior-to-admission medications per hospital protocol, which is entered into the EMR.

    Patients who died before discharge were excluded from the study. Only the first encounter of the patients with multiple admissions during the period of study was included. Patients who were initiated on the SUP were further screened for the continuation of the PPI or H2 blocker on discharge. Our final study population consisted of patients who were started on SUP in the MICU or CICU and prescribed the same medication upon discharge. These patients were further analysed for documented indication of long-term use of PPI or H2 blocker. This was accomplished by the use of diagnostic codes for oesophagitis, Barrett’s oesophagus, gastro-oesophageal reflux disease, Helicobacter pylori infection, peptic ulcer disease, chronic non-steroidal anti-inflammatory drug use and dual antiplatelet therapy. Based on the presence or absence of the indication for long-term use of PPI or H2 blocker upon discharge, they were categorised into appropriate (control group) or inappropriate (study group) continuation, respectively.

    Patient and public involvement

    As this study is retrospective, patients were not involved in setting the research question or outcome measures. However, the primary aim of this study is to improve the medication reconciliation process in a patient-centred manner, leading to better overall outcomes for patients and a decrease in adverse events.

    Study aim

    The primary aim was to identify the prevalence of inappropriate continuation of PPI or H2 blocker initiated as SUP at the time of discharge. This was calculated as the percentage of patients who were continued on the PPI or H2 blocker upon discharge, which was started in the ICU or CICU as SUP, and had no indication of long-term use of these medications upon discharge.

    The secondary aim was to study the influence of various medical covariates involved in the inappropriate continuation of the SUP. The various factors that were analysed included the age of the patient, gender, length of ICU stay, length of hospital stay, type of critical care unit (MICU vs CICU), number of medications at discharge, number of physicians involved in care, discharge destination (home vs other facilities), intubation, days of intubation, number of units the patient was transferred and class of drug used as SUP (PPI vs H2 blocker).

    Statistical analysis

    The continuous variables such as age, length of stay and ventilator days were expressed as mean and SD. The categorical variables, such as gender, type of anti-ulcer drugs, etc, were expressed as percentages. For analysis of the type of anti-ulcer drugs, cases in which only one type of anti-ulcer drug was used were considered and cases where both types of drug are used were excluded. The unpaired t-test was used for the comparison of means. Χ2 or Fisher’s exact test was used to assess the statistical significance of the various factors associated with inappropriate usage. A p value less than 0.5 was considered statistically significant.

    Results

    A total of 5704 were admitted to the MICU or CICU during the period 1 January 2018 and 30 April 2022. Among these, 3200 people were started on PPI or H2 blocker while in ICUs, which was not on the list of home medications. The initiated medication was prescribed to 1666 upon discharge, which consisted of our study population. The mean age was 59.04±15.216 years, and the male-to-female ratio was approximately 1:1 (832/834, respectively).

    Primary aim

    Of the 1666 patients included in the study, 922 patients had an indication for long-term use of PPI or H2 blocker, while 744 did not have a documented indication. Thus, the prevalence of inappropriate continuation of the SUP initiated in the ICUs was determined by the percentage of 744 out of 1666, which was 44.7% (figure 1).

    Figure 1
    Figure 1

    Inappropriate continuation of the stress ulcer prophylaxis (SUP). ICU, intensive care unit.

    Secondary aim

    The various covariates that were considered to play a significant role in the inappropriate continuation of the SUP were compared between the two groups (table 1). The group with an indication for long-term use of PPI or H2 blocker upon discharge was the control group (n=922), and the group with no documented indication but continued on PPI or H2 blocker as the study group (n=744).

    View this table:
    Table 1

    Factors associated with inappropriate continuation of stress ulcer prophylaxis

    There was no statistically significant association found in terms of gender (male vs female, p=0.551), ICU (MICU vs CICU, p=0.144), length of stay in critical care (p=0.184), number of physicians involved in care (more than five vs less than or equal to five, p=0.649), number of medications on discharge (p=0.131) or number of units transferred (p=0.537).

    There was a statistically significant association found in terms of discharge disposition (home vs other medical facilities, p=0.002), overall length of stay (more than 10 days vs less than or equal to 10 days, p<0.0001), mechanical ventilator use (p<0.001), number of days on mechanical ventilator (more than 2 days vs less than or equal to 2 days, p<0.001) and class of SUP drug used (H2 blocker vs PPI, p<0.001) (figure 2).

    Figure 2
    Figure 2

    Class of stress ulcer prophylaxis continued at discharge. H2 blocker, histamine receptor 2 blocker; PPI, proton pump inhibitor.

    Discussion

    Summary of the study

    There are various low-cost medications with a benign side effect profile being overused in the long term without proper indication; H2 blockers and PPIs fall under this category. These drugs are started in the acute care setting to prevent stress ulcers and are often inadvertently or inappropriately continued at discharge. There are few studies in the literature that aim to determine the prevalence of this inadvertent continuation of SUP focused only on PPI or H2 blocker or both. We aimed to identify the prevalence of injudicious continuation of SUP, including both H2 blockers and PPIs for the first time, in addition to comparing the various factors influencing their inappropriate continuation. We found that the prevalence of inappropriate continuation of the SUP at discharge was 44.7%, including both H2 blockers and PPIs. The individual prevalence of inappropriate continuation of PPI was 41.7% and H2 blocker was 51.2%, with a statistically significant increase in inappropriate continuation with H2 blockers compared with PPI. The other factors that were found to be significantly associated include the length of stay in the hospital of more than 10 days, use of a mechanical ventilator and especially more than 3 days on a ventilator. Given that there are controversies on the various adverse effects of PPI on prolonged use like osteoporosis, though now proven to be wrong, the use of PPI is more often scrutinised, whereas the H2 blockers are seldom reviewed.2 10 11 This would explain why the rate of inappropriate continuation of H2 blockers is significantly high in comparison with PPIs.

    Comparison with existing literature

    There are four studies in the literature that reported the prevalence of inappropriate continuation of SUP with PPIs. The prevalence reported in these studies for inappropriate continuation at discharge was 24.2–39%.5–8 Our study revealed the highest prevalence of inappropriate continuation compared with all the previous studies. The largest study conducted involved 2467 patients and found no statistically significant association between mechanical ventilation >48 hours (29%) versus those who were not (26%) (p=0.22), decreased likelihood of inappropriate continuation on ventilated patients (23%) compared with non-ventilated patients (38%) (p<0.0001), and a strong association with the number of providers, length of stay, discharge to a nursing home or rehabilitation facility, and the number of discharge medications.5 Another study found a statistically significant association between inappropriate continuation and mechanical ventilation >48 hours, as well as ICU stay >7 days.7

    Strengths and limitations of the study

    The strengths of this study are the population size, inclusion of both classes of drug used for SUP and comparison of various risk factors associated with inappropriate continuation.

    The limitation of the study is that it was conducted in a single academic hospital; therefore, the results may not be generalisable. There is also the possibility that undocumented indications for the continuation of SUP could have been missed in the chart review.

    Future research

    The results of our study indicate that the chance of continuation of a drug without an appropriate indication is a significant risk on discharge from the hospital, particularly those considered to have favourable safety profiles. This may, in turn, increase the healthcare cost burden and lay a path for polypharmacy.12 13 Though there are various quality improvement initiatives on board in other places, tailoring them to the resources and needs of each institution is required.14–17 This should be made cost-effective, less time-consuming for the treatment team and a long-term solution. We are focusing on further studies with this goal. A quality improvement initiative to decrease the unwarranted continuation of these drugs started in the ICU for acute care is recommended.

    Quality improvement implications

    A quality improvement project is planned to be initiated at the academic hospital to measure the difference in inappropriate SUP continuation after a certain intervention. The proposed intervention is to create a pop-up with a hard stop in the patients’ Epic EMR during the medication reconciliation process of discharge, which would notify the discharging provider that the PPI or H2 blocker was initiated during this hospitalisation. They would then consider discontinuing or continuing those medications before completing the discharge based on the presence or absence of an indication. This intervention is expected to be executed over a 3-month time frame and then remeasure the prevalence after implementation. The objective of the project is to determine if the intervention was effective in reducing the prevalence of inappropriate continuation by 20% or more. The purpose of this is to mitigate the long-term adverse effects of continuing inappropriate treatment, such as drug interactions, nutritional deficiencies and increased medication costs. The project team aims to educate current residents, fellows and faculty physicians through noon conferences, email reminders and lounge posters about the indications and complications of continuing SUP.

    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplemental information.

    Ethics statements

    Patient consent for publication

    Ethics approval

    Approval from the institution's research board was obtained.

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    Footnotes

    • Contributors JC was involved in conception, design, data analysis, and responsible for the overall content. RA-H was involved in drafting the article, ensuring integrity of data analysis, editing and review. NMJ was involved in data analysis, interpretation of data and review. EO was involved in data collection and reviewing the article critically for important intellectual content. PJM was involved in the conception, data analysis, drafting, ensuring accuracy of data collection, and final approval of the version to be published. All authors read and approved the final manuscript. JC is the guarantor of this article.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.