What is the clinical evidence from this study?

Study design: Observational. Population: Proton pump inhibitor prescribing in elderly patients (n=150). Intervention: Proton pump inhibitors. Primary outcome: Proportion of PPI prescriptions without valid documented indications (likely invalid).

November 30, 2014Open Access

Proton pump inhibitors: Are we still prescribing them without valid indications?

FAF AkramRoyal Oldham Hospital YHYu‐Fang HuangIndustrial Technology Research Institute VLValencia LimNational University Health System

Key Result

Among elderly patients prescribed proton pump inhibitors at hospital discharge, 81.2% had no valid documented indications, most commonly for primary gastrointestinal bleeding prophylaxis.

Study Design

Type

Observational (n=150)

Multicenter

Structured PICO

Population

150 elderly patients aged ≥65 years admitted to two internal medicine wards in a tertiary teaching hospital in Singapore. Median age 78, 59.3% female.

Intervention

Proton pump inhibitors (PPIs) prescribed at hospital discharge

Outcome

Prevalence of inappropriate prescription of PPI among elderly patients without documentation of valid indications

Inappropriate prescribing of PPIs without documented valid indications is highly prevalent (81.2% of prescriptions) among elderly patients at hospital discharge in Singapore, often for primary gastrointestinal bleeding prophylaxis in low-risk aspirin users.

Limitations

Retrospective design did not allow confirmation of the decision-making process supporting PPI prescriptions.
Reliance on physician documentation and clinical records might have led to overestimation of inappropriate PPI use.
Small sample size might have limited the reliability or precision of results.
Challenging to assess symptoms among the very elderly, frail, and debilitated patients with dementia and communication issues.

Abstract

BACKGROUND: Evidence from several Western studies has shown an alarmingly high and inappropriate rate of prescription of proton pump inhibitors (PPIs), which may be associated with increased healthcare costs and adverse outcomes. PPI prescribing patterns remain largely unknown in well-developed healthcare systems in Southeast Asia. AIMS: We aimed to determine the prevalence of inappropriate prescription of PPI among elderly patients without documentation of valid indications, in a tertiary teaching hospital in Singapore. METHOD: We carried out a retrospective clinical records review of 150 elderly patients aged ≥65 years that had been admitted to two internal medicine wards between 25 May 2011 and 28 June 2011 to determine the appropriateness of indications for PPIs prescribed at hospital discharge. PPI indications were categorised as "valid", "likely invalid", and "probable" based on current clinical literature. Pre-admission and discharge prescriptions were reviewed to determine continuation of pre-admission and new PPI prescriptions at discharge. Data on clinical characteristics and concurrent use of ulcerogenic medications were collected. RESULTS: From a total of 150 patients, 80 (53 per cent) received prescriptions for PPIs. Of these, 65 (81.2 per cent) had no valid documented indications (i.e., the indication was classed as "likely invalid"); 10 (12.5 per cent) had valid indications; and in five cases (6.2 per cent) the indication was "probable". The most common "likely invalid" indication was primary gastrointestinal bleeding prophylaxis (GIP) among low-dose aspirin users in 28 patients (43 per cent) of invalid PPI prescriptions. CONCLUSION: Inappropriate prescribing of PPIs without documented valid indications was prevalent among elderly patients at our tertiary teaching hospital in Singapore, providing evidence that shows a similar trend to PPI prescribing to data from Western countries.

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