Longitudinal analysis of the costs associated with inpatient initiation and subsequent outpatient continuation of proton pump inhibitor therapy for stress ulcer prophylaxis in a large managed care organization

Abstract

Background: Proton pump inhibitor (PPI) therapy is commonly initiatedin hospitals for a variety of reasons including stress ulcer prophylaxis. Outpatient use of inpatient-initiated PPI use may be medically unwarranted.

Objective: To (a) describe in a longitudinal analysis the incidence and reasons for hospital initiation of PPI therapy, (b) identify the proportion of members continued on PPI therapy at hospital discharge that is not medically warranted, and (c) estimate the total costs incurred by the managed care organization (MCO) and its members due to inappropriate continuation of hospital-initiated PPI therapy after discharge.

Methods: A retrospective review of de-identified medical and pharmacy claims was performed to identify commercial and Medicare patients with an acute care hospital admission and subsequent discharge on a PPI from January 1, 2003, through December 31, 2006, in an MCO with approximately 2.5 million members with medical and prescription drug coverage. Hospital-initiated PPI therapy was assumed based on the presence of a paid pharmacy claim for a PPI within the 30-day period following hospital discharge. All patients who during the study period had (a) no PPI claims during the 90 days prior to an inpatient admission, followed by (b) a hospital stay, and (c) at least 1 pharmacy claim for a PPI during 30 post-discharge days were included in this analysis. Patients with PPI claims during the 90 days prior to their inpatient admission were excluded from analysis as this use was assumed to be appropriate. Any member (a) initiated on PPI therapy during hospital admission without a medically appropriate diagnosis, either primary or secondary, 3 months prior to or during hospitalization and (b) continuing therapy after discharge, as determined by at least 1 pharmacy claim for a PPI during the first 30 post-discharge days, was categorized as an inappropriate user. For the sample subgroup with inappropriate PPI use, costs due to inappropriate PPI therapy were calculated as the total cost incurred by the MCO and its members-including ingredient cost, dispensing fees, member copayments, and coinsurance-for PPI claims during the first 30 days after hospital discharge.

Results: Of 29,348 study-eligible members, 68.8% (n = 20,197) were prescribed a PPI inappropriately at hospital discharge. Rates of inappropriate PPI use were approximately equal for patients who stayed in the intensive care unit or coronary care unit (ICU/CCU) versus non-ICU/CCU patients (68.7% vs. 68.9%, respectively, P = 0.796 using the Pearson chi-square test). Over the 4-year period of this analysis, the total cost to the MCO and its members associated with inappropriate continuation of PPI therapy during the first 30 days after hospital discharge was $3,013,069.

Conclusion: Increased health care costs associated with the utilization of PPIs can result from the inappropriate prescribing and continuation of PPI therapy after hospital discharge. Education of health care practitioners regarding medication reconciliation in general, and regarding continuation of PPI therapy specifically, is needed to increase responsible postdischarge medication utilization.