Improving appropriateness of acid-suppressive medication use via computerized clinical decision support

Abstract

As part of the Choosing Wisely Campaign, the Society of Hospital Medicine identified reducing inappropriate use of acid-suppressive medication for stress ulcer prophylaxis as 1 of 5 key opportunities to improve the value of care for hospitalized patients. We designed a computerized clinical decision support intervention to reduce use of acid-suppressive medication for stress ulcer prophylaxis in hospitalized patients outside of the intensive care unit at an academic medical center. Using quasiexperimental interrupted time series analysis, we found that the decision support intervention resulted in a significant reduction in use of acid-suppressive medication with stress ulcer prophylaxis selected as the only indication, a nonsignificant reduction in overall use, and no change in use on discharge. We found low rates of use of acid-suppressive medication for the purpose of stress ulcer prophylaxis even before the intervention, and continuing preadmission medication was the most commonly selected indication throughout the study. Our results suggest that attention should be focused on both the inpatient and outpatient settings when designing future initiatives to improve the appropriateness of acid-suppressive medication use.

Figure 1

Study Timeline

Figure 2

Unadjusted and modeled monthly rates of “inappropriate” ASM orders, stratified by campus. We used a logistic regression model with a generalized estimating equation to control for admission characteristics (Table 1) and repeated admissions, including a term for the interaction between time and the intervention. We defined “inappropriate” ASM orders as any order for ASM with stress ulcer prophylaxis as the only recorded indication in a patient located outside of the ICU. ASM = acid-suppressive medication.