Correlates and economic outcomes of proton pump inhibitor use by routes in intensive care unit patients

Abstract

Objectives were to evaluate correlates, and economic outcomes of proton pump inhibitor (PPI) use by route in the intensive care unit from an institutional-payer perspective. A 13-month retrospective study of electronic medical records was conducted of 534 adult (≥19 year-old) intensive care unit patients receiving a PPI (39% enteral-only, 34% parenteral-only, 27% both-route) in a Midwest USA academic medical center. Possible cost-savings with sensitivity analysis were estimated as differences in drug costs (US dollars) between switch eligible parenteral and alternate enteral-PPI medication doses. In multivariate logistic-regression of switch criteria (any oral-medication, orogastric-tube, nothing by oral route), significant correlate for enteral versus parenteral PPI-use was any oral-medication use but not orogastric-tube. Using enteral esomeprazole/lansoprazole instead of parenteral (esomeprazole/pantoprazole) PPI (in 37% i.e. 696 of 1895 switch-eligible doses) would have saved US$2384.17 or US$3564.86, respectively. By switching eligible patients on oral-medications or on orogastric-tube from parenteral- to enteral-PPI, institutions can realize significant drug cost-savings.

Keywords::

• acid suppressive agent
• correlates
• drug cost saving
• intensive care
• intravenous to oral switch

Acknowledgements

Authors would like to acknowledge Hays E, Orwe L, Max M, and Forsung E for their immense help in data collection efforts during their time as Pharm D students at the University of Nebraska Medical Center.

Financial & competing interests disclosure

This study was funded in part under an Investigator initiated grant provided by Takeda Pharmaceuticals, Inc. The sponsor had no role in study conceptualization or design or in interpretation of study findings which are all the sole work of the authors alone. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Presentation: This work was presented in part at 15th and 16th Annual Meeting of The International Society for Pharmacoeconomics and Outcomes Research in May, 2010 at Atlanta, GA and in May, 2011 at Baltimore, MD.

Authors’ contributions: All authors conceived and designed the study. JS and KMO gained ethical approval. KMO and JS got access to the data for the study. JS and TR carried out the analysis of the data. JS and KMO were involved in writing the initial draft of the manuscript. All authors (JS, TR and KMO) reviewed and revised the final paper for intellectual content.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Intensive care unit (ICU) patients not receiving acid-suppressive agents like proton pump inhibitors (PPIs) may develop bleeding from stress. The bleeding may extend their length of ICU stay and increase costs to the hospitals. Therefore, PPIs are commonly prescribed to critically ill patients for prophylaxis of acute stress-related gastrointestinal bleeding (known as stress ulcer prophylaxis [SUP]) and of clinically significant upper gastrointestinal bleeding.

• Randomized clinical trial data are limited for PPIs and other agents in SUP. However, the Joint Commission, formerly the Joint Commission on the Accreditation of Healthcare Organizations, requires acid-suppressive therapy for SUP to ventilated ICU patients. Recently published Surviving Sepsis Campaign Guidelines (2012) recommend PPIs in SUP for patients at risk. A systematic review and meta-analysis (2013) suggest PPIs are more effective than H₂RAs in preventing clinically important and overt upper gastrointestinal bleeding in SUP.

• This is one of the first large real-world retrospective study of ICU patients at a Midwest academic medical center in the USA. We found ICU patients who are able to swallow oral medications, and who were not on ‘nothing by oral route’ status received an enteral versus a parenteral PPI. Also, switching eligible medication doses from parenteral to alternate equivalent enteral route PPI can save drug costs.

• Our study findings suggest that

  • – PPIs were given via intravenous route over the cost–effective enteral or oral route even when the patient is able to take medications orally, and

  • – consequently, there were missed opportunities to convert PPIs from intravenous to oral and save on drug costs.

• Identifying and converting eligible patients from parenteral to enteral PPI can help institutions proactively implement informed formulary decisions, save costs and help realize cost–effective quality of care.