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2007 HSR&D National Meeting Abstract

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National Meeting 2007

3090 — Improving Adherence with PPI Prescribing Guidelines in High-Risk NSAID Users: A Controlled “Before and After” Study of a CPRS Reminder

Spiegel BM (VA Greater Los Angeles Healthcare System; Sepulveda HSR&D COE) , Glassman P (VA Greater Los Angeles Healthcare System), Dulai G (David Geffen School of Medicine at UCLA), Shekelle P (VA Greater Los Angeles Healthcare System), Ochotorena L (VA Greater Los Angeles Healthcare System), Talley J (VA Greater Los Angeles Healthcare System), Goldzweig C (VA Greater Los Angeles Healthcare System)

Objectives:
Nonsteroidal anti-inflammatory drugs (NSAID) cost the VA $40 million/year. This cost is partly driven by GI side effects of NSAIDs, such as ulcer bleeding. There have been calls within VA to develop cost-effective strategies to manage NSAID users at high-risk for GI complications. Proton pump inhibitor (PPI) co-therapy in high-risk users is cost-effective, and is a widely-accepted quality performance measure. Yet only 29% of high-risk NSAID users in VA receive PPIs. We sought to compare rates of “inappropriate underuse” of PPI therapy in high-risk NSAID users before versus after deployment of a CPRS reminder across the VA Greater Los Angeles Healthcare System.

Methods:
We developed a system-wide CPRS reminder to target inappropriate underuse of PPI therapy in high-risk NSAID users. The reminder identified patients on chronic (>=30 day) NSAID therapy with >=1 independent risk factor(s) for GI complications (warfarin, prednisone, multiple NSAIDs, history of ulcer, age >=65) who were not receiving PPI co-therapy. The reminder was based on social influence theory, and was designed with content and methods experts to maximize point-of-care effectiveness. The primary outcome was guideline adherence (adherence=reminder resolved by initiating PPI) during the 3 month period before versus after reminder deployment. The minimum cluster-adjusted sample size was N=676. We compared adherence between periods by chi-squared, and calculated frequency counts to summarize reasons for overriding the reminder.

Results:
There were 1113 and 949 patients in the pre and post periods, respectively. Eight percent versus 38% of patients were placed on PPIs in the pre versus post periods, respectively (p<0.01). Among the 62% not placed on PPI in the intervention period, 60% had unopened reminders, and 40% had overridden reminders. Reasons for overriding: patient refused PPI (28%), patient not on NSAID (28%), provider disagreed with recommendation (25%), patient taking non-VA source PPI (19%).

Implications:
The CPRS reminder improved adherence with guidelines by 30% over baseline. The study is limited by the short time horizon and lack of randomization.

Impacts:
If a future randomized trial is successful, then the reminder will be presented to the Clinical Decision Support Workgroup to consider exporting across VA to help enhance the capabilities of CPRS system-wide.