Use of physician education and computer alert to improve targeted use of gastroprotection among NSAID users.
BACKGROUND
Gastrointestinal (GI) hemorrhage accounts for 200-400,000 admissions in the United States annually. Around 50% of patients with bleeding ulcer have used aspirin and/or nonsteroidal anti-inflammatory drugs (NSAIDs). Misoprostol and proton pump inhibitors (PPIs) may reduce NSAID-related upper GI tract complications in high-risk patients, but their targeted use may be suboptimal.


OBJECTIVE
To determine the impact of physician education, a computer alert, or both on the targeted use of GI prophylaxis in high-risk patients discharged from hospital.


METHODS
To target high-risk patients, we studied cardiology telemetry and coronary care unit (CCU) services. Every 4th wk, 8 different residents managed these patients. Over a 32-wk period, residents were assigned to one of the four 8-wk groups sequentially: Group I: control; Group II: physician education, consisting of a 10-min tutorial on risk factors for NSAID-related GI complications; Group III: computer alert; and Group IV: combination of tutorial and computer alert. We reviewed all patients admitted to these cardiology services during the study period. Exclusion criteria included discharge on no ulcerogenic medications, incomplete discharge data, and inpatient death. Patients readmitted during the study period were not re-counted. Medical records were reviewed for discharge medications, past medical history, demographics, admission and discharge diagnoses, hospital days, and the Charlson comorbidity index. Other indications for acid suppression were documented. A chi(2) test was used to determine independence among all four groups.


RESULTS
We enrolled 721 patients, of whom 120 (16.7%) were excluded. The remaining 601 were divided by physician intervention group and risk for NSAID-related GI complications. In total, 270 of 601 (45%) patients were discharged home on appropriate gastroprotection. The overall use of gastroprotection increased from 43 to 61% with the combination of an electronic alert and physician education (P < 0.001); among PPI-naïve patients, the rate increased from 26% to 55% (P < 0.0001). When stratified by known risk factors for GI complications of NSAIDs, the odds of receiving a gastroprotective prescription among PPI-naïve patients was 1.6 with education alone, 1.8 with electronic alert alone, and 2.9 with the combination (P < 0.0001).


CONCLUSIONS
The combination of a computer alert and brief physician education led to an increase in the use of gastroprotection among NSAID users at the time of discharge from hospital. This effect was most evident among high-risk, PPI-naïve patients. Combining physician education and a computer alert appears to have an additive effect.
Coté
Gregory A
GA
Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
Rice
John P
JP
Bulsiewicz
William
W
Norvell
John P
JP
Christensen
Keri
K
Bobb
Anne
A
Postelnick
Michael
M
Howden
Colin W
CW
D000368:Aged; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000009:adverse effects* / Q000627:therapeutic use; D001241:Aspirin / Q000009:adverse effects / Q000627:therapeutic use; D002309:Cardiology; D003325:Coronary Care Units; D005260:Female; D005762:Gastroenterology / Q000193:education*; D006801:Humans; D007318:Inservice Training; D007396:Internship and Residency; D008297:Male; D050316:Medical Order Entry Systems; D016347:Medical Records Systems, Computerized; D008875:Middle Aged; D016595:Misoprostol / Q000627:therapeutic use; D009853:Omeprazole / Q000627:therapeutic use; D010351:Patient Discharge; D010438:Peptic Ulcer Hemorrhage / Q000139:chemically induced* / Q000517:prevention & control; D054328:Proton Pump Inhibitors / Q000627:therapeutic use; D012307:Risk Factors; D012984:Software; D013686:Telemetry
D000894:Anti-Inflammatory Agents, Non-Steroidal; D054328:Proton Pump Inhibitors; D016595:Misoprostol; D009853:Omeprazole; D001241:Aspirin