Use of physician education and computer alert to improve targeted use of gastroprotection among NSAID users

Gregory A. Coté, John P. Rice, William Bulsiewicz, John P. Norvell, Keri Christensen, Anne Bobb, Michael Postelnick, Colin Howden

Research output: Contribution to journalReview article

20 Citations (Scopus)

Abstract

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. AIM: 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 χ2 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). CONCLUSION: 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.

Original languageEnglish (US)
Pages (from-to)1097-1103
Number of pages7
JournalAmerican Journal of Gastroenterology
Volume103
Issue number5
DOIs
StatePublished - May 1 2008
Externally publishedYes

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Drug Users
Anti-Inflammatory Agents
Physicians
Education
Proton Pump Inhibitors
Gastrointestinal Agents
Cardiology
Pharmaceutical Preparations
Misoprostol
Coronary Care Units
Telemetry
Upper Gastrointestinal Tract
Gastrointestinal Hemorrhage
Aspirin
Ulcer
Medical Records
Prescriptions
Comorbidity
Inpatients
Demography

All Science Journal Classification (ASJC) codes

  • Hepatology
  • Gastroenterology

Cite this

Use of physician education and computer alert to improve targeted use of gastroprotection among NSAID users. / Coté, Gregory A.; Rice, John P.; Bulsiewicz, William; Norvell, John P.; Christensen, Keri; Bobb, Anne; Postelnick, Michael; Howden, Colin.

In: American Journal of Gastroenterology, Vol. 103, No. 5, 01.05.2008, p. 1097-1103.

Research output: Contribution to journalReview article

Coté, Gregory A. ; Rice, John P. ; Bulsiewicz, William ; Norvell, John P. ; Christensen, Keri ; Bobb, Anne ; Postelnick, Michael ; Howden, Colin. / Use of physician education and computer alert to improve targeted use of gastroprotection among NSAID users. In: American Journal of Gastroenterology. 2008 ; Vol. 103, No. 5. pp. 1097-1103.
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abstract = "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. AIM: 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 χ2 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-na{\"i}ve 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-na{\"i}ve patients was 1.6 with education alone, 1.8 with electronic alert alone, and 2.9 with the combination (P < 0.0001). CONCLUSION: 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-na{\"i}ve patients. Combining physician education and a computer alert appears to have an additive effect.",
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AU - Rice, John P.

AU - Bulsiewicz, William

AU - Norvell, John P.

AU - Christensen, Keri

AU - Bobb, Anne

AU - Postelnick, Michael

AU - Howden, Colin

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