Incidence and cost of stress ulcer prophylaxis after discharge from the intensive care unit: a retrospective study.

OBJECTIVE: To describe current patterns in initiation and cessation of proton pump inhibitors (PPIs) for stress ulcer prophylaxis (SUP) in intensive care units, and to assess the costs associated with inappropriate (non-evidence-based) SUP. DESIGN, SETTING AND PARTICIPANTS: Retrospective observational study in five ICUs in Western Australia. We assessed the medical records of consecutive patients admitted to the ICUs between September 2013 and January 2015. Patients aged < 18 years were excluded. RESULTS: We included 531 patients in the study. Of the 184 patients in whom PPIs were initiated for SUP in the ICU, 90 (48.9%) were still taking the therapy at the time of discharge from hospital. A documented indication for ongoing therapy was present in only nine patients (10%). We assumed a 10-year life expectancy after ICU discharge and that most patients continued taking a PPI, and calculated an additional cost of $180.20 per patient admitted to the ICU. This was based only on unnecessary PPI costs (ignoring costs of managing additional adverse events). The direct cumulative annual cost to the WA health system of PPIs continued unnecessarily for patients at discharge from hospital is estimated to be $250 800 for each year they continue to receive them. CONCLUSION: A substantial proportion of patients prescribed SUP in the ICU continue receiving this therapy at hospital discharge despite no clear indication. In addition to potential adverse clinical effects, this is associated with major direct and indirect cost implications.

Opinions and practice of stress ulcer prophylaxis in Australian and New Zealand intensive care units.

BACKGROUND: Intensivists frequently prescribe proton pump inhibitors (PPIs) or histamine-2 receptor blockers (H2RBs) to intensive care unit patients for stress ulcer prophylaxis (SUP). Despite the common use of SUP medicines, there is limited high-level evidence to support the choice between them. AIM: To describe self-reported practice of SUP by Australian and New Zealand intensivists. METHOD: An online questionnaire of intensivists between 13 January and 3 February 2014. RESULTS: Seventy-two intensivists responded to the survey: 61 (85%) practised in public metropolitan ICUs and 13/48 (27%) practised in paediatric ICUs. Fifty-two (72%) respondents indicated that PPIs were their preferred SUP medicine. Respondents estimated that an average of 84% of ventilated and 53% of non-ventilated patients received SUP medicines during their ICU admission. Seven respondents (9%) were concerned or very concerned about the possible increased risk of upper gastrointestinal bleeding associated with H2RBs versus PPIs. Ten respondents (14%) were concerned or very concerned about the possible greater risk of Clostridium difficile infection, and 15 respondents (21%) were concerned or very concerned about the possible greater risk or ventilator-associated pneumonia with PPIs versus H2RBs. Most respondents (64 [89%]) agreed or strongly agreed that there was insufficient evidence to support the choice of an optimal SUP medicine, and 58 respondents (81%) agreed or strongly agreed to patient enrollment in an RCT comparing PPIs with H2RBs. CONCLUSION: Most survey respondents felt that current evidence is insufficient to justify the preferential use of PPIs or H2RBs for SUP and would enroll patients in a comparative SUP RCT.

Treatment goals: health care improvement through setting and measuring patient-centred outcomes.

OBJECTIVE: To determine how frequently stress ulcer prophylaxis (SUP) medications prescribed in the intensive care unit are inappropriately continued on the ward and on hospital discharge. DESIGN: Retrospective cohort study; chart review. SETTING: Two Australian ICUs: one tertiary centre and one metropolitan centre. PARTICIPANTS: We included 387 adult, non-pregnant patients who were admitted to the ICU between 1 February 2011 and 31 March 2011 and who survived to hospital discharge. MAIN OUTCOME MEASURES: Rate of unnecessary continuation of ICU-prescribed SUP medications on the ward and on discharge from hospital. RESULTS: While in the ICU, 329 of the 387 patients (85%) were prescribed SUP medications. Of the 233 patients who had not been taking acid-suppressive medications before admission to the ICU, 190 were prescribed SUP medications in the ICU. Of these 190 patients, most (63%) had their SUP continued in the ward without any obvious indication, and many (39%) had their SUP medications inappropriately continued on discharge from hospital. CONCLUSIONS: SUP medications commenced in ICU are frequently continued unnecessarily, both in the wards and on hospital discharge.

Current use of preoperative intra-aortic balloon counterpulsation in high-risk cardiac surgery: a cohort study.

OBJECTIVE: To determine whether preoperative introduction of intra-aortic balloon counterpulsation (IABC) reduced mortality in high-risk patients undergoing coronary artery bypass graft (CABG) surgery. METHODS: This was a retrospective cohort study of prospectively collected data on all patients who underwent cardiac surgery at a university hospital in Sydney, New South Wales, between 1 January 2002 and 20 August 2007. High risk was defined as the presence of two or more recognised risk factors. We compared the observed mortality to the mortality predicted by the EuroSCORE, and conducted a logistic regression analysis to determine the effect of preoperative IABC on mortality. RESULTS: Among 358 patients deemed high risk, 36 underwent preoperative IABC. This group had higher EuroSCORE-predicted mortality than the group that did not undergo IABC (38% v 18%, P = 0.008). Despite this, observed mortality was similar for those with and without preoperative IABC (both 2.8%) and was significantly lower than predicted in both groups. This equates to a riskadjusted reduction in mortality associated with the use of preoperative IABC (hazard ratio, 0.47; 95%CI, 0.26-0.84; P = 0.005). This result was not confirmed in the logistic regression analysis, with an adjusted odds ratio for mortality of 0.85 (95% CI, 0.09-7.6; P = 0.88). Rates of postoperative complications, including limb ischaemia, were low and similar in both groups. CONCLUSIONS: In this study of high-risk CABG patients, the use of preoperative IABC in the group with higher predicted mortality was associated with a relative reduction in observed mortality. These data provide cautious support for the use of preoperative IABC in selected high-risk patients.