The rationality of continuous improvement of stress ulcer preventive medication by orthopedic clinical pharmacists in tertiary teaching hospitals

doi:10.21203/rs.3.rs-2480034/v1

Download PDF

Research Article

The rationality of continuous improvement of stress ulcer preventive medication by orthopedic clinical pharmacists in tertiary teaching hospitals

https://doi.org/10.21203/rs.3.rs-2480034/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Objective: We aim to evaluate the efficacy of clinical intervention by clinical pharmacists in improving prophylactic medication for stress ulcer, and explore the application of Plan-Do-Check-Act (PDCA) in promoting rational stress ulcer prophylaxis (SUP).

Methods: We conducted a retrospective study of 1702 patients in the Department of Orthopedics at a tertiary teaching hospital in China from January 2021 to October 2022. 778 and 924 patients were included in the pre-PDCA and post-PDCA groups, respectively. Clinical pharmacists established the criteria for SUP and conducted interventions, including doctor's prescription review, opinion feedback, clinical education and result analysis. We analyzed the improvement of irrational drug use and medical cost in stress ulcer prophylaxis before and after the establishment of PDCA cycle.

Results: Clinical pharmacist-led continuous intervention and PDCA cycle significantly reduced the incidence of irrational SUP (79.31% vs. 23.41%), including medication duration, indications, usage and drug selection. The average duration of use of acid-suppressive drugs in each patient (days 3.90±2.29 vs. 2.68±1.97) the average SUP cost (CNY 166.58±116.25 vs. 126.48±104.16) and inappropriate SUP cost (CNY 70.40±84.47 vs. 25.53±68.66) were significantly decreased. The target compliance rate was 109.41%.

Conclusions: Clinical pharmacists can effectively improve irrational SUP through PDCA cycle to optimize drug use, so as to obtain better clinical and economic outcomes.

stress ulcer prophylaxis

clinical pharmacist

intervention

Plan-Do-Check-Act

prescription evaluation

rational drug use

Stress ulcer (SU), also known as stress mucosal lesion and acute gastric mucosal lesion, refers to the acute gastrointestinal mucosal erosion, ulcer and other lesions that occur in the body under various stress conditions such as severe trauma, critical disease or severe psychological disease. In severe cases, gastrointestinal bleeding, or even perforation can occur, which can aggravate and worsen the original disease and increase the fatality rate ^[1]. The epidemiologic survey shows that stress ulcer is the second common cause of upper gastrointestinal bleeding in China^[2]. Clinically, stress ulcers are mainly characterized by blood vomiting, "coffee grounds" substance in nasogastric tube suction, blood in stool or black stool. Previous studies have reported that the incidence of stress ulcers is 0.4%-12.9%^{[3, 4]}. There are two main types of acid-suppressing drugs commonly used in clinical prevention of stress ulcers. One is Histamine 2 receptor antagonists (H₂RA), the other group is called Proton pump inhibitors (PPIs). H₂ receptor antagonists, drugs developed to treat excess acid and the first to be shown to reduce acid production, are competitive inhibitors of histamine 2 receptors on the surface of parietal cells. Cimetidine was synthesized by Sir James Blake in 1972 and marketed in 1976, the first commercially available H₂ receptor antagonist^[5]. Omeprazole was discovered in 1979 and approved for sale in Europe in 1988 and the United States in 1992^[6], after which numerous varieties including lansoprazole, rabeprazole, pantoprazole and esomeprazole were developed. Proton pump inhibitors, the most effective acid-suppressive drugs on the market, prevent parietal cells from releasing acid by inhibiting H⁺/K⁺ ATP^{[7, 8]}. Acid-suppressive drugs are available as oral tablets or intravenous formulations, and often have similar efficacy in the absence of active bleeding^{[9, 10]}. In recent years, the prescription intensity of acid-suppressive drugs has also increased year by year, with PPI prescriptions increasing from 0.2% in 1990 to 14.2% in 2018, and H₂ receptor antagonists from 1.2% to 3.4%. However, only half of these acid suppressant prescriptions have indications^[11]. Improper use of acid-suppressive drugs can lead to serious adverse effects, mainly pneumonia^[12-14], clostridium difficile infection^{[15, 16]}, increased risk of fracture^{[17, 18]}, kidney damage^[19], etc. In China, the unreasonable use of acid-suppressive drugs, especially proton pump inhibitors, is very serious^[20], and the unreasonable use of drugs will lead to the increase of medical expenses and potential adverse effects. Therefore, the rational use of acid suppressant drugs is an urgent problem to be solved in China, and effective measures should be adopted to improve the preventive use of acid-suppressive drugs, so as to reduce unnecessary drug costs.

"Plan-Do-Check-Act (PDCA) circulation" was proposed by Dr. Edwards Deming, an American quality management expert, in the 1950s^[21]. PDCA divides the management process into four parts, which is a process of finding and solving problems. In this paper, we report the rational use of perioperative acid-suppressive drugs for the prevention of stress ulcers in spinal fusion surgery in a tertiary teaching hospital in China through continuous improvement of PDCA by clinical pharmacists. This work is the basis for confirming the feasibility of the working model of clinical pharmacists.

Study design and participants

The retrospective study was conducted in the Department of Orthopaedics, a tertiary teaching hospital with 90 beds in China. The study reports four consecutive steps in the PDCA cycle, with prescription evaluation consisting of eight steps (Figure 1). Study data were collected from hospital records, patient information from the electronic medical record system and information related to acid suppressant administration. Patients are excluded for any of the following reasons: Age < 18 years old, died during hospitalization, used acid suppressant drugs before hospitalization, had a history of related chronic gastrointestinal diseases before hospitalization, the number of operations during hospitalization ≥2 times, after hospitalization, acid suppressant drugs were used to treat peptic ulcer, gastroesophageal reflux disease, helicobacter pylori infection, Zollinger-Ellison syndrome, upper gastrointestinal bleeding. After hospitalization, acid-suppressive drugs are used to prevent drug bleeding in high-risk patients (such as antiplatelet drugs, non-steroidal anti-inflammatory drugs, etc.).

Plan

Data collection and statistical analysis

We collected information on the use of acid-suppressive drugs during hospitalization, including drug selection, usage and dosage, duration of medication, and drug price. Chinese Yuan (CNY) is used to determine spending on acid-suppressive drugs. We investigated the use of acid-suppressive drugs in the orthopedic spine group from January 2021 to October 2021, which is considered the pre-intervention phase. The correct drug selection, dosage, frequency and course of medication were considered as reasonable use of acid-suppressive drugs.

Chi-square test and T-test were performed using IBM SPSS software version 21.0. Classification variables are expressed by quantity and percentage; Continuous variables are expressed in terms of mean and standard deviation. Non-parametric Mann-Whitney U test was used to analyze variables with discontinuous distribution. Statistical significance was defined as bilateral P < 0.05.

Objective setting and solution formulation

The purpose of this study was to evaluate the intervention effect of clinical pharmacists by improving the rationality of prophylactic medication for stress ulcer by PDCA. Use the following formula to calculate the target and target compliance rate:

Target value = Current rate - Improved value

Improved value = Current rate × Intervention department × Intervention coverage

Target compliance rate = Completion value / Target value

We evaluated stress ulcer prophylaxis in pre-PDCA patients using the 80/20 rule (Figure 2) and created fishbone charts to analyze the causes of each factor; The main reasons for improvement were identified (Figure 3). Finally, select and integrate countermeasures according to the main reasons, including: 1. Develop evaluation standards; 2. Carry out clinical education and personnel training; 3. Conducted medical order review and made medical order review software; 4. Arouse the attention of clinicians and formulate relevant regulations for supervision.

Establishment of clinical pharmacist team

We established a team of clinical pharmacists for this study, including senior clinical pharmacists, young clinical pharmacists and graduate students. This team of clinical pharmacists is responsible for drafting and determining the evaluation rules and presiding over the evaluation process to ensure that the work goes smoothly. The clinical pharmacists in this study had at least 1 year of clinical experience and were familiar with stress ulcer guidelines. Clinical pharmacists are responsible for a series of professional training for orthopaedic surgeons to help them quickly familiarize themselves with rational drug use standards for stress ulcers. Graduate students are responsible for the review of medical advice and the evaluation of medication.

Establishment of criteria for SUP

Based on the existing guidelines for the prevention of stress ulcers, we drafted a standard medication regimen for stress ulcers using an evidence-based approach. Reference criteria included the American Society of Health System Pharmacists Guidelines^[22], the Eastern American Surgical Trauma Society Guidelines for the prevention of Stress ulcers^[23], the Portuguese Intensive Care Unit Guidelines for the prevention of stress ulcers^[24], the Danish Guidelines for the prevention of Severe Stress Ulcers^[25], the Clinical Practice Guidelines for Severe Patients^[26], and two Chinese expert Consensus on the prevention of stress ulcers^{[27, 28]}.

Clinical pharmacist intervention

Orthopedic spine surgery patients were enrolled before the intervention (January to October 2021) and after the intervention (November 2021 to October 2022), with three months defined as a phase. At each stage, interventions by clinical pharmacists include: 1. Evaluate SUP prescription according to established criteria; 2. Collect inappropriate SUP medical records and feedback them to doctors; 3. Doctors modify prescriptions according to preventive criteria; 4. Clinical pharmacists conducted statistical analysis of data; 5. Clinical pharmacists optimize prevention standards; 6. Clinical pharmacists provide effective clinical education (Figure 1).

Check

According to the established criteria, the same prescriptions were evaluated and compared before and after the establishment of the PDCA cycle. Use the data collected to calculate economic benefits. The rational rate of SUP was evaluated according to four aspects: indications, drug selection, frequency of administration and course of medication.

Act

At each stage, statistical results are reported to the obligatory departments, and reward and punishment mechanisms are established. In addition, clinical pharmacists discuss problems identified during the examination and decide how to resolve them. Flow charts are standardized and updated every 3 months.

Patient characteristics

From January 2021 to October 2021, there were 778 patients in the early stage of PDCA. There were 924 patients in PDCA group from November 2021 to October 2022. The PDCA cycle takes 3 months as a stage, and there are 4 stages in total. There were no significant differences in demographic and clinical characteristics (such as sex, age, length of stay, diagnosis of admission, age-adjusted Charlson comorbidity index, and length of operation) before and after the PDCA cycle（Table1）.

Practice and effects of adopting the PDCA cycle

Standards and objectives.

According to the reference criteria, we summarized the main criteria and secondary criteria of SUP, and based on this, we developed a prevention program in line with the actual situation of our hospital (Figure 4). In 778 patients with pre-PDCA, the incidence of irrational SUP was 79.31%. Inappropriate duration of medication (67.91%, 419/778) and no indication (11.44%, 89/778) were the most common reasons. The statistical results are shown in Table 2 and Figure 2. According to the calculation, the target value of this study is 70% SUP reasonable rate.

Evaluation of clinical effects.

The study involved 4 stages, with a total duration of 1 year. The irrational rate in the first two stages (58.16% and 63.01%) was significantly reduced (P < 0.05), but there was still a big gap from our target value, so we increased the clinical education, and adhere to the daily medical advice review and timely feedback, the total irrational rate was finally reduced to 23.41% (P < 0.05). Table 2 shows the improvement of unreasonable causes at each stage. Inappropriate drug use duration (67.91% to 23.41%, P < 0.01), unindicated drug use (11.44% to 0, P < 0.01), inappropriate drug selection (7.84% to 0, P < 0.01) and inappropriate drug use (6.17% to 0, P < 0.01) were significantly improved (P < 0.05).

Table 1. General characteristics of patients before and after establishment of PDCA cycle.

Characteristics	Pre-PDCA (n=778)	Post-PDCA				P
Characteristics	Pre-PDCA (n=778)	PhaseⅠ (n=196)	PhaseⅡ (n=292)	PhaseⅢ (n=231)	PhaseⅣ (n=205)	P
Male,n(%)	360（46.27）	91(46.43)	125(42.81)	109(47.19)	86(41.95)	0.67
Age(years),IQR	65(57,71)	64(56,69)	64(56,71)	64(57,71)	66(59,70.5)	0.74
Length of stay(days),IQR	13(10,16)	13(10,16)	13(10,15)	12(9,15)	13(9,16)	0.09
Diagnosis of admission						0.87
lumbar spondylopathy	534(68.64)	130(66.33)	203(69.52)	148(64.07)	135(65.85)
cervical spondylosis	207(26.61)	56(28.57)	72(24.66)	71(30.74)	57(27.80)
others	37(4.75)	10(5.10)	17(5.82)	12(5.19)	13(6.34)
ACCI(scores),IQR	2(1,3)	2(1,3)	2(1,3)	2(1,3)	2(2,3)	0.83
Length of operation(min),IQR	180(136.75,225)	172(136.25,231.5)	180(130,229)	180(128,227)	180(126.5,242)	0.95

Before PDCA:Jan-Oct,2021; PhaseⅠ:Nov,2021-Jan,2022; PhaseⅡ:Feb-Apr,2022; PhaseⅢ:May-Jul,2022; PhaseⅣ:Aug-Oct,2022.

PDCA,Plan-Do-Check-Act;ACCI: Age-adjusted Charlson Comorbidity Index.

Table 2.Reasons for irrational SUP before and after establishment of the PDCA cycle.

	Pre-PDCA n (%) (n=778)	Post-PDCA n (%)				P-value
	Pre-PDCA n (%) (n=778)	PhaseⅠ (n=196)	PhaseⅡ (n=292)	PhaseⅢ (n=231)	PhaseⅣ (n=205)	P₁	P₂	P₃	P₄
Inappropriate duration	419(67.91)	104(53.06)	180(61.64)	96(41.56)	48(23.41)	0.87	0.02	＜0.01	＜0.01
No indication	89(11.44)	9(4.59)	2(0.68)	1(0.43)	0(0)	0.01	0.01	＜0.01	＜0.01
Inappropriate drug	61(7.84)	1(0.51)	1(0.34)	0(0)	0(0)	0.01	0.01	＜0.01	＜0.01
Inappropriate dosing frequency	48(6.17)	0(0)	1(0.34)	0(0)	0(0)	0.01	0.01	＜0.01	＜0.01
Total irrational rate	617(79.31)	114(58.16)	184(63.01)	97(41.99)	48(23.41)	＜0.01	＜0.01	＜0.01	＜0.01

Before PDCA:Jan-Oct,2021; PhaseⅠ:Nov,2021-Jan,2022; PhaseⅡ:Feb-Apr,2022; PhaseⅢ:May-Jul,2022; PhaseⅣ:Aug-Oct,2022. PDCA, Plan-Do-Check-Act.

Economic benefit and I-PPI consumption analysis.

As shown in Table 3, PDCA significantly reduced the average SUP duration and average SUP cost. The average duration of SUP before PDCA was 3.9 days, and the average duration of SUP at stage 1 and stage 4 after PDCA was 3.32 days and 2.68 days (P < 0.05), which were significantly decreased. The average cost of acid-suppressive drugs for SUP before PDCA was 166.58 yuan, and that for inappropriate SUP was 70.40 yuan. The average cost of acid-suppressive drugs for SUP at the first and fourth stages after PDCA was 154.18 yuan and 126.48 yuan (P < 0.05). The cost of inappropriate SUP acid suppressant was 54.28 yuan and 25.53 yuan (P < 0.05), both of which were significantly reduced. Overall, proper SUP greatly reduces health care costs and reduces potential adverse effects.

Table 3.Cost and consumption of SUP before and after establishment of PDCA cycle.

	Before PDCA	After PDCA		P-value
	Before PDCA	PhaseⅠ	PhaseⅣ	P₁	P₂
Total rational rate of SUP(%)	20.69	46.94	76.59	＜0.01	＜0.01
Duration of SUP(days),mean±SD	3.90±2.29	3.32±1.99	2.68±1.97	＜0.01	＜0.01
Cost of SUP per patient(CNY),mean±SD	166.58±116.25	154.18±90.75	126.48±104.16	0.93	＜0.01
Cost of inappropriate SUP per patient(CNY),mean±SD	70.40±84.47	54.28±70.90	25.53±68.66	0.01	＜0.01

Before PDCA:Jan-Oct,2021; PhaseⅠ:Nov,2021-Jan,2022; PhaseⅣ:Aug-Oct,2022.

PDCA,Plan-Do-Check-Act; CNY, China Yuan.

Continuous medical quality improvement.

After the PDCA cycle, the effective intervention rate of inappropriate SUP was significantly increased, and the irrational use was basically reduced every 3 months (Figure 4). In the fourth stage of PDCA, SUP reasonable rate was 76.59%, which reached the target value of the study. Compared with before the establishment of PDCA, higher reasonable SUP was achieved after the establishment of PDCA (20.69% to 76.59%, P < 0.05). The target compliance rate is 109.41%.

Our study showed that the intervention of clinical pharmacists improved the rational rate of SUP through the PDCA cycle, including optimizing medication time, medication according to indications, drug usage and dosage, and drug selection. Through one year of intervention, the rational rate of orthopedic SUP increased from 20.69% to 79.59%, the nearly 60% increase rate can reflect the work of clinical pharmacists is successful, and also has been recognized by the clinical, it is of great importance to reduce medical costs.

In 1999, the American Pharmacists Association published the first stress ulcer prevention guidelines, and in the following 20 years, various countries, regions and even medical institutions have issued stress ulcer prevention guidelines and recommendations. However, in routine clinical practice, we have found that compliance with these guidelines is not as high, and more clinicians still use medication empirically. A study^[29] conducted a survey on the knowledge, prescribing behavior and habits of Chinese doctors about SUP found that 46% of clinicians were completely unaware of any guidelines for SUP, and surgeons knew little about SUP guidelines, which may lead to insufficient knowledge and drug overdose. Researchers^[30] in the United States conducted a survey of 150 doctors' SUP knowledge and behavior through Internet mail, and found that only 38% of doctors would prescribe according to the guidelines, 34% of doctors did not know the adverse reactions of acid suppressant drugs, high prescription of acid suppressant drugs and doctors were afraid to assume bleeding and legal liability. A survey^[31] also showed that some clinicians believe that acid-suppressive drugs are harmless and can be used by anyone. It is these inappropriate views and perceptions that lead to the abuse of acid-suppressive drugs. The participation of clinical pharmacists can effectively improve the above problems.

In this study, we demonstrated that clinical pharmacists effectively improved the rational rate of SUP by establishing the PDCA cycle. The most direct effect of clinical pharmacists' intervention is to reduce the use of inappropriate acid suppressant drugs, reduce unnecessary medical expenditure, and significantly reduce the medical cost of patients without affecting the clinical efficacy. Although the target value was reached at the last phase, the rationality rate of the last three months was above the target value, and even showed a continuous rising trend, which indicated that the practice of clinical pharmacists was successful. The advantages of this study are standardized SUP protocol, application of PDCA cycle and effective intervention by clinical pharmacists. First of all, through the study of literature and guidelines, we developed a standard procedure for SUP in line with the situation of our hospital, and made detailed suggestions on the indications, course of treatment, usage and dosage of SUP and drug selection. Secondly, the PDCA cycle can ensure that the project is organized, systematic and scientific. Through the analysis of the problems in each stage, improve the scheme, so as to better converge to the target. For example, in the second phase, we saw a downward trend. The reason may be related to the low attention of clinical pharmacists, who did not review medical advice every day, so the deficiency in this aspect was improved. From the third stage, we saw an obvious upward trend. Thirdly, clinical pharmacists adopt effective intervention means, including review of medical advice, clinical feedback and clinical education. The final results also highlight the important role of clinical pharmacists in promoting rational drug use of SUP.

This study has several limitations. First of all, we only conducted this study in a single department, the data sources were relatively limited, and the conclusions were not easy to extrapolate. Second, the conclusions of this study are more management oriented, and the results are not as convincing as those of randomized controlled trials. Third, the conclusion of this study is more about the intervention results of pharmacists, and we should see more changes in clinicians. This study did not interfere the administration route, which is also a large unreasonable area^[32]. For the long-term use of acid-suppressive drugs, the intervention of the route of administration is also a very important direction. Our economic analysis is relatively simple, we should conduct a more comprehensive economic analysis.

Clinical pharmacists conduct clinical intervention through PDCA circulation method, which can effectively improve the situation of clinical irrational stress ulcer prophylactic medication, obtain beneficial clinical and economic results. Clinical irrational drug use cannot be completely avoided, and the results of this study still have great room for improvement. Informatization is a trend in the future, and the next research should be developed in this respect. Clinical pharmacists combined with informatization system can effectively promote clinical rational drug use and improve medical quality.

Ethics approval and consent to participate

The studies involving human participants were reviewed and approved by the Ethical Committee of Xuanwu Hospital Captial Medical University (No: 2022040). Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee at which the studies were conducted.

Human and animal rights

This study has been performed in accordance with the ethical standards as laid down in the 1964.

Declaration of Helsinki and its later amendments or comparable ethical standards. No animals have been involved.

Consent for publication

Not applicable.

Availability of data and materials

The datasets generated and/or analyzed during the study are available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

No financial support

Authors' contributions

Yichun Xu designed the study and wrote the article. Huan Yang, Jianghua Shen，Su Su and Xiaoxuan Xing participated in the design. All authors participated in critical revision of the manuscript and have seen and approved the final version. Yanqi Chu is the guarantor of this trial. All authors read and approved the final manuscript.

Acknowledgements

The authors are grateful to all of the participants and contributors. We would like to thank Huan Yang for helping to collect the data. Thank the orthopedic doctors of Xuanwu Hospital for their support.

Authors' information (optional)

Department of Pharmacy, Xuanwu Hospital of Capital Medical University, No. 45, Changchun Street, Xicheng District, Beijing, People’s Republic of China

Yichun Xu, Jianghua Shen, Su Su, Xiaoxuan Xing,Lan Zhang & Yanqi Chu.

School of Pharmacy, Zunyi Medical University，No. 1, Daxue Road, Honghuagang District, Zunyi City，Guizhou，People’s Republic of China

Huan Yang

Guidelines for clinical application of proton pump inhibitors(2020). 2021. 28(01): 1-9.
Wang Hai-yan DX, Bai Yu LZ. Clinical epidemiologic study of upper gastrointestinal bleeding in China. Chin J Dig Endosc. 2013. Vol.30(N0.2): 83-86.
Farsaei S, Ghorbani S, Adibi P. Variables Associated with Adherence to Stress Ulcer Prophylaxis in Patients Admitted to the General Hospital Wards: A Prospective Study. Adv Pharm Bull. 2017. 7(1): 73-80.
Wei J, Jiang R, Li L, et al. Stress-related upper gastrointestinal bleeding in adult neurocritical care patients: a Chinese multicenter, retrospective study. Curr Med Res Opin. 2019. 35(2): 181-187.
Freemantle M. Tagamet. Chem Eng News 2005;83:25 .
Olbe L, Carlsson E, Lindberg P. A proton-pump inhibitor expedition: the case histories of omeprazole and esomeprazole. Nat Rev Drug Discov. 2003. 2(2): 132-9.
Aronson JK. Inhibiting the proton pump: mechanisms, benefits, harms, and questions. BMC Med. 2016. 14(1): 172.
Strand DS, Kim D, Peura DA. 25 Years of Proton Pump Inhibitors: A Comprehensive Review. Gut Liver. 2017. 11(1): 27-37.
Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010. 152(2): 101-13.
Tsoi KK, Hirai HW, Sung JJ. Meta-analysis: comparison of oral vs. intravenous proton pump inhibitors in patients with peptic ulcer bleeding. Aliment Pharmacol Ther. 2013. 38(7): 721-8.
Abrahami D, McDonald EG, Schnitzer M, Azoulay L. Trends in acid suppressant drug prescriptions in primary care in the UK: a population-based cross-sectional study. BMJ Open. 2020. 10(12): e041529.
Laheij RJ, Sturkenboom MC, Hassing RJ, Dieleman J, Stricker BH, Jansen JB. Risk of community-acquired pneumonia and use of gastric acid-suppressive drugs. JAMA. 2004. 292(16): 1955-60.
Eom CS, Jeon CY, Lim JW, Cho EG, Park SM, Lee KS. Use of acid-suppressive drugs and risk of pneumonia: a systematic review and meta-analysis. CMAJ. 2011. 183(3): 310-9.
Herzig SJ, Howell MD, Ngo LH, Marcantonio ER. Acid-suppressive medication use and the risk for hospital-acquired pneumonia. JAMA. 2009. 301(20): 2120-8.
Howell MD, Novack V, Grgurich P, et al. Iatrogenic gastric acid suppression and the risk of nosocomial Clostridium difficile infection. Arch Intern Med. 2010. 170(9): 784-90.
Kwok CS, Arthur AK, Anibueze CI, Singh S, Cavallazzi R, Loke YK. Risk of Clostridium difficile infection with acid suppressing drugs and antibiotics: meta-analysis. Am J Gastroenterol. 2012. 107(7): 1011-9.
Eom CS, Lee SS. Risk of fracture and pneumonia from acid suppressive drugs. World J Methodol. 2011. 1(1): 15-21.
Cea Soriano L, Ruigómez A, Johansson S, García Rodríguez LA. Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting. Pharmacotherapy. 2014. 34(6): 570-81.
Qiu T, Zhou J, Zhang C. Acid-suppressive drugs and risk of kidney disease: A systematic review and meta-analysis. J Gastroenterol Hepatol. 2018 .
Ying J, Li LC, Wu CY, Yu ZW, Kan LD. The status of proton pump inhibitor use: a prescription survey of 45 hospitals in China. Rev Esp Enferm Dig. 2019. 111(10): 738-743.
Schneider PD. FOCUS-PDCA ensures continuous quality improvement in the outpatient setting. Oncol Nurs Forum. 1997. 24(6): 966.
ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis. ASHP Commission on Therapeutics and approved by the ASHP Board of Directors on November 14, 1998. Am J Health Syst Pharm. 1999. 56(4): 347-79.
EAST Practice Management Guidelines Committee. Practice management guidelines for stress ulcer prophylaxis. 2008 .
Mendes JJ, Silva MJ, Miguel LS, et al. Sociedade Portuguesa de Cuidados Intensivos guidelines for stress ulcer prophylaxis in the intensive care unit. Rev Bras Ter Intensiva. 2019. 31(1): 5-14.
Madsen KR, Lorentzen K, Clausen N, et al. Guideline for stress ulcer prophylaxis in the intensive care unit. Dan Med J. 2014. 61(3): C4811.
Ye Z, Reintam Blaser A, Lytvyn L, et al. Gastrointestinal bleeding prophylaxis for critically ill patients: a clinical practice guideline. BMJ. 2020. 368: l6722.
Bai Y, Li YQ, Ren X, Li ZS, Zhao SB, Wang SL. Expert consensus on stress ulcer prophylaxis(2018). Natl Med J China. 2018. 98(42): 3392-3395.
Zhao YP. Prophylaxis and Treatment of Stress Mucosal Lesions -- Consensus of Chinese General Surgery Experts(2015). Chinese Journal of Practical Surgery. 2015. 35(07): 728-730.
Xing XX, Zhu C, Chu YQ, et al. Physicians' knowledge, attitude, and prescribing behavior regarding stress ulcer prophylaxis in China: a multi-center study. BMC Gastroenterol. 2021. 21(1): 402.
Hussain S, Stefan M, Visintainer P, Rothberg M. Why do physicians prescribe stress ulcer prophylaxis to general medicine patients. South Med J. 2010. 103(11): 1103-10.
Koczka CP, Geraldino-Pardilla LB, Goodman AJ. Physicians' opinions of stress ulcer prophylaxis: survey results from a large urban medical center. Dig Dis Sci. 2013. 58(3): 777-81.
Tang Y, Zhang X, Yang C, Yang L, Wang H, Zhang X. Application of propensity scores to estimate the association between government subsidy and injection use in primary health care institutions in China. BMC Health Serv Res. 2013. 13: 183.

No competing interests reported.

supplement.docx

Download PDF

Version 1

posted

You are reading this latest preprint version

The rationality of continuous improvement of stress ulcer preventive medication by orthopedic clinical pharmacists in tertiary teaching hospitals

Status:

Version 1

Abstract

Figures

Introduction

Methods

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1