Cheaper PPI options: An EMR QI exercise

This post was contributed by Dr. Mario Elia. The original entry can be found on his blog at https://drmarioelia.wordpress.com

Back in December 2016, I was doing some work around proton pump inhibitor (PPI) costs in Ontario and did some digging into my EMR data to see what savings could be found.

Here was my Twitter thread about the topic.

In short, I identified 414 of my patients on a PPI, 314 (76%) of which were on rabeprazole or pantoprazole, the two cheapest options. I calculated the potential monetary savings by switching every patient in my practice who is on a more expensive PPI (esomeprazole, lansoprazole, omeprazole, dexlansoprazole) to generic rabeprazole; projected tally would be $22,340 over the course of a year. Not an insignificant sum.

It’s one thing to project a cost savings. But would it actually work?

I embarked on a very simple intervention in January 2017. Using my EMR (Telus PS Suite), I created a reminder that would place the note “Consider switch to cheaper PPI” on the chart of every patient on esomeprazole, lansoprazole, omeprazole, dexlansoprazole, or pantoprazole.

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That reminder would appear on their chart, and would prompt a discussion at their next appointment about a potential trial of rabeprazole.

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(I am intentionally omitting the issue of de-prescribing from this analysis, as de-pescribing PPIs has been another important undertaking in my practice, yet this analysis was strictly looking at looking at cost-saving from cheaper PPIs. The above reminder did prompt many instances of de-prescribing, but these were not as easily quantifiable retrospectively. In addition, I bristle at the idea of openly quantifying and applauding the cost savings from de-prescribing, as it would rightfully raise the question in patients’ eyes whether we are de-prescribing out of concern for their health, or simply to save money. This analysis looks at cost-savings from switching from one PPI to another, the goal of which is to produce no clinical negative change).

Of the patients who were engaged in a discussion, many were found not to be appropriate for a rabeprazole trial, either because of intolerance or lack of efficacy from previous trials of rabeprazole. Other patients were not open to a trial because of lack of interest in “rocking the boat” or because of an upcoming trip and concern about impacting travel insurance.

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28 patients (some private pay, some publicly-funded) who required ongoing PPI therapy (due to ongoing indication or due to previous failure with PPI wean) agreed to a rotation to rabeprazole as a trial. 7 patients described a clinical worsening of symptoms (most within the first two weeks), and requested to be put back onto their initial PPI (5 patients on lansoprazole, 1 on pantoprazole, and 1 on omeprazole).  21 patients saw no clinical change, and those 21 have been found to be stable at the 3-month mark post-rotation (11 on lansoprazole, 4 on omeprazole, 4 on esomeprazole, and 2 on pantoprazole).

The cost savings were as follows (using rabeprazole 20mg tablet, $0.24/pill):

  • Esomeprazole – $1.86 per pill ($1.62 savings/d, $591.30/yr per patient)
  • Omeprazole – $0.41 per pill ($0.14 savings/d, $51.10/yr per patient)
  • Lansoprazole – $0.50 per pill ($0.26 savings/d, $94.90/yr per patient)
  • Pantoprazole – $0.30 per pill ($0.06 savings/d, $21.90/yr per patient)

Total yearly savings from these 21 patients now stable on rabeprazole: $3657.30

A few things to take away from this:

  1. This was a ridiculously simple intervention, and took me virtually no time to create the reminder or to have those discussions with patients.
  2. This should be a wake-up call to the Ministry of Health on the importance of working with physicians on finding efficiencies in our system. Physicians know where these efficiencies are, so allow innovation and creativity, reward it appropriately, and we’ll find the money.
  3. It is critical that the first script for the rabeprazole be of short duration (I prescribed two weeks), otherwise 3 months of wasted pills for the 25% failure rate would have erased some of the cost savings.
  4. Most practices will likely see greater savings than I achieved in my practice, as I have been consciously working to prescribe exclusively rabeprazole for some time now. Even if you assume my prescribing rate to be on par with the Ontario average (2200 patients), extrapolating this out to Ontario’s population of 13.6 million, this simple intervention would amount to a provincial total of $22.6 million.
  5. Note that most of the savings were found in switching patients from esomeprazole. Please don’t use it unless you are absolutely handcuffed. It is insanely expensive compared to others in the class.

All of us have these opportunities in our practices for small interventions that we may actually find some element of satisfaction in evaluating, especially with the power of a well-functioning EMR behind us.

Keeping our Patients Safe: Prescribing in the Digital Era

This post was originally published in Quorum on August 17th, 2017.    

According to a recent study, poison control centres in the US receive a call about medication errors every 13 seconds, and that rate has doubled in the past 12 years (1). Doctors, nurses and nurse-practitioners prescribe medications (and more recently focus on de-prescribing many drugs) on a daily basis, largely without a second thought. These medicines change the lives of our patients every day – often for the better, but unfortunately sometimes for the worse. Given the power of drugs and the authority we wield every time we sign our name to a prescription, it’s important that we do everything we can to focus on safety and effectiveness.

Most prescribers become familiar enough with a handful of different medicines to confidently prescribe them without risk. But sometimes we introduce a distinct cognitive bias by extending our comfort level with one set of drugs to others, including rare, unfamiliar and dangerous ones. It is impossible for any human being to remember all the details of side effects and interactions for the thousands of medications we are thought to be experts on when we prescribe. Add in the notion that individual genetics dictate the way or bodies consume and dispose of medications, and it’s easy to see how this overconfidence and generalization can have dramatic consequences for patients.

Fortunately, there are systems and processes in place that lower our risk of error dramatically. Computerized provider order entry applications like e-prescribing involve electronic entry and transmission of medical orders, and have been found to reduce medication error rates by over 50%.(2)The EMRs used by most community-based physicians in Canada have built-in interaction checkers that compare not only drug-to-drug interactions, but also drug-to-disease-state interactions. And they will alert us when a potential problem arises – assuming we are using the most current version of our EMR and drug database, and have not turned off alert capabilities due to information overload.

While we certainly don’t want our prescription modules to alert us incessantly, we do need to understand the likelihood of severe interactions every time we prescribe. Reminder alerts can also be set up in the EMR for therapeutic monitoring, which is frequently forgotten when prescribing titrated drugs like lithium or anti-seizure meds. It may also be worthwhile to incorporate alerts regarding Beers List drugs that should never be prescribed to elderly patients.

Of course, these types of alerts are only as reliable as the accuracy of the patient information and medication lists in our EMR. So, it’s important for every provider to take the time needed to update medication lists at every patient visit, whether or not it’s considered our direct responsibility to do so.

Tools like EMR, CPOE and automated alerts represent the tipping point in our ability to avoid medication errors using digital health. But there’s more on the horizon. Integration of province-wide databases such as the Digital Health Drug Repository, Digital Health Immunization Repository and Narcotics Monitoring System through the ConnectingOntario and Clinical Connect viewers will be a huge leap forward, giving us the ability to review medications prescribed and dispensed from all practitioners involved in a patient’s care. Integrating this information into EMR prescribing modules will have an even greater impact.

The ability to quickly view and analyze data across our entire patient roster will soon be possible for all using the OntarioMD EMR dashboard.. Work being done on the EMR dashboard – in partnership with Health Quality Ontario, the Ontario College of Family Physicians, the Association of Family Health Teams of Ontario, Association of Ontario Health Centres and the College of Physicians and Surgeons of Ontario – will make it easier to track drugs of interest among our own patients, and will provide a practice-wide population health perspective. This becomes imperative when considering high risk prescribing scenarios like narcotics doses above 50 morphine mg equivalents per day, in immunocompromised patients, and for those on multiple medications with more than one complex chronic disease.

Important digital tools, combined with appropriate policy, education and advice on how to cautiously prescribe and monitor risky drugs, have the potential to help us stave off adverse reactions, overdoses and even deaths. But we must also focus on ensuring that we understand new prescribing guidelines, screen for misuse, employ narcotics contracts and periodically review long-term medication use with patients as diligently as we analyze new drug starts.

With the privilege of prescribing comes great responsibility. Thinking about prescribing safely at the point of care and asking ourselves if we’ve taken advantage of every tool available to make this work easier will give us the best chance we have in doing the right thing for our patients, our practices and ourselves.

  1. Nichole L. Hodges, Henry A. Spiller, Marcel J. Casavant, Thiphalak Chounthirath, Gary A. Smith. Non-health care facility medication errors resulting in serious medical outcomes. Clinical Toxicology, 2017; 1 DOI: 10.1080/15563650.2017.1337908
  2. Nuckols TK, Smith-Spangler C, Morton SC, et al. The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic review and meta-analysis. Systematic Reviews. 2014;3:56. DOI: 10.1186/2046-4053-3-56.