Appropriate Follow-up of Proton Pump Inhibitors in the Outpatient Setting: 1169

Introduction: Proton pump inhibitors (PPIs) are commonly prescribed and recent studies raise concerns of their potential for adverse effects. American College of Gastroenterology (ACG) guidelines recommend monitoring therapy 4-8 weeks after PPI initiation. We hypothesized patients with dyspepsia/GERD at our resident clinic who were started on a PPI would not be re-evaluated appropriately. Methods: We reviewed the subsequent encounter progress note for all patients 18 years and over who were newly prescribed a PPI at our resident clinic from November 2015 to December 2016 for evidence of re-evaluation of PPI therapy using the keywords: regurgitation, dyspepsia, heartburn, or GERD. To educate Internal Medicine residents, we designed a 20 minute didactic session using clinical scenarios illustrating appropriate PPI prescribing and follow up, including specialty referral based on ACG guidelines. Sessions were preceded by an 8 question survey to determine practice and baseline knowledge followed by a 3 question post survey to evaluate the session. Results: Sixty patients were started on a PPI but 24 were lost to follow up. Of the remaining, only 50% of charts showed evidence of re-evaluation of PPI therapy yet in 40% of those visits a PPI was renewed. The average time to follow up was 14 weeks. Seventy-two residents attended the session and 90% reported they newly prescribed at least 1 PPI in the past 9 months. Forty-two (58%) complied with ACG guideline 4-8 week re-evaluation (26% PGY-1, 31% PGY-2, and 43% PGY-3). During any clinic visit of a patient on a PPI, 25% responded they never evaluate the duration of PPI therapy, 47% do so less than half the time, 7% never assess the symptoms of a patient on a PPI and 56.9% do so less than half the time. Sixty-two (86%) residents did not correctly identify scenarios that required specialty referral. In the post survey, 95% found the session very useful and 94% found gaps in their knowledge. Conclusion: This is the first study examining adherence to ACG PPI guidelines in a resident clinic. Post PPI initiation, we found poor adherence in follow up timing, reassessment of symptoms and of therapy duration. Interactive clinical scenarios were useful in identifying gaps in resident knowledge. PPIs are primarily intended for short term therapy with specialty referral required in non-responders. This study highlights the need for resident education and future studies will re-evaluate ongoing resident practice post education.Figure: Pre-didactic session survey results reporting 90% of residents newly prescribed at least 1 PPI in the past 9 months.Figure: Pre-didactic session survey results showing 42 residents (58%) complied with ACG guideline 4-8 week re-evaluation.Figure: Post didactic session survey results showing 65 residents (95%) found the session useful.