Perspective

Value in healthcare is the clinical outcome and patient experience relative to the costs of care. Traditionally, healthcare providers have primarily focused on improving the quality of care in order to increase value. In fact, change introduced with the primary intention of saving costs is viewed with suspicion, lest it negatively impact the quality of care. Modifying existing practices to primarily decrease costs can thus be quite challenging, even when these changes are evidence-based and have no adverse impact on the quality of care. Attempting to limit the use of intravenous proton pump inhibitors (PPIs) to appropriate indications falls under this category of changes. PPIs are one of the most overused medications, and the intravenous route is often used when oral administration would suffice, significantly increasing medication and administration costs.1–3 Studies have shown that oral PPIs have similar efficacy compared with intravenous PPIs and may even be associated with reduced length of stay.4 5 Intravenous PPIs are recommended only in patients with active upper gastrointestinal bleeding prior to endoscopy, and sometimes after endoscopic treatment of an ulcer. However, intravenous PPIs per se have no perceived direct harms to patients (above oral PPIs), although intravenous administration of medications puts patients at higher risk for medication-related errors in general.6 7

We recently had a national shortage and subsequent urgent need to review the use of intravenous PPIs at our 870-bed county and medical school teaching hospital. In March 2015, a critical shortage of an intravenous PPI (pantoprazole) was announced due to manufacturing delays.8 The medication had to be purchased through secondary sources at exorbitant costs with the  spectre of not having enough available for patients with critical needs.

We performed a retrospective review of all orders of intravenous PPIs for 12 months prior to the shortage. Intravenous PPIs were …