The effect of a physician-targeted intervention on metoclopramide prescribing practice

Abstract

Yu-Xiao Yang1,2,3, Charles E Leonard2,3, Cristin Freeman2,3, Sean Hennessy2,31Division of Gastroenterology, 2Center for Clinical Epidemiology and Biostatistics, 3Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USABackground: Metoclopramide use is associated with serious and potentially irreversible neurologic side effects. However, it is often used for questionable or unclear indications in clinical practice.Objectives: To (1) determine whether an intervention targeted at the prescribing physician would increase the rate of metoclopramide discontinuation among patients prescribed the medication for questionable or unclear indications; and (2) assess the durability of the discontinuation.Study design: A randomized controlled trial.Setting: Ambulatory practices of a quaternary care medical center.Participants: Ambulatory, electronic medical record-utilizing clinicians of the quaternary medical center.Intervention: A letter regarding participating clinicians' prescription(s) of metoclopramide for patients with questionable or unclear indications.Main outcome measures: The rate and the durability of metoclopramide discontinuation.Results: Fourteen of 31 (45%) patients of intervention group clinicians and 10 of 30 (33%) patients of nonintervention group clinicians had metoclopramide discontinued within 12 weeks, yielding a risk ratio for metoclopramide discontinuation of 1.4 (95% confidence interval [CI] 0.6–3.0) in the intervention versus nonintervention group. Of the 29 patients who had their metoclopramide discontinued during the study, 26 (90%, 95% CI 73%–98%) still had no active metoclopramide prescription in the subsequent 6 months. No adverse events were detected during the follow-up period.Conclusion: A physician-targeted intervention letter did not lead to a statistically significantly increased rate of metoclopramide discontinuation among patients who had questionable or unclear indications for the medication. Discontinuation of metoclopramide therapy for questionable or unclear indications was durable in most patients.Keywords: metoclopramide therapy, EpicCare, prescription, discontinuation