Methods. In this observational cohort study, internal medicine patients who received care from teams with a pharmacy student were compared to patients who received care from teams without a pharmacy student. The primary endpoint was proportion of patients on inappropriate AST.

Results. The overall proportion of patients receiving inappropriate AST was 24.4%. There was no significant difference between patients seen by teams with a pharmacy student and those seen by teams without a pharmacy student. The proportion of patients discharged with new inappropriate AST prescriptions was lower after pharmacy student review, though not significantly (6.1% vs. 9.4%, p = 0.07). Pharmacy student reviews shortened the median duration of inappropriate AST by 1.5 days (6 vs. 8.5 days, p = 0.025).

Data were collected from electronic medical records. AST was defined as the prescription of at least one dose of PPI or H2RA at any point during hospitalization. AST was considered appropriate for all patients if at least 1 of the following indications could be identified in the patient's record: home AST at admission, history of gastroesophageal reflux disease, acute or suspected upper gastrointestinal (GI) bleeding or GI bleeding during the previous 3 months, erosive esophagitis or gastritis, dyspepsia, peptic ulcer disease, post bariatric surgery, or the administration of 2 or more of the following medications: nonsteroidal anti-inflammatory drugs, aspirin, clopidogrel, warfarin, heparin or low molecular weight heparin for therapeutic anticoagulation, or corticosteroids.^2,10 AST was considered inappropriate if these conditions were not met. These criteria for AST appropriateness also were applied to patients transferred into the internal medicine service from the ICU.

Medical residents in the internal medicine residency program worked in teaching teams consisting of 1 third-year and 2 first-year medical residents supervised by an attending physician. From October to January, teaching teams also had 1 fourth-year advanced pharmacy practice experience (APPE) student participating in patient rounds with them for 5 days per week. The internal medicine teams without pharmacy students (June through September) served as the control group for this study.

Patients were selected for medication review from the internal medicine team's daily list of new admissions. Every third patient who had been prescribed at least one dose of an acid suppressive medication was selected for review until 20 patients from each week during the study period were identified, allowing for equal sampling from each pharmacy student's clinical APPE.

Each pharmacy student began the APPE by undergoing standard training with a pharmacist. Training included a 30-minute teaching session based on a key review article describing appropriate AST.⁶ Sessions emphasized evidence-based AST in internal medicine patients and the impact of unnecessary AST, including increased risk of the patient developing Clostridium difficile colitis, pneumonia, osteoporosis, medication side effects, and drug-drug interactions, and increased costs. Strategies for student interventions for patients receiving inappropriate AST were discussed, including the pharmacy student questioning AST indication during rounds, presenting patient-specific implications of inappropriate AST, and following up with the patient's physician to determine whether the recommendation was accepted. Pharmacy students were evaluated on how successful their actions were in the discontinuation of inappropriate AST prescriptions.

The pharmacy students evaluated medication profiles daily for AST. When inappropriate AST was identified, students addressed AST therapeutic issues and determined the most effective method for communicating the information to the internal medicine team. Pharmacy students participated in patient rounds without a pharmacist preceptor present to encourage them to practice communicating directly with patients and physicians. Pharmacist preceptors met with students following rounds to review the recommendations the students had made. All pharmacy student recommendations to discontinue AST for a patient then were verified by a pharmacist preceptor who approved the recommendation or advised the student to communicate an alternative recommendation to the patient's physician.

Liberman and Whelan reported an educational intervention that reduced inappropriate AST in hospitalized inpatients by 26% for at least 6 months.¹¹ Our intervention had lower rates of inappropriate AST (24% vs. 33%) and therefore a lower than expected effect size. The most likely explanation for similar rates of inappropriate AST is that the physicians placing the initial AST order were on patient care teams that made patient rounds at night and did not receive the team-based education provided by pharmacy students.

Approximately 24% to 39% of patients started on AST while hospitalized are discharged inappropriately with new AST prescriptions.^5,10-12 We found much lower baseline levels of discharge with inappropriate AST prescriptions. Although having pharmacy students on the patient care teams may have reduced the number of patients discharged with inappropriate AST prescriptions, this finding would be incidental.

Our study has several limitations. First, it was performed at a single academic medical center, which may limit generalization, although overuse of AST is a frequent issue in hospitalized patients. Also, patients were not randomly assigned to the study groups so patient features may not have been balanced between the study and control groups. Specifically, the control group was historical, ie, comprised of patients who received care before the intervention took place, and included months in which new interns began training. Although staff members at our institution were required to perform medication reconciliation using the electronic medical record, pharmacy students were generally not required to participate. Because we did not require pharmacy students to verify the indication for home AST use, patients admitted to the hospital already on inappropriate AST would not have been targeted for a pharmacy student intervention. While standardized education on AST appropriateness was provided, the students who presented the information varied widely in their assertiveness, communication skills, and effectiveness in making pharmacotherapeutic recommendations. These observations highlight the importance of effective communication, team-building, and trust in educational partnerships with health care professionals encountered on clinical practice experiences.