Large-scale intervention program lowers proton pump inhibitor overuse among veterans
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Key takeaways:
- An intervention program was associated with an absolute reduction of 7.3% in patients who filled proton pump inhibitor prescriptions.
- It also reduced PPI use by 11.3% in patients at risk for upper GI bleeding.
A pharmacy-based, multicomponent intervention program reduced proton pump inhibitor use overall and also when appropriate for gastroprotection, with little evidence of either clinical harms or benefits, according to a study in BMJ.
“PPIs are one of the most commonly prescribed classes of drugs, but an estimated 25% to 70% of PPI users may not have an appropriate indication, depending on the clinical setting,” Jacob E. Kurlander, MD, MS, of Michigan Medicine and Ann Arbor VA Center for Clinical Management Research, and colleagues wrote. “For such patients, PPIs cause unnecessary health care spending and pill burden.”
They continued, “In this setting, PPI overuse has been a focus of efforts to reduce unnecessary and wasteful care, including as part of the Choosing Wisely campaign. Despite these efforts, the effect of interventions to reduce PPI overuse is unclear.”
In a difference-in-difference analysis, researchers evaluated the real-world effects of a large-scale, multicomponent, pharmacy-based initiative to reduce PPI overuse in the U.S. Veterans Affairs Healthcare System, comprised of 18 regional systems nationwide.
Medical and pharmacy leaders in the Veterans Integrated Service Network 17 (VISN 17), which includes facilities in Texas, New Mexico and Oklahoma, created the five-component initiative, which was rolled out across the network from August 2013 to July 2014. Components included targeted restrictions on PPI refills, voiding inactive prescriptions, education for clinicians and patients and data resources.
The study period ran from February 2009 to January 2019 to determine trends before and after implementation of the initiative.
Researchers evaluated outcomes every 6 months between VISN 17 and the remaining 17 networks, which served as controls. The primary outcome was percentage of patients who filled a PPI prescription, with the number of patients analyzed per interval ranging from 192,607 to 250,349 in VISN 17 and 3,775,953 to 4,360,868 in the control sites. Researchers noted 26% of patients received PPIs at baseline.
According to study results, the intervention was associated with an absolute reduction of 7.3% (95% CI, –7.6 to –7) in the proportion of patients filling PPI prescriptions, as well as absolute reductions of 11.3% (95% CI, –12 to –10.5) in PPI use among patients at high risk for upper gastrointestinal bleeding and 5.72% (95% CI, –6.08 to –5.36) in patients filling a PPI or H2 receptor antagonist prescription.
The intervention was not linked with an increase in primary care visits for upper GI diagnoses (3.18 per 1,000 patients), upper endoscopies (0.47 per 1,000 patients) or hospital admissions for acid peptic disease among older at-risk patients (0.085 per 100 risk years).
Researchers reported “no clinically significant” changes in any PPI-associated clinical conditions, including chronic kidney disease.
“A pharmacy based, multicomponent PPI overuse intervention was associated with reduced use in patients for whom PPIs were appropriate and those for whom they were inappropriate but without evidence of clinically significant harms or benefits,” Kurlander and colleagues wrote. “Thus, the primary benefits are likely to be reduced pill burden for patients and reduced drug costs for health systems. Ensuring that PPI de-implementation efforts are both highly effective but also focused on the right patients will be important to their long term success.”
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