Doctor and Patient Education Cuts PPI Use

Big drop in scripts after interventions in Texas program.

This article was first published on Thursday, January 2, 2019 in MedPage Today.

By Diana Swift, Contributing Writer

Interventions to reduce the use of proton pump inhibitors (PPIs) -- both overall and inappropriate -- resulted in a significant decrease over a year, researchers reported.

They found that in 2017, before the start of the de-escalation initiative in the Harris Health System in Harris County, Texas, 66,261 unique PPI prescriptions -- equating to 3,990,790 pills -- were dispensed across the network's 16 pharmacies. In the year after implementation of the program in January 2018, the number of unique scripts fell to 55,322, a 16.5% decrease (P<0.0001) equating to 3,194,651 pills dispensed and a decrease of 19.9% (P<0.0001).

In their prescription review, Derek Lin, MD, and colleagues at Baylor College of Medicine in Houston found that of 80 PPI prescriptions dispensed pre-intervention in the last quarter of 2017, a total of 56 (70%) were inappropriately prescribed, either by indication or duration. Post-intervention, 162 of 308 (52%) prescriptions were inappropriately prescribed (P=0.005).

Writing in Clinical Gastroenterology and Hepatology, the authors noted that PPI prescription rates have increased annually, with recent data suggesting use in as many as 9% of ambulatory patients.

That increase has raised concerns about appropriate indications, duration of use, adverse effects, and unnecessary costs for patients and the health system. "Arguably the most debated of these concerns by the public at large seems to be the reported adverse consequences associated with chronic PPI therapy as documented in several observational studies, including increased enteric infections and micronutrient deficiencies," Lin and co-authors wrote.

For example, a recent French study found prolonged PPI use to be correlated with a greater risk of viral gastroenteritis, with those researchers calling for monitoring of long-term PPI users. In terms of inappropriate prescription, a survey based on simulation research revealed that most doctors continue to prescribe PPIs for patients with the least need to prevent bleeding while stopping treatment in those most likely to have fatal upper gastrointestinal (GI) bleeds.

Asked for his perspective, Jacob E. Kurlander, MD, MS, of Michigan Medicine in Ann Arbor, who was not involved in the research, called the study important, and said it does seem that clinicians are using PPIs more cautiously, although underuse for conditions other than acid reflux has been a longstanding problem.

"While PPI for acid reflux can be considered low-value treatment with little benefit for some patients, our research has shown that only a minority of high-risk patients who really need these agents to prevent upper GI bleeding are prescribed them," Kurlander said.

He added that PPI cessation should always be considered in the context of the possible unintended consequences of inappropriate withdrawal, such as increased medical visits and gastroenterologist referrals for upper GI symptoms and more endoscopies.

Study Details

For the current study, clinicians in the Harris Health System, which had 1.9 million outpatient visits in 2017, received instruction on the appropriate use of PPIs. This included information on appropriate indications, duration, and reported adverse effects outlined during primary-care grand rounds and through system-wide emails. Baylor internal and family medicine residents received additional small-group teaching at noontime conferences.

To reduce the risk of rebound acid hypersecretion and improve patient compliance with PPI cessation, a tapering algorithm was implemented as a global order in the electronic medical record system. This order prescribed a PPI every other day for 2 weeks followed by a PPI every 4 days for 2 additional weeks before discontinuation.

In their assessment, Lin and co-researchers reviewed all 80 patient charts from September to December 2017 showing a previous dispensed PPI. In 2018, after implementation, all 308 charts with a dispensed PPI were analyzed for the full calendar year. Pre-intervention, of the 80 prescriptions analyzed, 56 were categorized as inappropriately prescribed (70%) either by indication or duration. Post-intervention, 162 of 308 prescriptions were inappropriately prescribed (52%, P=0.005).

In other project findings, 66 anonymous surveys conducted in pharmacy staff indicated that 49% of the time staff members were counseling patients on the potential risks of PPIs, and 58% were providing instructional handouts for patients with each script. These included instructions on discussing PPI discontinuation with the providers, if desired.

To see whether patients or providers were initiating discussions on de-escalation, 17 attending physicians and 55 resident physicians were also surveyed. Almost two-thirds of providers (63%) said they believed that addressing inappropriate PPI use was of intermediate or high priority during office visits. The actual decision to discontinue PPI therapy was deemed to be provider-initiated most of the time (80%), jointly initiated sometimes (17%), and rarely initiated by patients (3%).

Such tapering initiatives have worked elsewhere, the team noted. For example, one quality-improvement project at the Omaha Veterans Affairs resident continuity clinic successfully reduced inappropriate long-term PPI usage, defined as more than a year, by 17% within 2.5 months of the start of the intervention.

Once inappropriate PPI use has been identified, having a comprehensive discussion about de-escalation is critical, Lin and co-authors stressed. They noted that a review published in 2017 found that most patients (70%) were willing to discuss de-escalation and about 40% were willing to reduce or discontinue if so advised by their physicians.

Patient surveillance remains important, Lin and colleagues added. "We advise clinic follow-up within a month after beginning de-escalation to monitor the patient's symptoms and elicit general feedback."

They added that clinician education is also essential, and the prime movers of de-escalation, ambulatory primary-care givers, need to be especially well informed. "Having providers study the indications and durations for PPI use, as outlined by multiple gastroenterology organizations, would be useful to supplement baseline competency," and future efforts should focus on continued provider education and patient surveillance, the team concluded.

Lin and co-authors reported having no conflicts of interest.

Kurlander reported having no conflicts of interest.