Pharmacy-Based Intervention Linked to Reduced Proton Pump Inhibitor Overuse

A new study found a multicomponent intervention was linked to reduced proton pump inhibitor (PPI) overuse.

PPI, a commonly prescribed class of drug to reduce stomach acid production, is often overused. An estimated 25 – 70% of patients on proton pump inhibitors do not have the correct indication, creating unnecessary costs and burdens. Not only that but overusing the inhibitor may have dangerous consequences.

Observational studies found associations between PPI overuse and many medical conditions, such as chronic kidney disease, fractures, pneumonia, cardiovascular disease, and Clostridium difficle infection. However, these associations were only supported by indirect evidence with uncertain clinical significance.

“Our findings… suggest that PPIs may not be as harmful as some have feared,” said lead investigator Jacob Kurlander, MD, MS, a gastroenterologist at Michigan Medicine at U-M’s academic medical center and the Lieutenant Colonel Charles S. Kettles VA Ann Arbor Medical Center.

Investigators conducted a difference-in-difference study to assess how a multicomponent, pharmacy-based intervention to reduce proton pump inhibitor overuse impacts medication prescribing trends, health care utilization, and clinical outcomes. The team collected participants from the US Veterans Affairs Healthcare System, which includes 1255 healthcare facilities, 1074 outpatient sites, and 18 regional health systems known as Veterans Integrated Service Networks. For the study, 1 regional network implemented the intervention and the 17 others served as controls.

Investigators divided the study period into consecutive 6-month intervals. Each interval included patients with ≥ 2 primary care provider visits in the past 2 years. The team leveraged demographic, medical, pharmacy, laboratory, and inpatient/outpatient encounter data from the Veterans Affairs’ corporate data warehouse.

The number of participants ranged from 192,607 to 250,349 in intervention sites and 3,775,952 to 4,360,868 in control sites during the intervals. In total, 26% of patients received PPIs before the intervention.

The intervention, created by the Veterans Integrated Service Network 17, restricted PPI refills for patients lacking documented need for long-time use. If patients did not have an appropriate indication for long-term PPI use, it was limited to 90 days without refills to 30 days with up to 2 refills. The intervention also canceled non-recently filled prescriptions, promoted electronic prescriptions for H2 receptor antagonists, and provided educational resources for patients and clinicians. The network rolled out the intervention from August 2013 to July 2014, and the study period spanned February 2009 to January 2019 to analyze trends before and after implementation.

The focus of the study was to determine the proportion of patients who filled their PPI prescription every 6 months. Secondary outcomes included the percentage of days PPI gastroprotection was prescribed to individuals deemed at high risk for upper gastrointestinal bleeding, the percentage of patients who filled either a PPI or H2 receptor antagonist prescription, incidents of hospital admissions related to acid peptic disease among older adults (aged ≥ 65 years) eligible for PPI gastroprotection, primary care visits for an upper gastrointestinal diagnosis, upper endoscopies, and occurrences of clinical conditions linked to PPI usage.

Ultimately, the intervention was linked to an absolute reduction of 7.3% (95% confidence interval [CI], -7.6% to -7.0%) in patients who filled PPI prescriptions. The absolute reduction in PPI among patients eligible for gastroprotection was 11.3% (-12.0% to – 10.5%). Furthermore, the absolute reduction for patients who filled a PPI or H2 receptor antagonist prescription was 5.72% (-6.08% to -5.36%).

Investigators did not observe PPI usage increases in primary care visits for upper gastrointestinal diagnoses, upper endoscopies, or hospital admissions for acid peptic disease in older patients eligible for gastroprotection. Additionally, they did not find significant changes in clinical conditions associated with PPI.

The team noted several limitations, including the switch from ICD-9 to ICD-10 during the study period (in October 2015), the potential of patients transitioning to buying PPIs outside of the Veterans Affairs health system after the intervention was implemented, the results reflecting population-level effects, and not adjusting for testing for multiple clinical outcomes.

“This intervention worked so well because it was involuntary to some degree—refills could no longer be on autopilot for patients without a clear indication for the medication,” Kurlander said. “At the same time, what we saw is that patients who benefit from PPIs for bleeding prevention—which is sometimes overlooked by doctors—got swept up in this effort, too.”

^References

1. ^{Kurlander JE, Laine L, Kim HM, et al. Impact of large scale, multicomponent intervention to reduce proton pump inhibitor overuse in integrated healthcare system: difference-in-difference study. BMJ. 2024;385:e076484. Published 2024 Apr 11. doi:10.1136/bmj-2023-076484}
2. ^{In The Drive to Deprescribe, Heartburn Drug Study Teaches Key Lesson. News Wise. April 11, 2024. https://www.newswise.com/articles/in-the-drive-to-deprescribe-heartburn-drug-study-teaches-key-lessons. Accessed April 18, 2024.}