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van Gestel LC, Adriaanse MA, Kanis SL, Mensink-Bout SM, Schoones JW, Numans ME, Kiefte-de Jong JC, van den Brink G. Determinants of and interventions for Proton Pump Inhibitor prescription behavior: A systematic scoping review. BMC PRIMARY CARE 2024; 25:208. [PMID: 38862886 PMCID: PMC11165893 DOI: 10.1186/s12875-024-02459-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 06/03/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Proton Pump Inhibitors (PPI) are frequently prescribed. Long-term use is associated with side-effects and patients often lack a valid indication. Inappropriate PPI prescribing thus needs to be addressed. This review aims to scope 1) what determinants are studied as reasons for PPI prescribing, 2) what strategies are used for changing PPI (de)prescribing, and 3) whether important determinants are addressed in these interventions. METHODS We searched eight databases for papers on determinants of physician PPI prescribing. Studies were included if they were conducted in a Western country and focused on oral PPIs for an adult population. By following the Behaviour Change Wheel, we extracted information regarding PPI prescribing behavior, behavioral determinants and intervention strategies. FINDINGS We included 74 papers. Most focused on the determinants knowledge and beliefs about consequences. The latter was consistently related to PPI prescribing. Results for knowledge were mixed. Most interventions used education or enablement (e.g., algorithms, quality check improvements, involvement of pharmacists) as strategies. Enablement consistently improved PPI prescribing, while results for education were mixed. INTERPRETATION There is an overemphasis on reflective processes in studies on PPI prescribing. Future research should comprehensively identify behavioral determinants, focusing on reflective and impulsive processes, such that interventions can address the most important determinants.
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Affiliation(s)
- L C van Gestel
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, The Netherlands.
| | - M A Adriaanse
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - S L Kanis
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - S M Mensink-Bout
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - J W Schoones
- Directorate of Research Policy, Leiden University Medical Center, Leiden, The Netherlands
| | - M E Numans
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - J C Kiefte-de Jong
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - G van den Brink
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
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Lukac PJ, Bell D, Sreedharan P, Gornbein JA, Lerner C. The Application of Dental Fluoride Varnish in Children: A Low Cost, High-Value Implementation Aided by Passive Clinical Decision Support. Appl Clin Inform 2023; 14:245-253. [PMID: 36634698 PMCID: PMC10060097 DOI: 10.1055/a-2011-8167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 01/10/2023] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Fluoride is vital in the prevention of dental caries in children. In 2014, the U.S. Preventive Services Task Force deemed fluoride varnish a recommended preventive service (grade B). Electronic health record-based clinical decision support (CDS) tools have shown variable ability to alter physicians' ordering behaviors. OBJECTIVES This study aimed to increase the application of fluoride varnish in children while analyzing the effect of two passive CDS tools-an order set and a note template. METHODS Data on outpatient pediatric visits over an 18-month period before and after CDS implementation (October 15, 2020-April 15, 2022) were queried, while trends in application rate of fluoride were examined. We constructed a multiple logistic regression model with a primary outcome of whether a patient received fluoride at his/her visit. The primary predictor was a "phase" variable representing the CDS implemented. Physician interaction with CDS as well as the financial effects of the resulting service use were also examined. RESULTS There were 3,049 well-child visits of children aged 12 months to 5 years. The addition of a fluoride order to a "Well Child Check" order set led to a 10.6% increase in ordering over physician education alone (25.4 vs. 14.8%, p = 0.001), while the insertion of fluoride-specific text to drop-down lists in clinical notes led to a 6.2% increase (31.5 vs. 25.4%, p = 0.005). Whether a patient received topical fluoride was positively associated with order set implementation (odds ratio [OR] = 5.87, 95% confidence interval [CI]: 4.20-8.21) and fluoride-specific drop-down lists (OR = 7.81, 95% CI: 5.41-11.28). Female providers were more likely to use order sets when ordering fluoride (56.2 vs. 40.9% for males, p ≤ 0.0001). Added revenue totaled $15,084. CONCLUSION The targeted use of order sets and note templates was positively associated with the ordering of topical fluoride by physicians.
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Affiliation(s)
- Paul J. Lukac
- Department of Pediatrics, University of California, Los Angeles, Los Angeles, California, United States
- Office of Health Informatics and Analytics, University of California, Los Angeles, Los Angeles, California, United States
| | - Douglas Bell
- Department of Medicine, University of California, Los Angeles, Los Angeles, California, United States
| | - Priya Sreedharan
- Office of Health Informatics and Analytics, University of California, Los Angeles, Los Angeles, California, United States
| | - Jeffrey A. Gornbein
- Department of Biostatics, School of Public Health, University of California, Los Angeles, Los Angeles, California, United States
| | - Carlos Lerner
- Department of Pediatrics, University of California, Los Angeles, Los Angeles, California, United States
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3
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Russo M, Rodriguez-Castro KI, Franceschi M, Ferronato A, Panozzo MP, Brozzi L, Di Mario F, Crafa P, Brandimarte G, Tursi A. Appropriateness of Proton Pump Inhibitor Prescription Evaluated by Using Serological Markers. Int J Mol Sci 2023; 24:ijms24032378. [PMID: 36768710 PMCID: PMC9917011 DOI: 10.3390/ijms24032378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/18/2023] [Accepted: 01/21/2023] [Indexed: 01/27/2023] Open
Abstract
Inappropriate prescription of proton pump inhibitors (PPI) has been widely reported, often lacking initial exclusion of Helicobacter pylori (HP) infection and evaluation of gastric functional status. The aim of this study was to evaluate the utility of gastric functional tests to define the acid output, as well as HP status, in order to better direct PPI therapy prescription. Dyspeptic patients without alarm symptoms from a primary care population were evaluated. For each patient, serum Pepsinogen I (PGI) and II (PGII), gastrin 17 (G17) and anti-HP IgG antibodies (Biohit, Oyj, Finland) were determined. For each subject, data were collected regarding symptoms, past medical history of HP infection, and PPI use. Therapeutic response to PPIs was determined according to PGI and G17 values, where G17 > 7 in the presence of elevated PGI and absence of chronic atrophic gastritis (CAG) was considered an adequate response. Among 2583 dyspeptic patients, 1015/2583 (39.3%) were on PPI therapy for at least 3 months before serum sampling, and were therefore included in the study. Active HP infection and CAG were diagnosed in 206 (20.2%) and 37 (3.6%) patients, respectively. Overall, an adequate therapeutic response to PPIs was observed in 34.9%, reaching 66.7% at the highest dose. However, 41.1% and 20.4% of patients showed low (G17 1-7) or absent (G17 < 1) response to PPI, regardless of the dosage used. According to gastric functional response, most patients currently on PPI maintenance therapy lack a proper indication for continuing this medication, either because acid output is absent (as in CAG) or because gastrin levels fail to rise, indicating absence of gastric acid negative feedback. Lastly, HP eradication is warranted in all patients, and gastric function testing ensures this pathogen is sought for and adequately treated prior to initiating long-term PPI therapy.
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Affiliation(s)
- Michele Russo
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, 43121 Parma, Italy
| | | | - Marilisa Franceschi
- Endoscopy Unit, Department of Medicine, ULSS7 “Pedemontana”, “Alto Vicentino” Hospital, 36014 Santorso, Italy
| | - Antonio Ferronato
- Endoscopy Unit, Department of Medicine, ULSS7 “Pedemontana”, “Alto Vicentino” Hospital, 36014 Santorso, Italy
| | - Maria Piera Panozzo
- Laboratory of Clinical Pathology, ULSS7 “Pedemontana”, “Alto Vicentino” Hospital, 36014 Santorso, Italy
| | - Lorenzo Brozzi
- Endoscopy Unit, Department of Medicine, ULSS7 “Pedemontana”, “Alto Vicentino” Hospital, 36014 Santorso, Italy
| | - Francesco Di Mario
- Department of Medicine and Surgery, University of Parma, 43121 Parma, Italy
| | - Pellegrino Crafa
- Department of Medicine and Surgery, University of Parma, 43121 Parma, Italy
| | - Giovanni Brandimarte
- Division of Internal Medicine and Gastroenterology, “Cristo Re” Hospital, 00167 Rome, Italy
| | - Antonio Tursi
- Territorial Gastroenterology Service, ASL BAT, 76123 Andria, Italy
- Correspondence: ; Tel.: +39-0883-577853; Fax: +39-0883-577826
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Ingvarsson S, Hasson H, von Thiele Schwarz U, Nilsen P, Powell BJ, Lindberg C, Augustsson H. Strategies for de-implementation of low-value care-a scoping review. Implement Sci 2022; 17:73. [PMID: 36303219 PMCID: PMC9615304 DOI: 10.1186/s13012-022-01247-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 10/13/2022] [Indexed: 11/27/2022] Open
Abstract
Background The use of low-value care (LVC) is a persistent problem that calls for knowledge about strategies for de-implementation. However, studies are dispersed across many clinical fields, and there is no overview of strategies that can be used to support the de-implementation of LVC. The extent to which strategies used for implementation are also used in de-implementing LVC is unknown. The aim of this scoping review is to (1) identify strategies for the de-implementation of LVC described in the scientific literature and (2) compare de-implementation strategies to implementation strategies as specified in the Expert Recommendation for Implementing Change (ERIC) and strategies added by Perry et al. Method A scoping review was conducted according to recommendations outlined by Arksey and O’Malley. Four scientific databases were searched, relevant articles were snowball searched, and the journal Implementation Science was searched manually for peer-reviewed journal articles in English. Articles were included if they were empirical studies of strategies designed to reduce the use of LVC. Two reviewers conducted all abstract and full-text reviews, and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data-charting form. The strategies were first coded inductively and then mapped onto the ERIC compilation of implementation strategies. Results The scoping review identified a total of 71 unique de-implementation strategies described in the literature. Of these, 62 strategies could be mapped onto ERIC strategies, and four strategies onto one added category. Half (50%) of the 73 ERIC implementation strategies were used for de-implementation purposes. Five identified de-implementation strategies could not be mapped onto any of the existing strategies in ERIC. Conclusions Similar strategies are used for de-implementation and implementation. However, only a half of the implementation strategies included in the ERIC compilation were represented in the de-implementation studies, which may imply that some strategies are being underused or that they are not applicable for de-implementation purposes. The strategies assess and redesign workflow (a strategy previously suggested to be added to ERIC), accountability tool, and communication tool (unique new strategies for de-implementation) could complement the existing ERIC compilation when used for de-implementation purposes. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01247-y.
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Affiliation(s)
- Sara Ingvarsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden.
| | - Henna Hasson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden.,Unit for implementation and evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, Stockholm, Sweden
| | - Ulrica von Thiele Schwarz
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden.,School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
| | - Per Nilsen
- Department of Health, Medicine and Caring Sciences, Division of Public Health, Linköping University, Linköping, Sweden
| | - Byron J Powell
- Center for Mental Health Services Research, Brown School, Washington University in St. Louis, St. Louis, MO, USA.,Center for Dissemination and Implementation, Institute for Public Health, Washington University in St. Louis, St. Louis, MO, USA.,Division of Infectious Diseases, John T. Milliken Department of Medicine, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Clara Lindberg
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden
| | - Hanna Augustsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden.,Unit for implementation and evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, Stockholm, Sweden
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5
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Tan CJY, Lee SX, Ng TM. The impact of deprescribing interventions on oral proton pump inhibitor utilisation in a Singapore tertiary hospital: A quality improvement initiative. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022; 51:8-15. [PMID: 35091726 DOI: 10.47102/annals-acadmedsg.2021308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Proton pump inhibitors (PPIs) are effective treatments for upper gastrointestinal pathologies and short-term courses are well-tolerated. However, indiscriminate use of PPIs is undesirable due to its potential harms. We implemented a series of deprescribing interventions between 2016 and 2017 to curb PPI overutilisation in our institution. The aim of this study was to evaluate the effectiveness and safety of these interventions. METHODS An institutional PPI deprescribing guide was disseminated by email and educational roadshows were conducted to prescribers. Interrupted time series analysis was used to evaluate the effectiveness of the deprescribing interventions over a 7-year period from 2013 to 2019. To ascertain the safety of PPI deprescribing, we analysed the peptic ulcer disease incidence from 2015 to 2018 and conducted a retrospective chart review of 262 inpatients who were deprescribed PPIs. RESULTS Following the first intervention, there was a significant decrease in mean oral PPI utilisation by 2,324.46 defined daily doses (DDD) per 1,000 prescriptions (95% confidence interval [CI] -3,542.66, -1,106.26) per month, followed by a month-to-month decrease of 302.61 DDD per 1,000 prescriptions per month thereafter (95% CI -473.95, -131.27). A second targeted educational intervention was only effective in sustaining the decline in the outpatient, but not in the inpatient setting. There were no significant changes in incidence of peptic ulcer disease. In the retrospective chart review, a majority (62.6%) of patients remained deprescribed at 6 months. CONCLUSION We observed a sustained decrease in PPI utilisation in our institution for more than 12 months following our educational interventions. Cautious deprescribing of PPIs in eligible candidates was found to be safe with low recurrence rates of upper gastrointestinal events.
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6
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Daniels B, Schaffer A, Buckley NA, Bruno C, Jun M, Pearson SA, Zoega H. The impact of tightened prescribing restrictions on proton pump inhibitor use in Australia: An evaluation using interrupted time series analysis. Pharmacoepidemiol Drug Saf 2021; 31:370-378. [PMID: 34894368 DOI: 10.1002/pds.5395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/23/2021] [Accepted: 12/06/2021] [Indexed: 11/10/2022]
Abstract
AIM In May 2019, Australia's Pharmaceutical Benefits Scheme (PBS) tightened the prescribing restrictions for publicly subsidized high and standard strength proton-pump inhibitors (PPIs). We aimed to determine the impacts on PPI use in Australia. METHODS Population-based interrupted time series analysis of PBS dispensing claims for a 10% sample of PBS-eligible Australian residents from January 2017 to December 2020 and national prescription and over-the-counter sales to pharmacies from January 2017 to October 2020. We examined trends in monthly PPI dispensings, switches from higher to lower strength formulations, and volume (kg) dispensed and sold. RESULTS From May 2019, we observed a small, immediate decrease (-7830 [95%CI: -8818 to -6842]) in standard strength PPI dispensings/month, which rebounded to exceed pre-intervention levels by December 2020. High strength dispensings decreased until the end of the study period to less than half their pre-intervention average/month; low strength dispensings/month increased until the end of the study period to more than double their pre-intervention average/month. We observed transient increases in switches to lower strength formulations post-intervention. The kilograms of PPIs sold/month followed a similar pattern to PBS kilograms dispensed/month with the exception of standard strength formulations where PBS dispensings decreased by -74 (95%CI: -93 to -55) but total sales remained unchanged (comprising PBS and private prescriptions, and over-the-counter sales). CONCLUSIONS Tightened prescribing restrictions had an immediate and sustained impact on PPI use in Australia, with decreased high strength use and increased low strength use. Some patients likely switched to private market prescriptions for standard strength PPI, given the observed patterns in total volume sold/dispensed.
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Affiliation(s)
- Benjamin Daniels
- Medicines Policy Research Unit, Centre for Big Data Research in Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Andrea Schaffer
- Medicines Policy Research Unit, Centre for Big Data Research in Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Nicholas A Buckley
- Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, University of Sydney, Sydney, New South Wales, Australia
| | - Claudia Bruno
- Medicines Policy Research Unit, Centre for Big Data Research in Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Min Jun
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Sallie-Anne Pearson
- Medicines Policy Research Unit, Centre for Big Data Research in Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Helga Zoega
- Medicines Policy Research Unit, Centre for Big Data Research in Health, UNSW Sydney, Sydney, New South Wales, Australia.,Faculty of Medicine, Centre of Public Health Sciences, University of Iceland, Reykjavík, Iceland
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7
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Spiegel MC, Simpson AN, Philip A, Bell CM, Nadig NR, Ford DW, Goodwin AJ. Development and implementation of a clinical decision support-based initiative to drive intravenous fluid prescribing. Int J Med Inform 2021; 156:104619. [PMID: 34673308 DOI: 10.1016/j.ijmedinf.2021.104619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/01/2021] [Accepted: 10/09/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Studies suggest superior outcomes with use of intravenous (IV) balanced fluids compared to normal saline (NS). However, significant fluid prescribing variability persists, highlighting the knowledge-to-practice gap. We sought to identify contributors to prescribing variation and utilize a clinical decision support system (CDSS) to increase institutional balanced fluid prescribing. MATERIALS AND METHODS This single-center informatics-enabled quality improvement initiative for patients hospitalized or treated in the emergency department included stepwise interventions of 1) identification of design factors within the computerized provider order entry (CPOE) of our electronic health record (EHR) that contribute to preferential NS ordering, 2) clinician education, 3) fluid stocking modifications, 4) re-design and implementation of a CDSS-integrated IV fluid ordering panel, and 5) comparison of fluid prescribing before and after the intervention. EHR-derived prescribing data was analyzed via single interrupted time series. RESULTS Pre-intervention (3/2019-9/2019), balanced fluids comprised 33% of isotonic fluid orders, with gradual uptake (1.4%/month) of balanced fluid prescribing. Clinician education (10/2019-2/2020) yielded a modest (4.4%/month, 95% CI 1.6-7.2, p = 0.01) proportional increase in balanced fluid prescribing, while CPOE redesign (3/2020) yielded an immediate (20.7%, 95% CI 17.7-23.6, p < 0.0001) and sustained increase (72% of fluid orders in 12/2020). The intervention proved most effective among those with lower baseline balanced fluids utilization, including emergency medicine (57% increase, 95% CI 0.7-1.8, p < 0.0001) and internal medicine/subspecialties (18% increase, 95% CI 14.4-21.3, p < 0.0001) clinicians and substantially reduced institutional prescribing variation. CONCLUSION Integration of CDSS into an EHR yielded a robust and sustained increase in balanced fluid prescribing. This impact far exceeded that of clinician education highlighting the importance of CDSS.
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Affiliation(s)
- Michelle C Spiegel
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, United States.
| | - Annie N Simpson
- Department of Health Care Leadership and Management, Medical University of South Carolina, Charleston, SC, United States
| | - Achsah Philip
- Department of Information Solutions, Medical University of South Carolina, Charleston, SC, United States
| | - Carolyn M Bell
- Department of Pharmacy, Medical University of South Carolina, Charleston, SC, United States
| | - Nandita R Nadig
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Dee W Ford
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Andrew J Goodwin
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
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Dharmarajan TS. The Use and Misuse of Proton Pump Inhibitors: An Opportunity for Deprescribing. J Am Med Dir Assoc 2020; 22:15-22. [PMID: 33321078 DOI: 10.1016/j.jamda.2020.09.046] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 08/26/2020] [Accepted: 09/06/2020] [Indexed: 02/07/2023]
Abstract
Proton pump inhibitors (PPIs) are proven medications of choice for gastroesophageal reflux disease (GERD), acid-related disorders, erosive esophagitis, Barrett esophagus, prevention of gastrointestinal bleeding while on nonsteroidal anti-inflammatory drugs, eosinophilic esophagitis, peptic ulcer disease, stress ulcer prophylaxis in critically ill patients, and other indications. Best practice guidelines from several sources on the appropriate indications and duration of PPI therapy have been summarized for easy assimilation. Individualized decision with regard to PPI use is illustrated by case vignettes; best approaches are provided. The significant increase in use of PPIs for ill-defined indications over the years, associated adverse outcomes with long-term use, and consequent increase in health care costs have drawn much attention. Adverse outcomes due to PPI therapy may be categorized as unrelated or related to gastric acid inhibition. Examples of outcomes unrelated to acid inhibition include allergic reactions, acute interstitial nephritis, chronic kidney disease, poor cardiovascular outcomes, dementia, and drug interactions; consequences of acid inhibition include gastrointestinal infections, pneumonia, nutrient deficiencies, fractures, spontaneous bacterial peritonitis, and small intestinal bacterial overgrowth. Provider awareness regarding best practice guidelines on PPI use and imparting pertinent education to patients may be the rational approach to safe and effective PPI therapy. In individuals in whom the drug is not indicated, efforts at deprescribing the PPI may be attempted following discussion with the patient. Approaches include stopping the drug, reducing the dose or using "on-demand" therapy after completing the course of treatment for the specific indication. Barriers to successful deprescribing exist. Follow-up is recommended for recurrence of manifestations; in the event of recurrence, the PPI may need to be re-instituted. PPIs are valuable, irreplaceable drugs in the prevention and treatment of certain disorders for specific durations of time. Evidence nevertheless suggests that excessive and inappropriately prolonged use of PPIs is associated with a broad range of adverse effects. Education of provider and patient, stewardship, and motivation are key to appropriate use of PPIs for the right indications. Key implications for practice are offered.
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Affiliation(s)
- Thiruvinvamalai S Dharmarajan
- Department of Medicine, Geriatric Medicine, Geriatric Medicine Fellowship Program, Montefiore Medical Center, Wakefield Campus, Bronx, NY, USA; Albert Einstein College of Medicine, Bronx, NY, USA.
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9
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Daniels B, Pearson SA, Buckley NA, Bruno C, Schaffer A, Zoega H. Coming to grips with seemingly conflicting results in programme evaluation: the devil's in the detail. BMJ Qual Saf 2020; 30:70-71. [PMID: 32900853 DOI: 10.1136/bmjqs-2020-012118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 07/30/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Benjamin Daniels
- Medicine Policy Research Unit, Centre for Big Data Research in Health, Sydney, New South Wales, Australia
| | - Sallie-Anne Pearson
- Medicine Policy Research Unit, Centre for Big Data Research in Health, Sydney, New South Wales, Australia
| | - Nicholas A Buckley
- Clinical Pharmacology and Toxicology Research Group, The University of Sydney Discipline of Pharmacology, Sydney, New South Wales, Australia
| | - Claudia Bruno
- Medicine Policy Research Unit, Centre for Big Data Research in Health, Sydney, New South Wales, Australia
| | - Andrea Schaffer
- Medicine Policy Research Unit, Centre for Big Data Research in Health, Sydney, New South Wales, Australia
| | - Helga Zoega
- Medicine Policy Research Unit, Centre for Big Data Research in Health, Sydney, New South Wales, Australia.,Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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10
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Choosing quality problems wisely: identifying improvements worth developing and sustaining. BMJ Qual Saf 2020; 29:1-2. [DOI: 10.1136/bmjqs-2020-011054] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2020] [Indexed: 12/21/2022]
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11
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Daniels B, Pearson SA, Buckley NA, Bruno C, Zoega H. Long-term use of proton-pump inhibitors: whole-of-population patterns in Australia 2013-2016. Therap Adv Gastroenterol 2020; 13:1756284820913743. [PMID: 32218806 PMCID: PMC7082869 DOI: 10.1177/1756284820913743] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 02/26/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Proton-pump inhibitors (PPIs) are among the most prescribed medicines worldwide and concern about their long-term use is growing. We used dispensing claims for every person in Australia dispensed publicly subsidized PPIs between 2013 and 2016 to determine the incidence and prevalence of PPI use and to examine the patterns and durations of PPI treatment among individuals continuing treatment beyond the guideline-recommended maximum 12 weeks. METHODS We estimated annual prevalence and incidence per 100 people and duration of treatment for every Australian dispensed publicly subsidized PPIs between 2013 and 2016. We examined patterns of PPI treatment in three patient subgroups using PPIs for more than 12 weeks duration; people receiving maintenance, long-term continuous or long-term intermittent treatment. We calculated the proportion in each subgroup stepping down from higher to lower PPI strengths, stepping up from lower to higher PPI strength and discontinuing treatment. RESULTS PPIs were dispensed to 4,388,586 people; 60% were women; median age at initiation was 52 years [interquartile range (IQR): 36-65]. Standard and high strength PPIs accounted for 95% of dispensings. Annual incidence and prevalence were 3.9/100 and 12.5/100, respectively, in 2016 and highest among individuals over 65 years (prevalence range: 33-43/100). Most people (67%) stopped treatment after one dispensing; while 25%, 6% and 10% continued on maintenance, long-term continuous and long-term intermittent treatment, respectively. Median duration of treatment in people continuing treatment was 501 days (IQR: 180-not reached) for maintenance treated individuals and 'not reached' for long-term treated individuals. We observed 35%, 20% and 47% of people stepping down from higher to lower treatment strengths on maintenance, long-term continuous and long-term intermittent treatment, respectively. CONCLUSIONS Longer-term treatment with higher strength PPIs is common. Targeted regulation of PPI prescribing may improve the uptake of lower strength formulations and reduce both harms and costs associated with long-term PPI treatment.
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Affiliation(s)
| | - Sallie-Anne Pearson
- Medicines Policy Research Unit, Centre for Big
Data Research in Health, UNSW, Sydney, NSW, Australia
| | - Nicholas A. Buckley
- Clinical Pharmacology and Toxicology Research
Group, Discipline of Pharmacology, University of Sydney, Sydney, NSW,
Australia
| | - Claudia Bruno
- Medicines Policy Research Unit, Centre for Big
Data Research in Health, UNSW, Sydney, NSW, Australia
| | - Helga Zoega
- Medicines Policy Research Unit, Centre for Big
Data Research in Health, UNSW, Sydney, NSW, Australia,Centre of Public Health Sciences, Faculty of
Medicine, University of Iceland
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Soong C, Shojania KG. Education as a low-value improvement intervention: often necessary but rarely sufficient. BMJ Qual Saf 2019; 29:353-357. [PMID: 31843878 DOI: 10.1136/bmjqs-2019-010411] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2019] [Indexed: 12/27/2022]
Affiliation(s)
| | - Kaveh G Shojania
- Department of Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
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