Why do GPs continue inappropriate hospital prescriptions of proton pump inhibitors? A qualitative study

Knowledge and Attitudes Regarding the Inappropriate Use of Proton Pump Inhibitors Among Students of Umm Al-Qura University in Saudi Arabia: A Cross-Sectional Study

Background Proton pump inhibitors (PPIs) are commonly prescribed to manage various upper gastrointestinal conditions such as dyspepsia, gastroesophageal reflux disease (GERD), and peptic ulcer disease. However, concerns are increasing regarding their excessive and inappropriate use, particularly in cases where there is no clear medical indication. Inappropriate use can lead to unnecessary side effects and complications, emphasizing the need for better awareness of appropriate PPI use. Objectives This study aimed to assess the knowledge and attitudes of Umm Al-Qura University (UQU) students in Makkah, Saudi Arabia, regarding the inappropriate use of PPIs, highlighting the necessity of targeted educational interventions to improve awareness and promote safe PPI practices. Methods A cross-sectional online survey was conducted among 534 UQU students, aged 18-30, from both health-related and non-health-related majors. Participants were selected through convenience sampling, with the questionnaire distributed via Google Forms across various channels. Data were prepared using Microsoft Excel and analyzed with IBM SPSS Statistics for Windows, V. 25.0 (IBM Corp., Armonk, NY, USA). Results The survey revealed a significant lack of awareness about the potential side effects of PPIs, with 48.1% of participants (n=247) exhibiting low awareness, 30.9% (n=165) demonstrating high awareness, and 21% (n=112) showing moderate understanding. A chi-squared test confirmed that this awareness distribution significantly differed from what was expected, χ²(2, n=534)=60.48, p<0.001. In terms of behavior, 70.4% of participants adhered to good practices regarding PPI use, following appropriate guidelines such as using PPIs only when prescribed, following the correct dosage, and avoiding self-medication. Additionally, 21.3% (n=114) displayed moderate behavior, and 8.2% demonstrated poor behavior by engaging in practices such as using PPIs without medical supervision or not adhering to the recommended dosage and duration. A chi-squared test indicated significant differences in the behavior distribution, χ²(2, n=534)=344.14, p<0.001. Conclusion While most respondents displayed good behavior regarding PPI usage, there remains a significant gap in knowledge and attitudes. Addressing these gaps through targeted educational interventions, such as workshops, e-learning modules, and awareness campaigns, could promote the safe and effective use of PPIs among students in Saudi Arabia. The next steps would involve implementing these programs in collaboration with healthcare professionals and university departments, with effectiveness measured through follow-up surveys, behavior assessments, and analysis of PPI usage trends over time.

Timely Cessation of Proton Pump Inhibitors in Critically Ill Patients Impacts Morbidity and Mortality: A Propensity Score-Matched Cohort Study

OBJECTIVE

Proton pump inhibitors (PPIs) are among the drugs most commonly used in critically ill patients. Although mainly applied temporarily for stress ulcer prophylaxis, their application is frequently not terminated. Potential adverse effects of PPI treatment could impact the outcome in case of unnecessary and, therefore, avoidable long-term continuation. We tested the hypotheses that nonindicated PPI therapy continued beyond hospital discharge is associated with increased morbidity, rehospitalization rate, and mortality.

DESIGN

Nationwide retrospective cohort study considering critically ill patients treated on German ICUs between January, 2017, and December, 2018 with a 2-year follow-up.

SETTING

A total of 591,207 patient datasets of a German healthcare insurer were screened.

PATIENTS

We identified 11,576 ICU patients who received PPI therapy for the first time during their index ICU stay without having an indication for its continuation.

INTERVENTIONS

The cohort was stratified into two groups: 1) patients without further PPI therapy and 2) patients with continuation of PPI therapy beyond 8 weeks after hospital discharge.

MEASUREMENTS AND MAIN RESULTS

Frequency of predescribed adverse events associated with PPI therapy, 1-year rehospitalization rate, and 2-year mortality were determined. The proportion of patients with continued PPI therapy without an objectifiable indication was 41.7% (4,825 of 11,576 patients). These patients had a 27% greater risk of pneumonia (odds ratio [OR] 1.27; 95% CI, 1.15-1.39; p < 0.001) and a 17% greater risk of cardiovascular events (OR 1.17; 95% CI, 1.08-1.26; p < 0.001). Continued PPI therapy was associated with a 34% greater risk of rehospitalization (OR 1.34; 95% CI, 1.23-1.47) and a nearly 20% greater 2-year mortality risk (hazard ratio 1.17; 95% CI, 1.08-1.27; p = 0.006).

CONCLUSIONS

These data demonstrate that an unnecessary continuation of PPI therapy after hospital discharge may significantly impact morbidity and mortality. To avoid potentially harmful overuse of a PPIs, intensivists should ensure timely cessation of a temporarily indicated PPI therapy.

Efficacy of a computer based discontinuation strategy to reduce PPI prescriptions: a multicenter cluster-randomized controlled trial

Deprescribing of inappropriate long-term proton pump inhibitors (PPI) is challenging and there is a lack of useful methods for general practitioners to tackle this. The objective of this randomized controlled trial was to evaluate the effectiveness of the electronic decision aid tool arriba-PPI on reduction of long-term PPI intake. Participants (64.5 ± 12.9 years; 54.4% women) with a PPI intake of at least 6 months were randomized to receive either consultation with arriba-PPI from their general practitioner (n = 1256) or treatment as usual (n = 1131). PPI prescriptions were monitored 6 months before, 6 and 12 months after study initiation. In 49.2% of the consultations with arriba-PPI, the general practitioners and their patients made the decision to reduce or discontinue PPI intake. At 6 months, there was a significant reduction by 22.3% (95% CI 18.55 to 25.98; p < 0.0001) of defined daily doses (DDD) of PPI. A reduction of 3.3% (95% CI - 7.18 to + 0.62) was observed in the control group. At 12 months, the reduction of DDD-PPI remained stable in intervention patients (+ 3.5%, 95% CI - 0.99 to + 8.03), whereas control patients showed a reduction of DDD-PPI (- 10.2%, 95% CI - 6.01 to - 14.33). Consultation with arriba-PPI led to reduced prescription rates of PPI in primary care practices. Arriba-PPI can be a helpful tool for general practitioners to start a conversation with their patients about risks of long-term PPI intake, reduction or deprescribing unnecessary PPI medication.

Patients' perspectives on a patient-oriented electronic decision support tool to reduce overuse of proton pump inhibitors (arriba-PPI): a qualitative study in primary care

BACKGROUND

To evaluate patients' perspectives and their experiences with a consultation involving a computer-assisted and patient-centered discontinuation strategy (arriba-PPI tool) as part of a German multicenter study on reducing the prescription of proton pump inhibitors (PPIs).

METHODS

Qualitative in-depth telephone interviews on proton pump inhibitors with patients who had received an arriba-PPI tool-based counseling by their general practitioner (GP). A random sample of 30 patients was taken from study participants. Interviews were conducted in 2020 and analyzed using a thematic qualitative text analysis.

RESULTS

Although this was meant to be the key to shared decision making with regard to PPI reduction, study participants mostly did not recall the visual features of the tool. However, a few patients remembered them very clearly. Above all, patients appreciated a trustful relationship with the GP as well as comprehensive, individualized counseling.

CONCLUSION

Application of the arriba-PPI tool can support the decision process but can also hinder the consultation process if the tool is not properly embedded in the consultation. GPs using the arriba-PPI tool to support the shared decision-making process should consider the patients' and their own expectations on the benefit of the visual representation of the tool.

[Proton-pump inhibitors treatment. Does your patient really need it?]

INTRODUCTION

Proton-pump inhibitors (PPI) are frequently prescribed for wide gastrointestinal disorders. The indications are well established, although a high rate of misuse has been reported.

METHODS

Observation cross-sectional study conducted a tertiary hospital. Adult patients who attended the emergency department were eligible. The appropriate indication was evaluated. Also, the prescription period, dosage and the prescribing clinician were reviewed.

RESULTS

300 patients were included. The indication was adequate in 142 patients (47.3%). The main indication was the primary prophylaxis for NSAIDs/ASA-induced enteropathy (n=95 patients, 31.7%). Polypharmacy was the main misuse indication (n=82 patients, 27.3%). The median prescription duration was 31 months (IQR 9-72), ranging from one month to 360 months. The duration was lower in those with correct indication (42.3 vs 59.6 months, P=.02). The primary care physician was the main responsible for prescription (n=165 patients, 55%), followed by gastroenterologist (n=38 patients, 12.7%) without significant differences in appropriateness by speciality.

CONCLUSIONS

Studies like this raise awareness about the PPI overuse and misuse. Deprescribing should be considered as essential to reduce iatrogenic risk and redundant health expenditure.

Proton pump inhibitor use and appropriateness analysis: a snapshot from a secondary care hospital

Objectives

Proton pump inhibitors (PPIs) have become one of the most frequently prescribed drugs since their introduction 30 years ago. Effectiveness and safety profile of PPIs has led to their overutilization and has exposed patients to a number of potential risks. The objective of this study was to evaluate the use of PPIs in a secondary care hospital in the United Arab Emirates.

Methods

This prospective observational drug-utilization study was conducted in patients receiving treatment with PPIs and admitted to internal medicine wards of the study site. Electronic patient case records were reviewed and data on PPI prescribing was collected and analysed. Appropriateness of PPI use was assessed as per international guidelines.

Key findings

Out of 172 patients enrolled, 53.5% were females with median age of 57 years (34.3, 71.0). Four different PPIs were prescribed to study patients, pantoprazole (86.6%), esomeprazole (5.8%), rabeprazole (4.1%) and omeprazole (3.5%). Ninety-two (53.5%) patients were prescribed intravenous PPI, whereas 80 (46.5%) patients were given PPI in oral form. Overall, 103 (59.9%) patients had inappropriate PPI prescriptions. Of these inappropriate prescriptions, 22 patients had no clear indication for PPI use and for 16 patients; PPIs were indicated for stress ulcer prophylaxis in low-risk category. Corticosteroid use [odds ratio (OR): 4.34, 95% confidence interval (CI): 1.22–15.46; P = 0.023] was significantly associated with greater odds of inappropriate PPI use.

Conclusions

We report a high prevalence of inappropriate PPI prescribing among the hospitalized patients in our study. Inappropriate PPI prescribing is a concerning issue and collective efforts should be made to check and minimize the same.

Community-dwelling older adults' awareness of the inappropriate use of proton pump inhibitors

Background

Proton pump inhibitors (PPIs) are effective in treating gastroesophageal reflux, peptic ulcers, and esophagitis. However, the long-term use of PPIs by older adults is associated with adverse health outcomes. There is limited evidence about older adults’ awareness of long-term PPI use and its associated adverse effects. This study aimed to assess older adults’ awareness of the adverse effects of the long-term use of PPIs, and their willingness to stop PPI use given of the risks and benefits of PPI use.

Methods

this cross-sectional study was conducted on a convenience sample of 120 older adults from three local healthcare centers located in Irbid, Jordan. Older adults’ awareness of PPI use was measured using the Patients’ Perceptions of Proton Pump Inhibitor Risks and Attempts at Discontinuation Survey.

Results

the majority of the participating older adults were not familiar with any reports linking long-term PPI use with adverse effects, reported no concerns related to the chronic use of PPIs, and reported that they had not discussed the benefits and risks of PPI use with their primary care providers (PCPs). Although the majority of the participants had not previously attempted to stop using PPIs, the majority expressed a willingness to stop PPIs due to their adverse effects, especially if advised to do so by a PCP. The factors associated with the long-term use of PPIs included age, indications for gastrointestinal reflux disease (GERD), improvement of GERD symptoms, and the willingness to reduce or stop PPIs. Being advised by a PCP to stop PPIs (p = 0.049) and having increased concerns about the adverse effects of long-term PPI use (p < 0.0001) were the only two statistically significant predictors of previous attempts to stop PPIs.

Conclusions

concerns regarding the adverse effects of long-term PPI use were associated with attempts to stop PPIs, especially in cases where this was recommended by a PCP. Discussions between PCPs and patients regarding the risks and benefits of PPIs are necessary in order to ensure that patients do not make inappropriate decisions regarding ongoing PPI therapy. Careful evaluation of the long-term use of PPIs among older adults is required.

Community-dwelling older adults' awareness of the inappropriate use of proton pump inhibitors

BACKGROUND

Proton pump inhibitors (PPIs) are effective in treating gastroesophageal reflux, peptic ulcers, and esophagitis. However, the long-term use of PPIs by older adults is associated with adverse health outcomes. There is limited evidence about older adults' awareness of long-term PPI use and its associated adverse effects. This study aimed to assess older adults' awareness of the adverse effects of the long-term use of PPIs, and their willingness to stop PPI use given of the risks and benefits of PPI use.

METHODS

this cross-sectional study was conducted on a convenience sample of 120 older adults from three local healthcare centers located in Irbid, Jordan. Older adults' awareness of PPI use was measured using the Patients' Perceptions of Proton Pump Inhibitor Risks and Attempts at Discontinuation Survey.

RESULTS

the majority of the participating older adults were not familiar with any reports linking long-term PPI use with adverse effects, reported no concerns related to the chronic use of PPIs, and reported that they had not discussed the benefits and risks of PPI use with their primary care providers (PCPs). Although the majority of the participants had not previously attempted to stop using PPIs, the majority expressed a willingness to stop PPIs due to their adverse effects, especially if advised to do so by a PCP. The factors associated with the long-term use of PPIs included age, indications for gastrointestinal reflux disease (GERD), improvement of GERD symptoms, and the willingness to reduce or stop PPIs. Being advised by a PCP to stop PPIs (p = 0.049) and having increased concerns about the adverse effects of long-term PPI use (p < 0.0001) were the only two statistically significant predictors of previous attempts to stop PPIs.

CONCLUSIONS

concerns regarding the adverse effects of long-term PPI use were associated with attempts to stop PPIs, especially in cases where this was recommended by a PCP. Discussions between PCPs and patients regarding the risks and benefits of PPIs are necessary in order to ensure that patients do not make inappropriate decisions regarding ongoing PPI therapy. Careful evaluation of the long-term use of PPIs among older adults is required.

Barriers and facilitators to deprescribing in primary care: a systematic review

BACKGROUND

Managing polypharmacy is a challenge for healthcare systems globally. It is also a health inequality concern as it can expose some of the most vulnerable in society to unnecessary medications and adverse drug-related events. Care for most patients with multimorbidity and polypharmacy occurs in primary care. Safe deprescribing interventions can reduce exposure to inappropriate polypharmacy. However, these are not fully accepted or routinely implemented.

AIM

To identify barriers and facilitators to safe deprescribing interventions for adults with multimorbidity and polypharmacy in primary care.

DESIGN & SETTING

A systematic review of studies published from 2000, examining safe deprescribing interventions for adults with multimorbidity and polypharmacy.

METHOD

A search of electronic databases: MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature (CINHAL), Cochrane, and Health Management Information Consortium (HMIC) from inception to 26 Feb 2019, using an agreed search strategy. This was supplemented by handsearching of relevant journals, and screening of reference lists and citations of included studies.

RESULTS

In total, 40 studies from 14 countries were identified. Cultural and organisational barriers included: a culture of diagnosing and prescribing; evidence-based guidance focused on single diseases; a lack of evidence-based guidance for the care of older people with multimorbidities; and a lack of shared communication, decision-making systems, tools, and resources. Interpersonal and individual-level barriers included: professional etiquette; fragmented care; prescribers' and patients' uncertainties; and gaps in tailored support. Facilitators included: prudent prescribing; greater availability and acceptability of non-pharmacological alternatives; resources; improved communication, collaboration, knowledge, and understanding; patient-centred care; and shared decision-making.

CONCLUSION

A whole systems, patient-centred approach to safe deprescribing interventions is required, involving key decision-makers, healthcare professionals, patients, and carers.

Passing the acid test? Evaluating the impact of national education initiatives to reduce proton pump inhibitor use in Australia

BACKGROUND

Proton pump inhibitor (PPI) use is widespread. There have been increasing concerns about overuse of high-dose PPIs for durations longer than clinically necessary.

OBJECTIVE

To evaluate the impact of national education initiatives on reducing PPI use in Australia.

DESIGN

Population-based, controlled interrupted time series analysis of PPI dispensing claims data for Australian adults from July 2012 to June 2018; we used statin dispensing as a control.

INTERVENTIONS

A year-long educational initiative led by NPS MedicineWise (previously the National Prescribing Service) from April 2015. Simultaneously, Choosing Wisely released recommendations in April 2015 and May 2016. Both promoted review of prolonged PPI use and encouraged stepping down or ceasing treatment, where appropriate.

MEASUREMENTS

We examined monthly changes in PPI (and statin) dispensing (stratified by high, standard and low tablet strength), rates of switching from higher to lower strength PPIs and rates of PPI (and statin) discontinuation.

RESULTS

We observed 12 040 021 PPI dispensings to 579 594 people. We observed a sustained -1.7% (95% CI: -2.7 to -0.7%) decline in monthly dispensing of standard strength PPIs following the initiatives until the end of the study period. There were no significant changes in high or low strength PPI (or statin) dispensings, switching to lower strength PPIs, or PPI (and statin) treatment discontinuation.

CONCLUSION

Our findings suggest that these educational initiatives alone were insufficient in curbing overuse of PPIs on a national level. Concerted efforts with policy levers such as imposing tighter restrictions on subsidised use of PPIs may be more effective. Noting low strength esomeprazole is not publicly subsidised in Australia, availability of these preparations may also facilitate more appropriate practice.

We have had a gutful: The need for deprescribing proton pump inhibitors

WHAT IS KNOWN AND OBJECTIVE

Proton pump inhibitor (PPI) prescribing may often be inappropriate and expose patients to a risk of adverse effects, while incurring unnecessary healthcare expenditure. Our objective was to determine PPI usage in Australia since 2002 and review international studies investigating inappropriate PPI prescribing, including those that discussed interventions to address this issue.

METHODS

Australian Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Scheme (RPBS) data were analysed. A narrative literature review relevant to the objective was conducted. Time series analysis was also used to examine the trend of reported PPI appropriate use across the international studies included in this review.

RESULTS AND DISCUSSION

Proton pump inhibitor use in Australia increased between 2002 and 2010 and then gradually decreased. Estimates of the extent of inappropriate use in the international literature had a wide variation (11-84%). There appeared to be little change in the extent of appropriate PPI use reported through 34 international studies from 2000 to 2016. Interventions to address inappropriate use included patient-centred deprescribing, academic detailing, educational programmes and drug safety notifications.

WHAT IS NEW AND CONCLUSION

Proton pump inhibitors continue to be overused worldwide and should be a focus for deprescribing programmes. Ongoing education and awareness campaigns for health professionals and patients, including electronic reminders at the point of prescribing, are strategies that have potential to reduce PPI use in individuals who do not have an evidence-based clinical indication for their long-term use.

Use of proton pump inhibitors in general practice

AIM

To evaluate the characteristics of the prescription of the proton pump inhibitor drugs (PPI) and the adherence to the indications of the guidelines regulating the reimbursement limitations set forth by the Italian Drug Agency.

METHODS

Thirty general practitioners (GP) participated in the study, providing data on more than 40000 patients in total. The population was divided into non occasional users of PPI drugs (PPI users) and non-users (PPI non-users) based on evidence of a prescription of at least 3 packs of PPIs in the last 90 d before analysis. The data provided allowed an assessment of compliance with the requirements of eligibility for PPI reimbursement according to the Italian Drug Agency rules, in order to obtain subpopulations which complied or not with the rules.

RESULTS

Six thousand three hundred and twenty-two patients were found to be PPI users, accounting for 14.9% of the patient population. PPI users were more frequently female, older and more frequently diagnosed with gastroesophageal reflux disease, gastric or duodenal ulcers, arthropathy, heart disease and cancer than the rest of the population. PPI users had more frequently received prescriptions for non-steroidal ant-inflammatory drugs (NSAIDS), acetylsalicylic acid (ASA), oral anticoagulant therapy (OAT) and systemic steroids. PPI reimbursement resulted applicable to 69.3% of the PPI users, but a potential for reimbursement of PPI prescriptions was identified in the non PPI users for the treatment of peptic or reflux disease (8.5%) and for the protection of gastric damage caused by NSAIDS (6.1%). Patients who are potentially eligible for reimbursement are older, diagnosed with arthropathy and heart disease more frequently and most commonly receive NSAID and ASA prescriptions compared with PPI users who do not satisfy eligibility requirements. Patients in whom it was not possible to identify conditions related to prescription suitability were more frequently associated with use of OAT.

CONCLUSION

A substantial number of patients who apparently do not meet prescription suitability conditions can be identified, but among non PPI users on the contrary, it is possible to identify an equal number of patients for whom prescription would be suitable. Poor suitability can be identified in the population receiving OAT. Thus, there is scope for decreasing inappropriate use of PPI drugs by adhering to certain criteria and by involving all interested parties.

General practitioners' views on (long-term) prescription and use of problematic and potentially inappropriate medication for oldest-old patients-A qualitative interview study with GPs (CIM-TRIAD study)

Background

Potentially inappropriate medication (PIM) is defined as medication with uncertain therapeutic effects and/or potential adverse drug reactions outweighing the clinical benefits. The prescription rate of PIM for oldest-old patients is high despite the existence of lists of PIM (e.g. the PRISCUS list) and efforts to raise awareness. This study aims at identifying general practitioners’ views on PIM and aspects affecting the (long-term) use of PIM.

Methods

As part of the CIM-TRIAD study, we conducted semi-structured, qualitative interviews with 47 general practitioners, discussing 25 patients with and 22 without PIM (according to the PRISCUS list). The interview guideline included generic and patient-specific questions. Interviews were digitally recorded and transcribed verbatim. We content analyzed the interviews using deductive and inductive category development.

Results

The majority of the general practitioners were not aware of the PRISCUS list. Agents deemed potentially inappropriate from the general practitioners’ point of view and the PRISCUS list are not completely superimposable. General practitioners named their criteria to identify appropriate medication for elderly patients (e.g. renal function, cognitive state) and emphasized the importance of monitoring.

We identified prescription- (e.g. benzodiazepines on alternative private prescription), medication- (e.g. subjective perception that PIM has no alternative), general practitioner- (e.g. general practitioner relies on specialists), patient- (e.g. “demanding high-user”, positive subjective benefit-risk-ratio) and system-related aspects (e.g. specialists lacking holistic view, interface problems) related to the (long term) use of PIM.

Conclusions

While the PRISCUS list does not seem to play a decisive role in general practice, general practitioners are well aware of risks associated with PIM. Our study identifies some starting points for a safer handling of PIM, e.g. stronger dissemination of the PRISCUS list, better compensation of medication reviews, “positive lists”, adequate patient information, multifaceted interventions and improved communication between general practitioners and specialists.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-017-0595-3) contains supplementary material, which is available to authorized users.

Effective and safe proton pump inhibitor therapy in acid-related diseases - A position paper addressing benefits and potential harms of acid suppression

BACKGROUND

The introduction of proton pump inhibitors (PPIs) into clinical practice has revolutionized the management of acid-related diseases. Studies in primary care and emergency settings suggest that PPIs are frequently prescribed for inappropriate indications or for indications where their use offers little benefit. Inappropriate PPI use is a matter of great concern, especially in the elderly, who are often affected by multiple comorbidities and are taking multiple medications, and are thus at an increased risk of long-term PPI-related adverse outcomes as well as drug-to-drug interactions. Herein, we aim to review the current literature on PPI use and develop a position paper addressing the benefits and potential harms of acid suppression with the purpose of providing evidence-based guidelines on the appropriate use of these medications.

METHODS

The topics, identified by a Scientific Committee, were assigned to experts selected by three Italian Scientific Societies, who independently performed a systematic search of the relevant literature using Medline/PubMed, Embase, and the Cochrane databases. Search outputs were distilled, paying more attention to systematic reviews and meta-analyses (where available) representing the best evidence. The draft prepared on each topic was circulated amongst all the members of the Scientific Committee. Each expert then provided her/his input to the writing, suggesting changes and the inclusion of new material and/or additional relevant references. The global recommendations were then thoroughly discussed in a specific meeting, refined with regard to both content and wording, and approved to obtain a summary of current evidence.

RESULTS

Twenty-five years after their introduction into clinical practice, PPIs remain the mainstay of the treatment of acid-related diseases, where their use in gastroesophageal reflux disease, eosinophilic esophagitis, Helicobacter pylori infection, peptic ulcer disease and bleeding as well as, and Zollinger-Ellison syndrome is appropriate. Prevention of gastroduodenal mucosal lesions (and symptoms) in patients taking non-steroidal anti-inflammatory drugs (NSAIDs) or antiplatelet therapies and carrying gastrointestinal risk factors also represents an appropriate indication. On the contrary, steroid use does not need any gastroprotection, unless combined with NSAID therapy. In dyspeptic patients with persisting symptoms, despite successful H. pylori eradication, short-term PPI treatment could be attempted. Finally, addition of PPIs to pancreatic enzyme replacement therapy in patients with refractory steatorrhea may be worthwhile.

CONCLUSIONS

Overall, PPIs are irreplaceable drugs in the management of acid-related diseases. However, PPI treatment, as any kind of drug therapy, is not without risk of adverse effects. The overall benefits of therapy and improvement in quality of life significantly outweigh potential harms in most patients, but those without clear clinical indication are only exposed to the risks of PPI prescription. Adhering with evidence-based guidelines represents the only rational approach to effective and safe PPI therapy. Please see related Commentary: doi: 10.1186/s12916-016-0724-1 .

Characterizing Potentially Inappropriate Prescribing of Proton Pump Inhibitors in Older People in Primary Care in Ireland from 1997 to 2012

OBJECTIVES

To characterize prescribing of proton pump inhibitors (PPIs) and medicines that increase gastrointestinal bleeding risk (ulcerogenic) in older people from 1997 to 2012 and assess factors associated with maximal-dose prescribing in long-term PPI users.

DESIGN

Repeated cross-sectional study of pharmacy claims data.

SETTING

Eastern Health Board region of Ireland.

PARTICIPANTS

Individuals aged 65 and older from a means-tested health plan in 1997, 2002, 2007, and 2012 (range 78,489-133,884 individuals).

MEASUREMENTS

PPI prescribing prevalence was determined per study year, categorized according to duration (≤8 or >8 weeks), dosage (maximal or maintenance), and co-prescribed drugs. Logistic regression in long-term PPI users was used to determine whether age, sex, polypharmacy, and ulcerogenic medicine use were associated with being prescribed a maximal dose rather than a maintenance dose. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) are presented.

RESULTS

Half of this older population received a PPI in 2007 and 2012. Long-term use (>8 weeks) of maximal doses rose from 0.8% of individuals in 1997 to 23.6% in 2012. Although some ulcerogenic medicines and polypharmacy were significantly associated with maximal PPI doses, any nonsteroidal anti-inflammatory drug use was significantly associated with lower odds of maximal PPI dose (adjusted OR = 0.87, 95% CI = 0.85-0.89), as were aspirin use and older age. Adjusting for medication and demographic factors, odds of being prescribed a maximal PPI dose were significantly higher in 2012 than in 1997 (adjusted OR = 6.30, 95% CI = 5.76-6.88).

CONCLUSIONS

Long-term maximal-dose PPI prescribing is highly prevalent in older adults and is not consistently associated with gastrointestinal bleeding risk factors. Interventions involving prescribers and patients may promote appropriate PPI use, reducing costs and adverse effects of PPI overprescribing.

Use of proton-pump inhibitors among adults: a Danish nationwide drug utilization study

BACKGROUND

The use of proton-pump inhibitors (PPIs) has increased over the last decade. The objective of this study was to provide detailed utilization data on PPI use over time, with special emphasis on duration of PPI use and concomitant use of ulcerogenic drugs.

METHODS

Using the nationwide Danish Prescription Registry, we identified all Danish adults filling a PPI between 2002 and 2014. Using descriptive statistics, we reported (i) the distribution of use between single PPI entities, (ii) the development in incidence and prevalence of use over time, (iii) measures of duration and intensity of treatment, and (iv) the prevalence of use of ulcerogenic drugs among users of PPIs.

RESULTS

We identified 1,617,614 adults using PPIs during the study period. The prevalence of PPI use increased fourfold during the study period to 7.4% of all Danish adults in 2014. PPI use showed strong age dependency, reaching more than 20% among those aged at least 80 years. The proportion of users maintaining treatment over time increased with increasing age, with less than10% of those aged 18-39 years using PPIs 2 years after their first prescription, compared with about 40% among those aged at least 80 years. The overall use of ulcerogenic drugs among PPI users increased moderately, from 35% of users of PPI in 2002 to 45% in 2014.

CONCLUSIONS

The use of PPIs is extensive and increasing rapidly, especially among the elderly.

Sustained effectiveness of a multifaceted intervention to reduce potentially inappropriate prescribing in older patients in primary care (OPTI-SCRIPT study)

BACKGROUND

Potentially inappropriate prescribing (PIP) is common in older people in primary care and can result in increased morbidity, adverse drug events and hospitalisations. We previously demonstrated the success of a multifaceted intervention in decreasing PIP in primary care in a cluster randomised controlled trial (RCT).

OBJECTIVE

We sought to determine whether the improvement in PIP in the short term was sustained at 1-year follow-up.

METHODS

A cluster RCT was conducted with 21 GP practices and 196 patients (aged ≥70) with PIP in Irish primary care. Intervention participants received a complex multifaceted intervention incorporating academic detailing, medicine review with web-based pharmaceutical treatment algorithms that provide recommended alternative treatment options, and tailored patient information leaflets. Control practices delivered usual care and received simple, patient-level PIP feedback. Primary outcomes were the proportion of patients with PIP and the mean number of potentially inappropriate prescriptions at 1-year follow-up. Intention-to-treat analysis using random effects regression was used.

RESULTS

All 21 GP practices and 186 (95 %) patients were followed up. We found that at 1-year follow-up, the significant reduction in the odds of PIP exposure achieved during the intervention was sustained after its discontinuation (adjusted OR 0.28, 95 % CI 0.11 to 0.76, P = 0.01). Intervention participants had significantly lower odds of having a potentially inappropriate proton pump inhibitor compared to controls (adjusted OR 0.40, 95 % CI 0.17 to 0.94, P = 0.04).

CONCLUSION

The significant reduction in the odds of PIP achieved during the intervention was sustained after its discontinuation. These results indicate that improvements in prescribing quality can be maintained over time.

TRIAL REGISTRATION

Current controlled trials ISRCTN41694007 .

General practice variation when initiating long-term prescribing of proton pump inhibitors: a nationwide cohort study

Background

Suggestions of overprescribing of proton pump inhibitors (PPIs) for long-term treatment in primary care have been raised. This study aims to analyse associations between general practice characteristics and initiating long-term treatment with PPIs.

Methods

A nationwide register-based cohort study of patients over 18 years redeeming first-time prescription for PPI issued by a general practitioner in Denmark in 2011. Patients redeeming more than 60 defined daily doses (DDDs) of PPI within six months were defined first-time long-term users. Detailed information on diagnoses, concomitant drug use and sociodemography of the cohort was extracted. Practice characteristics such as age and gender of the general practitioner (GP), number of GPs, number of patients per GP, geographical location and training practice status were linked to each PPI user. Logistic regression analysis was used to determine associations between practice characteristics and initiating long-term prescribing of PPIs.

Results

We identified 90 556 first-time users of PPI. A total of 30 963 (34.2 %) met criteria for long-term use at six months follow-up. GPs over 65 years had significantly higher odds of long-term prescribing (OR 1.32, CI 1.16-1.50), when compared to younger GPs (<45 years). Furthermore, female GPs were significantly less likely to prescribe long-term treatment with PPIs (OR 0.87, CI 0.81-0.93) compared to male GPs.

Conclusions

Practice characteristics such as GP age and gender could explain some of the observed variation in prescribing patterns for PPIs. This variation may indicate a potential for enhancing rational prescribing of PPIs.

Appropriateness of Proton Pump Inhibitor (PPI) prescription in patients admitted to hospital: Attitudes of general practitioners and hospital physicians in Italy

INTRODUCTION

Proton pump inhibitor (PPI) prescriptions have raised concern for both huge increase of health expenditure and possible long-term adverse effects.

OBJECTIVE

To evaluate appropriateness of PPI prescription in ambulatory and hospital care.

DESIGN

Observational cohort study.

PATIENTS

Patients admitted to the Internal Medicine Unit of Bologna S. Orsola Hospital between 15/09/2013 and 15/12/2013. Data on clinical condition and drug therapy were collected at three time points: admission (reflecting GP's prescription), hospital stay and discharge.

MAIN MEASURES

Appropriateness of PPI use was evaluated as follows: (1) agreement between PPI use/non-use and appropriate clinical condition; (2) in PPI users, assessment of Medication Appropriateness Index (MAI). Differences in appropriateness among time points were analyzed by chi-square test. Logistic regression model was used to identify possible determinants of PPI appropriateness.

KEY RESULTS

Among 280 patients, 56% received PPI at least once in the three time points. Appropriateness, according to indication of use, was similar between admission and hospital stay (61% vs. 62%; p=0.82) and between hospital stay and discharge (62% vs. 59%; p=0.94). MAI score showed important, although statistically non-significant, change in appropriateness between admission and hospital stay (20% vs. 28%; p=0.16). Age≥65 was always associated with appropriate PPI use (up to OR=4.37; p<0.01), whereas cardiovascular comorbidity and conditions requiring analgesic treatment influenced appropriateness only at admission (OR=3.84; p<0.01 and OR=0.34; p<0.01, respectively).

CONCLUSIONS

Hospital clinicians only rarely reconsidered GP's choice to prescribe PPI. Room for improvement in PPI appropriateness is represented by (1) assessing gastrointestinal risk in each patient under analgesics and anti-inflammatory drugs, and (2) short-term re-evaluation of PPI prescription after discharge.

Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis

OBJECTIVE

To synthesise qualitative studies that explore prescribers' perceived barriers and enablers to minimising potentially inappropriate medications (PIMs) chronically prescribed in adults.

DESIGN

A qualitative systematic review was undertaken by searching PubMed, EMBASE, Scopus, PsycINFO, CINAHL and INFORMIT from inception to March 2014, combined with an extensive manual search of reference lists and related citations. A quality checklist was used to assess the transparency of the reporting of included studies and the potential for bias. Thematic synthesis identified common subthemes and descriptive themes across studies from which an analytical construct was developed. Study characteristics were examined to explain differences in findings.

SETTING

All healthcare settings.

PARTICIPANTS

Medical and non-medical prescribers of medicines to adults.

OUTCOMES

Prescribers' perspectives on factors which shape their behaviour towards continuing or discontinuing PIMs in adults.

RESULTS

21 studies were included; most explored primary care physicians' perspectives on managing older, community-based adults. Barriers and enablers to minimising PIMs emerged within four analytical themes: problem awareness; inertia secondary to lower perceived value proposition for ceasing versus continuing PIMs; self-efficacy in regard to personal ability to alter prescribing; and feasibility of altering prescribing in routine care environments given external constraints. The first three themes are intrinsic to the prescriber (eg, beliefs, attitudes, knowledge, skills, behaviour) and the fourth is extrinsic (eg, patient, work setting, health system and cultural factors). The PIMs examined and practice setting influenced the themes reported.

CONCLUSIONS

A multitude of highly interdependent factors shape prescribers' behaviour towards continuing or discontinuing PIMs. A full understanding of prescriber barriers and enablers to changing prescribing behaviour is critical to the development of targeted interventions aimed at deprescribing PIMs and reducing the risk of iatrogenic harm.