Physicians' approaches to the use of gastroprotective strategies in low-risk non-steroidal anti-inflammatory drug users

Predictors for inappropriate proton pump inhibitor use: observational study in primary care

Background: Proton pump inhibitor (PPI) indications are limited to gastrointestinal disorders and ulcer prophylaxis. Still, PPIs are among the most frequently prescribed drugs. Aim: To evaluate the appropriateness of PPI prescriptions and identify predictive factors for inappropriate PPI use. Design and Setting: Observational study using a Dutch primary care database with all new PPI prescriptions between 2016 and 2018. Methods: Individual patient data and details on PPI use were collected. Appropriateness of initiation and continuation of PPI prescriptions was evaluated using the applicable guidelines. Results: We evaluated 148,926 patients (≥ 18 years) from 27 general practices. A total of 23,601 (16%) patients started PPI therapy (mean age 57 ± 17 years, 59% female). Valid PPI indications at initiation were seen in 10,466 PPI users (44%). Predictors for inappropriately initiated PPI use were older age (OR 1.03, 95%CI 1.03-1.03), and use of non-selective NSAIDs (OR 5.15, 95%CI 4.70-5.65), ADP receptor inhibitors (OR 5.07, 95%CI 3.46-7.41), coxibs (OR 3.93, 95%CI 2.92-5.28) and low-dose aspirin (OR 3.83, 95%CI 3.07-4.77). Despite an initial valid indication, PPI use was inaccurately continued in 32% of patients on short-course therapy for dyspepsia and in 11% of patients on ulcer prophylaxis. Conclusion: More than half of PPI users in primary care seem to have an inappropriate indication with unnecessary ulcer prophylaxis related to drug use being one of the leading causes. Future initiatives to reduce PPI use for unnecessary ulcer prophylaxis and timely deprescription if PPI is no longer indicated, are needed.

Potentially inappropriate proton-pump inhibitor prescription in the general population: a claims-based retrospective time trend analysis

BACKGROUND

Proton-pump inhibitors (PPI) are among the most prescribed drugs worldwide, and a large body of evidence raises concerns about their inappropriate use. Previous estimates of inappropriate use varied due to different definitions and study populations.

AIMS

We aimed to measure the population-based incidence and time trends of PPI and potentially inappropriate PPI prescriptions (PIPPI) with a novel method, continuously assessing excessive cumulative doses based on clinical practice guidelines. We also assessed association of patient characteristics with PPI prescriptions and PIPPI.

METHODS

This was an observational study based on a large insurance claims database of persons aged >18 years with continuous claims records of ⩾12 months. The observation period was January 2012 to December 2017. We assessed the incidence and time trends of PPI prescriptions and PIPPI based on doses prescribed, defining ⩾11.5 g of pantoprazole dose equivalents during any consecutive 365 days (average daily dose >31 mg) as inappropriate.

RESULTS

Among 1,726,491 eligible persons, the annual incidence of PPI prescriptions increased from 19.7% (2012) to 23.0% (2017), (p = <0.001), and the incidence of PIPPI increased from 4.8% (2013) to 6.4% (2017), (p = <0.001). Age, male gender, drugs with bleeding risk and multimorbidity were independent determinants of PIPPI (p = <0.001 for all).

CONCLUSIONS

This study provides evidence that one of the most prescribed drug groups is commonly prescribed inappropriately in the general population and that this trend is increasing. Multimorbidity and drugs with bleeding risks were strong determinants of PIPPI. Addressing PPI prescriptions exceeding guideline recommendations could reduce polypharmacy and improve patient safety.

GPs' understanding of the benefits and harms of treatments for long-term conditions: an online survey

Background

GPs prescribe multiple long-term treatments to their patients. For shared clinical decision-making, understanding of the absolute benefits and harms of individual treatments is needed. International evidence shows that doctors’ knowledge of treatment effects is poor but, to the authors knowledge, this has not been researched among GPs in the UK.

Aim

To measure the level and range of the quantitative understanding of the benefits and harms of treatments for common long-term conditions (LTCs) among GPs.

Design & setting

An online cross-sectional survey was distributed to GPs in the UK.

Method

Participants were asked to estimate the percentage absolute risk reduction or increase conferred by 13 interventions across 10 LTCs on 17 important outcomes. Responses were collated and presented in a novel graphic format to allow detailed visualisation of the findings. Descriptive statistical analysis was performed.

Results

A total of 443 responders were included in the analysis. Most demonstrated poor (and in some cases very poor) knowledge of the absolute benefits and harms of treatments. Overall, an average of 10.9% of responses were correct allowing for ±1% margin in absolute risk estimates and 23.3% allowing a ±3% margin. Eighty-seven point seven per cent of responses overestimated and 8.9% of responses underestimated treatment effects. There was no tendency to differentially overestimate benefits and underestimate harms. Sixty-four point eight per cent of GPs self-reported ‘low’ to ‘very low’ confidence in their knowledge.

Conclusion

GPs’ knowledge of the absolute benefits and harms of treatments is poor, with inaccuracies of a magnitude likely to meaningfully affect clinical decision-making and impede conversations with patients regarding treatment choices.

Time-trends in gastroprotection with nonsteroidal anti-inflammatory drugs (NSAIDs)

BACKGROUND

Preventive strategies are advocated in patients at risk of upper-gastrointestinal complications associated with nonsteroidal anti-inflammatory drugs (NSAIDs).

AIM

To examine time-trends in preventive strategies.

METHODS

In a study population comprising 50 126 NSAID users > or =50 years from the Integrated Primary Care Information database, we considered two preventive strategies: co-prescription of gastroprotective agents and prescription of a cyclooxygenase-2-selective inhibitor. In patients with > or =1 risk factor (history of upper-gastrointestinal bleeding/ulceration, age >65 years, use of anticoagulants, aspirin, or corticosteroids), correct prescription was defined as the presence of a preventive strategy and under-prescription as the absence of one. In patients with no risk factors, correct prescription was defined as the lack of a preventive strategy, and over-prescription as the presence of one.

RESULTS

Correct prescription rose from 6.9% in 1996 to 39.4% in 2006 (P < 0.01) in high-risk NSAID users. Under-prescription fell from 93.1% to 59.9% (P < 0.01). In the complete cohort, over-prescription rose from 2.9% to 12.3% (P < 0.01).

CONCLUSIONS

Under-prescription of preventive strategies has steadily decreased between 1996 and 2006; however, 60% of NSAID users at increased risk of NSAID complications still do not receive adequate protection.

Co-prescription of gastro-protectants in hospitalized patients: an analysis of what we do and what we think we do

BACKGROUND

Proton pump inhibitors (PPIs) reduce the risk of upper gastrointestinal hemorrhage (UGIH) associated with the use of many medications.

GOALS

To examine how clinicians perceive such risk and whether PPI co-prescribing is based on an accurate assessment.

STUDY METHODS

Clinicians in a single teaching hospital were asked to estimate risk of UGIH and comment on PPI co-prescription in hypothetical patients. Records of 160 hospital in-patients (median age; 74 y) were then reviewed to examine PPI prescribing and risk factors for UGIH.

RESULTS

In general, clinicians estimated UGIH risk accurately and reported low thresholds for PPI co-prescription. Prescribing records showed regular PPI use increased between admission and discharge of patients from 61/160 (38%) to 93/160 (58%). Ten percent had a prior history of peptic ulcer disease. Proton pump inhibitor prescription was significantly associated with the use of aspirin and clopidogrel. Half of the patients with multiple risk factors for UGIH on admission and almost a third at discharge were not co-prescribed a PPI.

CONCLUSIONS

Clinicians generally estimate correctly the risk of UGIH and report a low threshold for prescribing gastro-protection. Despite this, prescribing practice does not consistently take account of relative risk of UGIH. Targeted PPI co-prescribing on the basis of risk factors would lead to more rational PPI use.

Resident physician's knowledge of risk factors for upper gastrointestinal complications from NSAIDs

Although physician compliance with the use of gastroprotection among nonsteroidal anti-inflammatory drugs (NSAIDs) users is suboptimal, we previously showed that the combination of an electronic alert with an educational intervention modestly improved rates of gastroprotection at hospital discharge. We sought to assess understanding of risk factors for NSAID-related upper gastrointestinal (GI) complications among junior and senior residents, some of whom had previously been exposed to the targeted educational intervention. We developed a 21-question survey based on known risk factors for upper GI complications from NSAIDs. Cumulative scores were calculated based on answers to knowledge-based questions. Among 78 eligible physicians, 72 participated (35 interns, 37 residents). Mean composite scores were 10.31 for interns and 12.30 for residents (P < 0.0001). Eight residents previously exposed to the targeted educational intervention tended to higher scores than 29 residents who were not (12.25 vs. 11.52, respectively, not significant). Senior residents demonstrated marginally better knowledge of risk factors for upper GI complications from NSAIDs. A combined educational intervention and electronic alert did not have a durable impact on knowledge.

The effects of guideline implementation for proton pump inhibitor prescription on two pulmonary medicine wards

BACKGROUND

It has been demonstrated that 40% of patients admitted to pulmonary medicine wards use proton pump inhibitors (PPIs) without a registered indication.

AIM

To assess whether implementation of a guideline for proton pump inhibitor (PPI) prescription on pulmonary medicine wards could lead to a decrease in use and improved appropriateness of prescription.

METHODS

This prospective study comprised two periods, i.e. the situation before and after guideline implementation. In each period, 300 consecutive patients were included. We registered patient characteristics, medications and occurrence of upper gastrointestinal-related disorders.

RESULTS

After implementation, fewer patients were started on PPIs [21% vs. 13%; odds ratio (OR): 0.56; 95% confidence interval (CI): 0.33-0.97] and more users discontinued their use; however, the latter was not significant (3% vs. 6%; OR for continuation: 0.56; 95% CI: 0.14-2.23). Multivariable logistic regression analysis confirmed that PPI use during hospitalization decreased after implementation (adjusted pooled OR: 0.54; 95% CI: 0.32-0.90). Implementation did not result in a change in reported reasons for PPI prescription. There was no significant difference in the occurrence of upper GI-related disorders in the first 3 months after discharge.

CONCLUSIONS

Guideline implementation for PPI prescription on two pulmonary medicine wards resulted in a reduction in the number of patients starting PPIs during hospitalization, but appropriateness of prescribing PPIs was not affected. Further studies are needed to determine how appropriateness of PPI prescription on pulmonary medicine wards can be further improved.

Inappropriate prescription of proton pump inhibitors on two pulmonary medicine wards

OBJECTIVE

We recently noticed that proton pump inhibitor (PPI) use was high on a pulmonary medicine ward of a university clinic and reasons for this high usage were not clear. Our aim was to determine the indications for PPI use on two pulmonary medicine wards and to assess whether this use was appropriate.

METHODS

We assessed prospectively the number of patients on PPIs and the indications for PPI use on two pulmonary medicine wards, one from a university and one from a regional clinic in The Netherlands.

RESULTS

On admission, 88 of 300 (29%) patients already used PPIs. The use of PPIs was discontinued in three (1%) patients, whereas PPIs were initiated in 45 (15%) patients, resulting in 130 (43%) patients on PPIs during hospitalization. The most common indication for PPI use was the prevention of medication-associated complications. In 78 of 130 (60%) patients on PPIs, this medication was used for a registered indication, whereas in 52 (40%) patients a registered indication was not present (overuse). In contrast, 19 of 300 (6%) patients were not prescribed PPIs despite the presence of a registered indication for its use (underuse). No differences were found in prescription rate and indications for PPI use between the university and the regional clinic.

CONCLUSION

PPI use was very common on two pulmonary medicine wards in the Netherlands. Forty percent of the patients used their PPIs for a nonregistered indication. As use of PPIs is costly and may be associated with side effects, hospital physicians should to be better educated on guidelines for its use.

Medical evidence and health policy: a marriage of convenience? The case of proton pump inhibitors

RATIONALE

In Belgium, several policies regulating reimbursement of acid suppressant drugs and evidence-based recommendations for clinical practice were issued in a short period of time, creating a unique opportunity to observe their effect on prescribing.

AIMS AND OBJECTIVES

To describe the evolution of prescriptions for acid suppressants and explore the interaction of policies and practice recommendations with prescribing patterns.

METHOD

Monthly claims-based data for proton pump inhibitors (PPIs) and H(2)-antihistamines by general practitioners, internists and gastroenterologists were obtained from the Belgian national health insurance database (1997-2005). The evolution of reimbursed defined daily doses and expenses after introduction of reimbursement regulations and dissemination of practice recommendations was explored.

RESULTS

Recommendations had no impact on prescribing. All changes can be related to concomitant policies. Lifting reimbursement restrictions for cheaper products did not control growth or save costs in the long term. Only restricting reimbursement of all PPIs managed to curb the growth. We observed an unintended increase of non-omeprazole PPIs by gastroenterologists.

CONCLUSIONS

Reimbursement policies influence prescribing, but their effect can be unintended. A dialogue between policymakers and guideline developers, and evidence-based policies that are linked to clinical guidelines, could be an effective way to pursue both cost-containment and quality of care.