Impact of NPS MedicineWise general practitioner education programs and Choosing Wisely Australia recommendations on prescribing of proton pump inhibitors in Australia

Reducing proton pump inhibitors overuse with an advisory, risk-based, context-aware electronic alert system: A controlled interrupted time series analysis

BACKGROUND

Proton pump inhibitors (PPI) are frequently overprescribed despite guidelines recommending cautious use. Electronic alert systems have shown potential in improving prescribing practices, but their effectiveness varies. This study evaluates a novel electronic alert system designed to reduce perioperative PPI overuse by leveraging real-time, patient-specific clinical data.

METHODS

A retrospective controlled interrupted time series analysis was conducted from February 2015 to October 2021 in a tertiary care hospital. The intervention group comprised patients undergoing internal fixation surgeries in the orthopedic department, while the control group included patients receiving appendectomies in the general surgery department. A novel electronic alert system was integrated into the computerized physician order entry system, providing risk assessments and advisory alerts for intravenous PPI prescriptions. The system operated from July 2019 to November 2020. Key outcomes measured every two weeks included Defined Daily Doses (DDD) and Days of Therapy (DOT) per patient, prescription rates, and proportions of high-dose and alert-triggering orders.

RESULTS

The study included 8,303 patients in the intervention group and 5,728 in the control group. Post-implementation, the intervention group showed a significant decrease in DDD per patient (β = -1.21, p = 0.003) and DOT per patient (β = -0.698, p = 0.011), primarily due to reduced intravenous administration. Prescription rates for PPI decreased significantly (OR = 0.710, p = 0.002), and there was a reduction in high-dose prescriptions (OR = 0.243, p < 0.001). While consumption metrics remained sustained after alert deactivation, quality indicators showed partial rebounds but remained improved compared to baseline.

CONCLUSIONS

The advisory, risk-based, context-aware electronic alert system effectively reduced PPI overuse and improved prescribing quality in a surgical department. The differential impact post-intervention, with more durable effects on consumption metrics than on prescribing quality, suggests a certain degree of sustainability in prescribing behaviors. Implementing advisory, context- aware electronic alerts may offer a scalable solution for optimizing medication use in healthcare settings.

Factors influencing the effects of policies and interventions to promote the appropriate use of medicines in high-income countries: A rapid realist review

BACKGROUND

The appropriate use of medicines has long been recognized as a fundamental component of medicine policies. We aimed to extract lessons from published research on how policy contexts and mechanisms can affect the outcomes of national- or health-system level interventions to promote appropriate medicine use (defined as an increase in underutilized medications or decrease in inappropriate medication use).

METHODS

We conducted a rapid realist review of published evidence concerning system-level policies to promote the appropriate use of medicines in high-income countries with universal prescription drug coverage. We searched MEDLINE and Embase to identify relevant publications. We used a realist evaluation framework to identify contexts, mechanisms, and outcomes for each intervention and to hypothesize which policy contexts and mechanisms supported successful outcomes in terms of relative changes in the prevalence of use of the specific medication classes targeted.

RESULTS

From 1,318 identified studies, 18 met our inclusion criteria. 13 distinct policies were identified. Three main policy-related factors underpinned successful interventions: involving providers and patients through program interventions; central coordination through national agencies dedicated to medicine policies; and the establishment of an explicit and integrated national medicine policy strategy.

CONCLUSION

Policymakers can improve coordination of national pharmaceutical policies to reduce harms from inappropriate medicines use, thus improving health outcomes through cost-effective programs.

Proton Pump Inhibitors: Rational Use and Use-Reduction - The Windsor Workshop

BACKGROUND

Despite deprescribing initiatives to curb overutilization of proton pump inhibitors (PPIs), achieving meaningful reductions in PPI use is proving a challenge.

SUMMARY

An international group of primary care doctors and gastroenterologists examined the literature surrounding PPI use and use-reduction to clarify: (i) what constitutes rational PPI prescribing; (ii) when and in whom PPI use-reduction should be attempted; and (iii) what strategies to use when attempting PPI use-reduction.

KEY MESSAGES

Before starting a PPI for reflux-like symptoms, patients should be educated on potential causes and alternative approaches including dietary and lifestyle modification, weight loss, and relaxation strategies. When commencing a PPI, patients should understand the reason for treatment, planned duration, and review date. PPI use at hospital discharge should not be continued without a recognized indication for long-term treatment. Long-term PPI therapy should be reviewed at least annually. PPI use-reduction should be based on the lack of a rational indication for long-term PPI use, not concern for PPI-associated adverse events. PPI use-reduction strategies involving switching to on-demand PPI or dose tapering, with rescue therapy for rebound symptoms, are more likely to succeed than abrupt cessation.

Potentially inappropriate medication use is associated with increased risk of incident disability in healthy older adults

BACKGROUND

Efforts to minimize medication risks among older adults include avoidance of potentially inappropriate medications (PIMs). However, most PIMs research has focused on older people in aged or inpatient care, creating an evidence gap for community-dwelling older adults. To address this gap, we investigated the impact of PIMs use in the ASPirin in Reducing Events in the Elderly (ASPREE) clinical trial cohort.

METHODS

Analysis included 19,114 community-dwelling ASPREE participants aged 70+ years (65+ if US minorities) without major cardiovascular disease, cognitive impairment, or significant physical disability. PIMs were defined according to a modified 2019 AGS Beers Criteria. Cox proportional-hazards regression models were used to estimate the association between baseline PIMs exposure and disability-free survival, death, incident dementia, disability, and hospitalization, with adjustment for sex, age, country, years of education, frailty, average gait speed, and comorbidities.

RESULTS

At baseline, 7396 (39% of the total) participants were prescribed at least one PIM. Compared with those unexposed, participants on a PIM at baseline were at an increased risk of persistent physical disability (adjusted hazard ratio [HR] 1.47, 95% confidence interval [CI] 1.21, 1.80) and hospitalization (adjusted HR 1.26, 95% CI 1.20, 1.32), but had similar rates of disability-free survival (adjusted HR 1.02; 95% CI 0.93, 1.13) and death (adjusted HR 0.92, 95% CI 0.81, 1.05). These effects did not vary by polypharmacy status in interaction analyses. PIMs exposure was associated with higher risk of disability followed by hospitalization (adjusted HR 1.92, 95% CI 1.25, 2.96) as well as vice versa (adjusted HR 1.54, 95% CI 1.15, 2.05). PPIs, anti-psychotics and benzodiazepines, were associated with increased risk of disability.

CONCLUSIONS

PIMs exposure is associated with subsequent increased risk of both incident disability and hospitalization. Increased risk of disability prior to hospitalization suggests that PIMs use may start the disability cascade in healthy older adults. Our findings emphasize the importance of caution when prescribing PIMs to older adults in otherwise good health.

Treatment patterns and out-of-hospital healthcare resource utilisation by patients with advanced cancer living with pain: An analysis from the Stop Cancer PAIN trial

BACKGROUND

About 70% of patients with advanced cancer experience pain. Few studies have investigated the use of healthcare in this population and the relationship between pain intensity and costs.

METHODS

Adults with advanced cancer and scored worst pain ≥ 2/10 on a numeric rating scale (NRS) were recruited from 6 Australian oncology/palliative care outpatient services to the Stop Cancer PAIN trial (08/15-06/19). Out-of-hospital, publicly funded services, prescriptions and costs were estimated for the three months before pain screening. Descriptive statistics summarize the clinico-demographic variables, health services and costs, treatments and pain scores. Relationships with costs were explored using Spearman correlations, Mann-Whitney U and Kruskal-Wallis tests, and a gamma log-link generalized linear model.

RESULTS

Overall, 212 participants had median worst pain scores of five (inter-quartile range 4). The most frequently prescribed medications were opioids (60.1%) and peptic ulcer/gastro-oesophageal reflux disease (GORD) drugs (51.6%). The total average healthcare cost in the three months before the census date was A$6,742 (95% CI $5,637, $7,847), approximately $27,000 annually. Men had higher mean healthcare costs than women, adjusting for age, cancer type and pain levels (men $7,872, women $4,493, p<0.01) and higher expenditure on prescriptions (men $5,559, women $2,034, p<0.01).

CONCLUSIONS

In this population with pain and cancer, there was no clear relationship between healthcare costs and pain severity. These treatment patterns requiring further exploration including the prevalence of peptic ulcer/GORD drugs, and lipid lowering agents and the higher healthcare costs for men.

TRIAL REGISTRATION

ACTRN12615000064505. World Health Organisation unique trial number U1111-1164-4649. Registered 23 January 2015.

Knowledge, attitude, and practices regarding proton pump inhibitors among community pharmacists and pharmacy students

Background

There are concerns about inappropriate use and insufficient knowledge of proton pump inhibitors (PPIs) use among medical staff.

Aims

This study was designed to examine pharmacy students' and community pharmacists' knowledge, attitude, and practices toward PPIs and their relationship with specific sociodemographic characteristics.

Subjects and Methods

This descriptive study was conducted on the pharmacy students (first and last year) at Eastern Mediterranean University and community pharmacists in North Cyprus Data were collected by a validated questionnaire, which assessed knowledge, attitude, and practices regarding PPI use. Students were included without sampling in a volunteer-based manner. Registered community pharmacists were selected randomly.

Results

First-year pharmacy students (n = 77) showed significantly lower knowledge levels than last-year students (12.00 vs. 13.65; P < 0.001); however, there was no significant difference between last-year students (n = 111) and community pharmacists (n = 59). First-year pharmacy students were significantly less aware of PPIs' "dosage and administration" than the other two groups. Last-year students and community pharmacists exhibited significantly higher attitude scores regarding PPI use (24.7 and 24.6 vs. 22.7; P < 0.001). Omeprazole was found to be the most preferred PPI among the three studied populations. Community pharmacists used PPIs mainly to treat acid reflux. Gender, nationality, and pharmacy education program type did not influence pharmacy students' knowledge, attitude, or practices.

Conclusions

There was not a significant difference regarding knowledge and attitude between the last-year pharmacy students and community pharmacists. The practices of community pharmacists were significantly different from the pharmacy students. It was concluded that certain essential topics regarding PPI use should be emphasized in pharmacy education and during pharmacy practice. Further, it is essentially important for community pharmacists to continue their education through training programs after graduation to enhance their knowledge of PPI use.

The impact of tightened prescribing restrictions on proton pump inhibitor use in Australia: An evaluation using interrupted time series analysis

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.

Head of bed elevation to relieve gastroesophageal reflux symptoms: a systematic review

BACKGROUND

Overuse of proton pump inhibitors (PPIs) - frequently used for relieving symptoms of gastroesophageal reflux disease (GORD) - raises long-term safety concerns, warranting evidence-based non-drug interventions. We conducted a systematic review to evaluate the effect of head-of-bed elevation on relieving symptoms of GORD in adults.

METHODS

We included controlled trials comparing the effect of head-of-bed elevation interventions to control in adults with GORD. Two independent reviewers screened articles, extracted data, and assessed quality of included studies. Primary outcomes were changes in GORD symptoms and use of PPIs.

RESULTS

We screened 1206 records; and included five trials (four cross-over and one factorial) comprising 228 patients. All five included trials were judged to be at high-risk of performance bias and four of selection bias. Of five included trials, two used 'bed blocks' under the bed legs; one used 'sleeping on a wedge' pillow, and two used both. High heterogeneity in outcome measures and reported outcomes data precluded meta-analyses. The four studies that reported on GORD symptoms found an improvement among participants in the head-of-bed elevation; a high-quality crossover trial showed a clinical important reduction in symptom scores at 6 weeks (risk ratio of 2.1; 95% CI 1.2 to 3.6). These results are supported by the observed improvement in physiological intra-oesophageal pH measurements.

CONCLUSIONS

Methodological and reporting limitations in available literature preclude definitive recommendations. However, head-of-bed elevation could be still considered as a cheap and safe alternative to drug interventions with unfavourable safety profiles.

PROTOCOL REGISTRATION

Open Science Framework: http://osf.io/2hz3j.