Deprescribing Proton Pump Inhibitors in an Academic, Primary Care Clinic

Abstract

Goals:To reduce the percentage of inappropriately prescribed proton pump inhibitors (PPIs) in patients aged 50 and older from 80% (baseline) to 60% within 12 months in an academic, internal medicine clinic. Background:The use of PPIs has increased drastically worldwide. Internal medicine clinic patients had inappropriate use of PPIs for an average of 4-5 years. Study:A multidisciplinary quality improvement team used the Plan-Do-Study-Act Model of health care improvement and performed a root cause analysis to identify barriers to inappropriate use of PPIs. The outcome measure was the percentage of patients inappropriately prescribed PPI. Process measures were completion rates of PPI risk assessment and esophagogastroduodenoscopy. Interventions included creation of customized electronic health record templates and education to providers and patients. Analysis was performed using monthly statistical process control charts. Results:The average rate of PPI discontinuation was 51.1% (n=92/180), which corresponds to 30.0% inappropriate PPI usage within 12 months. The mean PPI discontinuation rate in the oneyear pre-study, study and 6 months post-study period was 2.0%, 32.0% and 49.7% respectively. The mean esophagogastroduodenoscopy completion rate was 49.8% from the baseline of less than 30%. Conclusions:We achieved a statistically significant and sustainable reduction of inappropriate PPI use to 30% from the baseline rates of 80% and surpassed our goal within 12 months. This quality improvement was unique as no pharmacy personnel were utilized in this process. The

Analysis of deprescription strategies of proton pump inhibitors in primary care: a narrative review

“…Nallapeta et al (Nallapeta, Reynolds and Bakhai, 2020) used the American Gastroenterological Association (AGA) guidelines to identify those patients who were taking PPIs inappropriately. The registry used in this study was the electronic medical record.…”

Effectiveness of a multi-faceted intervention to deprescribe proton pump inhibitors in primary care: protocol for a population-based, pragmatic, cluster-randomized controlled trial

“…In 2017, the multi-faceted Australian national quality improvement programs that also included patient education material contributed to reducing PPI use in older adults by 21% [ 19 ]. In 2020, several interventional cycles in the United-States included patient education pamphlets and discontinued inappropriate chronic PPI use by 30% within 12 months [ 20 ]. Based on these previous studies in Australia, Ireland and United-States, we anticipate that involving patients in the deprescribing process using an education brochure should improve the PPI deprescribing rate.…”

“…Using an intraclass correlation coefficient (ICC) of 0.05 thus lead to an inflation factor of 3.365. Literature data suggested a “natural” PPI deprescribing rate between 2 and 7% in the control arm [ 17 , 20 , 30 ].…”

“…Although some interventions have been developed to promote deprescribing of PPIs among physicians, pharmacist or nurses, they have limited efficacy [ 17 ]. However, multi-faceted interventions that include patients have demonstrated greater success in Australia, the United-States, and Europe [ 18 – 20 ].…”

Patient Awareness of Reported Adverse Effects Associated with Proton Pump Inhibitors in a Medically Underserved Community

“…Rates of inappropriate PPI prescription range from 27 to 81% in hospitalized patients and 36 to 63% in patients in primary care settings [ 14 ]. Multiple strategies have been described to identify PPI overuse and reduce rates of inappropriate prescription, including provider education initiatives and guideline-driven medication review by independent pharmacists and gastroenterologists [ 33 , 34 , 35 ]. While some studies have reported success with such strategies, the role of patient education in reducing inappropriate PPI use has not been fully elucidated.…”