Restricting PPI prescription refills reduced use without noticeable clinical effects

Restrictions on proton-pump inhibitor (PPI) refills for patients without a documented long-term indication were associated with a rapid and sustained 7.3% absolute reduction in such prescriptions—a relative decline of nearly 30%, a Veterans Affairs study found.

A multicomponent pharmacy-based intervention was associated with reduced proton-pump inhibitor (PPI) use overall but also in patients in whom gastroprotection was appropriate, with minimal evidence of either clinical benefits or harms.

To determine how an intervention affected PPI prescribing patterns, health care use, and clinical outcomes among patients receiving primary care from 2009 to 2019, researchers conducted a difference-in-difference study among Veterans Affairs regions, in which one regional network implemented an intervention and all 17 others served as controls. Based on a previous successful project to reduce off-label use of atypical antipsychotics, the intervention limited PPI refills for patients without a documented indication for long-term use, voided PPI prescriptions not recently filled, facilitated electronic prescribing of H2 receptor antagonists, and educated patients and clinicians.

The number of patients analyzed ranged from 192,607 to 250,349 in intervention sites and from 3,775,953 to 4,360,868 in control sites, with 26% of patients receiving PPIs before the intervention. The primary outcome was the percentage of patients who filled a PPI prescription for six months, with secondary outcomes including percentage of days PPI gastroprotection was prescribed in patients at high risk for upper GI bleeding, percentage of patients who filled either a PPI or H2 receptor antagonist prescription, hospital admission for acid peptic disease in older adults in whom PPI gastroprotection was appropriate, primary care visits for an upper GI diagnosis, upper endoscopies, and PPI-associated clinical conditions. Results were published by The BMJ on April 11.

The intervention was associated with an absolute reduction of 7.3% (95% CI, −7.6% to −7.0%) in filling of PPI prescriptions. There was an absolute reduction of 11.3% (95% CI, −12.0% to −10.5%) in PPI use in patients for whom gastroprotection was appropriate and an absolute reduction of 5.72% (95% CI, −6.08% to −5.36%) in the rate of filling a PPI or H2 receptor antagonist prescription. There were no increases in primary care visits for upper GI diagnoses, upper endoscopies, or hospital admissions for acid peptic disease among older patients for whom gastroprotection was appropriate. No clinically significant changes were seen in any PPI-associated clinical conditions such as incident chronic kidney disease or changes in hospital admissions for pneumonia, ischemic stroke, or myocardial infarction.

"This effort to reduce PPI overuse did not lead to increased healthcare resource utilization related to upper gastrointestinal symptoms as assessed by primary care visits with gastrointestinal diagnoses and upper gastrointestinal endoscopies," the study authors wrote. "In addition, the intervention was not associated with the incidence of multiple PPI associated conditions that were examined, except for hip fractures in older patients, for which a 0.018% absolute reduction was found."