Research

Impact of large scale, multicomponent intervention to reduce proton pump inhibitor overuse in integrated healthcare system: difference-in-difference study

Jacob E Kurlander, Loren Laine, Hyungjin Myra Kim, et al

BMJ 2024; 385 doi: https://doi.org/10.1136/bmj-2023-076484 (Published 11 April 2024)Cite this as: BMJ 2024;385:e076484

Abstract

Objective To determine how a large scale, multicomponent, pharmacy based intervention to reduce proton pump inhibitor (PPI) overuse affected prescribing patterns, healthcare utilization, and clinical outcomes.

Design Difference-in-difference study.

Setting US Veterans Affairs Healthcare System, in which one regional network implemented the overuse intervention and all 17 others served as controls.

Participants All individuals receiving primary care from 2009 to 2019.

Intervention Limits on PPI refills for patients without a documented indication for long term use, voiding of PPI prescriptions not recently filled, facilitated electronic prescribing of H2 receptor antagonists, and education for patients and clinicians.

Main outcome measures The primary outcome was the percentage of patients who filled a PPI prescription per 6 months. Secondary outcomes included percentage of days PPI gastroprotection was prescribed in patients at high risk for upper gastrointestinal bleeding, percentage of patients who filled either a PPI or H2 receptor antagonist prescription, hospital admission for acid peptic disease in older adults appropriate for PPI gastroprotection, primary care visits for an upper gastrointestinal diagnosis, upper endoscopies, and PPI associated clinical conditions.

Results The number of patients analyzed per interval 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 intervention was associated with an absolute reduction of 7.3% (95% confidence interval −7.6% to −7.0%) in patients who filled PPI prescriptions, an absolute reduction of 11.3% (−12.0% to −10.5%) in PPI use among patients appropriate for gastroprotection, and an absolute reduction of 5.72% (−6.08% to −5.36%) in patients who filled a PPI or H2 receptor antagonist prescription. No increases were seen in primary care visits for upper gastrointestinal diagnoses, upper endoscopies, or hospital admissions for acid peptic disease in older patients appropriate for gastroprotection. No clinically significant changes were seen in any PPI associated clinical conditions.

Conclusions The multicomponent intervention was associated with reduced PPI use overall but also in patients appropriate for gastroprotection, with minimal evidence of either clinical benefits or harms.