Low‐Value Proton Pump Inhibitor Prescriptions Among Older Adults at a Large Academic Health System

Abstract

BACKGROUND Older adults are particularly vulnerable to complications from proton pump inhibitor (PPI) drugs. We sought to characterize the prevalence of potentially low‐value PPI prescriptions among older adults to inform a quality improvement (QI) intervention. METHODS We created a cohort of patients, aged 65 years or older, receiving primary care at a large academic health system in 2018. We identified patients currently prescribed any PPI using the electronic health record (EHR) medication list (current defined as September 1, 2018). A geriatrician, a gastroenterologist, a QI expert, and two primary care physicians (PCPs) created multidisciplinary PPI appropriateness criteria based on evidenced‐based guidelines. Supervised by a gastroenterologist and PCP, two internal medicine residents conducted manual chart reviews in a random sample of 399 patients prescribed PPIs. We considered prescriptions potentially low value if they lacked a guideline‐based (1) short‐term indication (gastroesophageal reflux disease [GERD]/peptic ulcer disease/Helicobacter pylori gastritis/dyspepsia) or (2) long‐term (>8 weeks) indication (severe/refractory GERD/erosive esophagitis/Barrett esophagus/esophageal adenocarcinoma/esophageal stricture/high gastrointestinal bleeding risk/Zollinger‐Ellison syndrome). We used the Wilson score method to calculate 95% confidence intervals (CIs) on low‐value PPI prescription prevalence. RESULTS Among 69 352 older adults, 8729 (12.6%) were prescribed a PPI. In the sample of 399 patients prescribed PPIs, 63.9% were female; their mean age was 76.2 years, and they were seen by 169 PCPs. Of the 399 prescriptions, 143 (35.8%; 95% CI = 31.3%‐40.7%) were potentially low value—of which 82% began appropriately (eg, GERD) but then continued long term without a guideline‐based indication. Among 169 PCPs, 32 (18.9%) contributed to 59.2% of potentially low‐value prescriptions. CONCLUSION One in eight older adults were prescribed a PPI, and over one‐third of prescriptions were potentially low‐value. Most often, appropriate short‐term prescriptions became potentially low value because they lacked long‐term indications. With most potentially low‐value prescribing concentrated among a small subset of PCPs, interventions targeting them and/or applying EHR‐based automatic stopping rules may protect older adults from harm. J Am Geriatr Soc 67:2600–2604, 2019

Potentially Inappropriate Medication and Associated Factors Among Older Patients with Chronic Coronary Syndrome at Hospital Discharge in Beijing, China

“…54 Long-term use of PPI without a clear indications has been common in older adults. 55 A metaanalysis showed that the non-PPI group was associated with less myocardial infarction recurrence than the clopidogrel supplemented with PPI group. 56 Healthcare providers should be prompted to check and reduce needless use of long-term PPI.…”

An Update on Medication Use in Older Adults: a Narrative Review

“…Appropriate polypharmacy involves the prescribing of appropriate combinations of medications to people with multimorbidity, whilst inappropriate polypharmacy can give rise to potentially inappropriate prescribing and prescribing of potentially inappropriate medications [56,57,64]. Psychotropic polypharmacy remains problematic [65], and polypharmacy can be associated with certain classes of medications, particularly central nervous system (CNS) drugs, anticholinergics, sedatives, and proton pump inhibitors [66][67][68]. Several epidemiological studies have demonstrated that potentially inappropriate prescribing increases with polypharmacy [69][70][71][72][73].…”

Trends in Low-Value Health Service Use and Spending in the US Medicare Fee-for-Service Program, 2014-2018

“… 6 , 7 Nevertheless, despite increasing awareness of low-value care and its associated harms, such care remains a common fixture in US medicine. 6 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 …”