Passing the acid test? Evaluating the impact of national education initiatives to reduce proton pump inhibitor use in Australia

Abstract

BackgroundProton pump inhibitor (PPI) use is widespread. There have been increasing concerns about overuse of high-dose PPIs for durations longer than clinically necessary.ObjectiveTo evaluate the impact of national education initiatives on reducing PPI use in Australia.DesignPopulation-based, controlled interrupted time series analysis of PPI dispensing claims data for Australian adults from July 2012 to June 2018; we used statin dispensing as a control.InterventionsA year-long educational initiative led by NPS MedicineWise (previously the National Prescribing Service) from April 2015. Simultaneously, Choosing Wisely released recommendations in April 2015 and May 2016. Both promoted review of prolonged PPI use and encouraged stepping down or ceasing treatment, where appropriate.MeasurementsWe examined monthly changes in PPI (and statin) dispensing (stratified by high, standard and low tablet strength), rates of switching from higher to lower strength PPIs and rates of PPI (and statin) discontinuation.ResultsWe observed 12 040 021 PPI dispensings to 579 594 people. We observed a sustained −1.7% (95% CI: −2.7 to −0.7%) decline in monthly dispensing of standard strength PPIs following the initiatives until the end of the study period. There were no significant changes in high or low strength PPI (or statin) dispensings, switching to lower strength PPIs, or PPI (and statin) treatment discontinuation.ConclusionOur findings suggest that these educational initiatives alone were insufficient in curbing overuse of PPIs on a national level. Concerted efforts with policy levers such as imposing tighter restrictions on subsidised use of PPIs may be more effective. Noting low strength esomeprazole is not publicly subsidised in Australia, availability of these preparations may also facilitate more appropriate practice

Long-term use of proton-pump inhibitors: whole-of-population patterns in Australia 2013–2016

“…Previous research from Australia has reported mixed impacts of deprescribing initiatives and it is unclear why the growth in PPI use has slowed. 33,34 These prevalence figures are slightly below that reported in the Icelandic population 14 and estimated in the UK population, 1 but nearly double that reported in the Danish population. 2 Similar to these population based studies, we found that more females used and initiated PPIs than males.…”

“…We used the Australian Bureau of Statistics' mid-year population estimate for Australia on June of the financial year as the denominator for both measures. 31 We stratified prevalence and incidence estimates by sex and age groups (18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46)(47)(48)(49), 50-64, 65-74, 75-84 and 85 years and older). We further stratified prevalence and incidence estimates by PPI medicine strength -standard strength, high strength and low strength (Table 1).…”

Education as a low-value improvement intervention: often necessary but rarely sufficient

“…[16][17][18] In this issue of BMJ Quality and Safety, Bruno and colleagues examined the impact of a national educational intervention aimed at reducing outpatient PPI prescriptions in Australia. 19 Australia's NPS MedicineWise (previously the National Prescribing Service) developed the study intervention released in association with Choosing Wisely Australia's similar educational materials and alerts highlighting the importance of reducing or ceasing PPI prescribing in the absence of specific indications. The programme began with mailings to general practitioners (GPs) showing data about their own PPI prescribing compared with other GPs nationwide.…”

The Use and Misuse of Proton Pump Inhibitors: An Opportunity for Deprescribing

“…60 Although education is helpful, a national Australian study suggested that imposing restrictions on subsidized use of PPIs is even more effective. 49 One concern is the PPI-induced gastrin elevation secondary to hypoacidity and the subsequent hypergastrinemia-related rebound hyperacidity and dyspeptic symptoms following discontinuation of the PPI; the long-term gastrin elevation may have carcinogenic effects, raising concerns about consensus for deprescribing strategies. 61…”