The impact of deprescribing interventions on oral proton pump inhibitor utilisation in a Singapore tertiary hospital: A quality improvement initiative

Abstract

Introduction: Proton pump inhibitors (PPIs) are effective treatments for upper gastrointestinal pathologies and short-term courses are well-tolerated. However, indiscriminate use of PPIs is undesirable due to its potential harms. We implemented a series of deprescribing interventions between 2016 and 2017 to curb PPI overutilisation in our institution. The aim of this study was to evaluate the effectiveness and safety of these interventions. Methods: An institutional PPI deprescribing guide was disseminated by email and educational roadshows were conducted to prescribers. Interrupted time series analysis was used to evaluate the effectiveness of the deprescribing interventions over a 7-year period from 2013 to 2019. To ascertain the safety of PPI deprescribing, we analysed the peptic ulcer disease incidence from 2015 to 2018 and conducted a retrospective chart review of 262 inpatients who were deprescribed PPIs. Results: Following the first intervention, there was a significant decrease in mean oral PPI utilisation by 2,324.46 defined daily doses (DDD) per 1,000 prescriptions (95% confidence interval [CI] -3,542.66, -1,106.26) per month, followed by a month-to-month decrease of 302.61 DDD per 1,000 prescriptions per month thereafter (95% CI -473.95, -131.27). A second targeted educational intervention was only effective in sustaining the decline in the outpatient, but not in the inpatient setting. There were no significant changes in incidence of peptic ulcer disease. In the retrospective chart review, a majority (62.6%) of patients remained deprescribed at 6 months. Conclusion: We observed a sustained decrease in PPI utilisation in our institution for more than 12 months following our educational interventions. Cautious deprescribing of PPIs in eligible candidates was found to be safe with low recurrence rates of upper gastrointestinal events. Keywords: Deprescribing, drug utilisation study, interrupted time series analysis, proton pump inhibitor, quality improvement initiative

Predictors of older patients' willingness to have medications deprescribed: A cross‐sectional study

“…In studies using the PATD or rPATD questionnaires, there is mixed evidence on the associations between certain patients' characteristics and their willingness to have their medications deprescribed. For example, age and willingness to have medications deprescribed were found to be positively associated in four studies, 20,21,29,30 negatively associated in another four studies, 18,19,22,31 and non‐significant in 15 other studies 23–27,32–41 . Among the 21 studies that examined the association between patient willingness to have a medication deprescribed and the number of medications, three found a positive association, 20,22,23 one a negative association, 34 and 17 found no significant association 21,24–27,29,30,32,33,36,37,39,40,42–45 .…”

“…For example, age and willingness to have medications deprescribed were found to be positively associated in four studies, 20,21,29,30 negatively associated in another four studies, 18,19,22,31 and non-significant in 15 other studies. [23][24][25][26][27][32][33][34][35][36][37][38][39][40][41] Among the 21 studies that examined the association between patient willingness to have a medication deprescribed and the number of medications, three found a positive association, 20,22,23 one a negative association, 34 and 17 found no significant association. 21,[24][25][26][27]29,30,32,33,36,37,39,40,[42][43][44][45] These unclear findings support the need for more research on what factors are associated with the patients' willingness to have their medications deprescribed.…”

Outcomes of de‐prescribing proton pump inhibitors during acute admissions in a general medical unit: a pilot study

“…Most published data on PPI de‐prescribing relate to ambulatory or residential care settings 10,12,15 . To our knowledge, only one other study, by Calvo et al ., investigated PPI de‐prescribing during acute hospital admissions 9 .…”

“…Most published data on PPI de-prescribing relate to ambulatory or residential care settings. 10,12,15 To our knowledge, only one other study, by Calvo et al, investigated PPI de-prescribing during acute hospital admissions. 9 This study showed a better de-prescription rate at 3 and 6 months, 75% and 72%, respectively, and a higher patient participation rate of 69%.…”