De-Prescribing Intervention Reduced Overuse of Proton Pump Inhibitors Among Veterans
BACKGROUND:
Proton pump inhibitors (PPIs) such as Prilosec (omeprazole), Protonix (pantoprazole), and Nexium (esomeprazole) are among the most prescribed medications in the U.S. PPIs are frequently used by patients without an appropriate indication, increasing healthcare costs and pill burden. Further, their long-term use has been associated with increased risk for serious medical conditions such as pneumonia, bone fracture, chronic kidney disease, and even death from cardiovascular disease. However, there is only indirect evidence of a causal link between PPIs and these outcomes, and it is unknown if de-prescribing these medications improves health outcomes. This study (February 2009–January 2019) determined how a large-scale pharmacy-based intervention to reduce PPI overuse in VISN 17 affected prescribing patterns, healthcare utilization, and clinical outcomes compared to patients in all other VISNs, who served as controls. The VISN 17 intervention, which started in 2013, restricted PPI refills, voided inactive prescriptions, facilitated prescribing of a non-PPI acid blocking medication to help with PPI tapering, and provided Veteran and clinician education. Researchers included all Veterans who had ≥2 VA primary care visits in the preceding two years and used data from VA and CMS. The primary outcome was the percentage of Veterans who filled a PPI prescription per six months. Secondary outcomes included PPI use in Veterans at high risk for upper gastrointestinal (GI) bleeding, healthcare utilization, and PPI-associated clinical conditions. The number of Veterans analyzed per interval ranged from 192,607 to 250,349 in VISN 17, and 3,775,953 to 4,360,868 in the control VISNs, with 26% of Veterans receiving PPIs pre-intervention.
FINDINGS:
- The intervention was associated with a rapid and sustained 7% absolute reduction in Veterans receiving PPI prescriptions—a relative decline of nearly 30%.
- The intervention was also associated with an 11% reduction in PPI use among Veterans at high risk for upper GI bleeding, in whom PPIs are guideline-recommended (unintended de-prescribing). However, there was no increase seen in primary care visits for upper GI diagnoses, upper endoscopies, or hospital admissions for acid peptic disease in these patients.
IMPLICATIONS:
- This intervention’s primary benefits are likely to be reduced pill burden for Veterans and reduced drug costs for health systems. A budget impact analysis by the same team (unpublished) found that, if implemented nationwide, the intervention would have reduced spending on PPIs by up to $328 million over 4.5 years.
LIMITATIONS:
- Some VISN 17 Veterans might have shifted to buying PPIs outside of VA after the PPI overuse initiative started, which would have attenuated the true effect of the intervention.
AUTHOR/FUNDING INFORMATION:
HSR funded this study. Drs. Kurlander and Kim are part of HSR’s Center for Clinical Management Research (CCMR).
Kurlander JE, Laine L, Kim HM, et al. Impact of Large-Scale, Multicomponent Intervention to Reduce Proton Pump Inhibitor Overuse in Integrated Healthcare System: Difference-In-Difference Study. BMJ. April 11, 2024;385:e076484.
