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

John N. Mafi, MD, MPH; Folasade P. May, MD, PhD; Katherine L. Kahn, MD, MPH; Michelle Chong, MD; Edgar Corona, MPH; Liu Yang, MD, MPH; Margaret M. Mongare, MD; Vishnu Nair, BS; Courtney Reynolds, MD, PhD; Reshma Gupta, MD, MHPM; Cheryl L. Damberg, PhD; Eric Esrailian, MD; Catherine Sarkisian, MD, MSPH

Disclosures

J Am Geriatr Soc. 2019;67(12):2600-2604. 

In This Article

Abstract and Introduction

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.

Introduction

Proton pump inhibitor (PPI) drugs are associated with complications, such as Clostridioides difficile infections or kidney toxicity, and older adults are particularly vulnerable to such adverse events.[1–6] Moreover, PPIs contribute to polypharmacy, prescription drug costs, and aging-related complications (eg, osteoporotic fractures).[7,8]

Despite these harms, many PPI prescriptions are potentially low value, meaning they lack an evidenced-based indication.[9,10] Promisingly, six randomized PPI deintensification trials in a meta-analysis found that deprescribing can reduce PPI use and pill burden.[11] Other well-designed quality improvement (QI) studies attempting to reduce potentially low-value PPI prescriptions have found mixed results[12,13] and importantly none of the six randomized trials were conducted among older Americans.

We sought to characterize the prevalence of potentially low-value PPI prescriptions among older adults at the University of California, Los Angeles (UCLA) Health, a large academic health system, to inform a randomized QI intervention.

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