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

Methods

Study Design and Cohort Selection

We performed a chart review on a subset of older adults prescribed PPIs at UCLA Health in 2018 (Supplementary Figure S1). First, we identified the total cohort of patients, aged 65 years or older, meeting any of the following criteria: (1) two or more UCLA primary care physician (PCP) visits in the past 3 years; (2) one or more UCLA preventive care PCP visits in the past year; or (3) current membership in UCLA's medical group insurance plan. We identified patients currently prescribed any PPI using the electronic health record (EHR) medication list (Supplementary Table S1), with "current" defined as September 1, 2018. We excluded PPIs included historically on the medication list that were prescribed by non-UCLA clinicians or bought over the counter (n = 3317) because our proposed intervention to reduce PPI use will focus on UCLA clinician prescribing.

Because our expected low-value prescription rate was 30% (based on literature[9,10] and an exploratory chart review; data not shown), we determined that a chart review sample size of 357 would ensure an estimate precision of 5% (ie, half width of 95% confidence interval [CI] ≤5%).

Supervised by a board-certified gastroenterologist and general internist, two internal medicine residents performed standardized chart review on a small training set to assess interrater agreement for appropriateness (>90% agreement on the cases is considered excellent agreement).[14] Next, the residents performed the standardized chart review on a random sample of 399 patients from the larger cohort to obtain demographic, clinical, and physician practice data. We also collected information on medication adherence (Supplementary Appendix S1 provides these results).

Appropriateness Measurement

A multidisciplinary committee (geriatrician, gastroenterologist, QI expert, and two general internists) created guideline-based appropriateness criteria based on the American Geriatrics Society Beers Criteria®, American Gastroenterological Association, and American College of Gastroenterology Practice Guidelines.[15–17] The committee reviewed each recommendation and strength of evidence; all recommendations were accepted based on group discussion and consensus. We determined appropriateness by reviewing charts for problem lists, diagnoses, medications, visit notes, and endoscopy reports based on two categories of appropriateness: short-term and long-term PPI prescriptions from January 1, 2013, to March 21, 2019 (Supplementary Table S2). Regarding evidenced-based indications for short-term (≤8 weeks) PPI prescriptions, we looked for gastroesophageal reflux disease (GERD), peptic ulcer disease, Helicobacter pylori gastritis, and dyspepsia diagnoses. Regarding evidenced-based indications for long-term (>8 weeks) PPI prescriptions, we reviewed the chart for erosive esophagitis, refractory/severe GERD, high risk for gastrointestinal (GI) bleeding (eg, on chronic nonsteroidal anti-inflammatory drugs), Barrett esophagus, esophageal stricture, esophageal adenocarcinoma, or Zollinger-Ellison syndrome diagnoses. Reviewers deemed prescriptions lacking evidence-based indications as potentially low value.

Analysis

We performed an exploratory analysis to assess whether any demographic characteristics are associated with potentially low-value prescriptions using χ2 tests and Student t-tests. We also used the Wilson score method to calculate 95% CIs on low-value PPI prescription prevalence. We created histograms of potentially low-value PPI prescription rates among all PPI prescriptions ranked by the patients' primary care practice and the patients' PCP. All analyses were completed using SAS, version 9.4 (SAS Institute Inc). The UCLA Health Institutional Review Board approved this retrospective QI study.

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