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

Discussion

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[18] and/or applying EHR-based automatic stopping rules may protect older adults from harm.

Our results are concordant with prior studies assessing the rate of potentially low-value PPI prescriptions among older adults (range = 20%-40%).[9,10] Previous research highlights inpatient prescriptions as a major source of potentially low-value PPI prescriptions,[19] suggesting that this is a major problem for post–acute care and primary care providers who are trying to determine if and when the PPI can be discontinued and is a major reason for ongoing low-value use. This work also suggests that requiring indications on post-acute care transfer forms could curb potentially low-value PPI prescriptions.

Our study adds to the literature by focusing on clinician-level performance data as a means for targeted QI as well as highlighting the dynamic nature of low-value care. For example, because most potentially low-value prescriptions began appropriately but then continue without an indication, an EHR choice architecture automatically defaulting prescriptions to the lowest dose, 8 weeks' duration, and no refills could reduce needless long-term PPIs with minimal clinical workflow disruption.[20] However, these defaults may inadvertently stop necessary PPIs if they lack clinical nuance.[21,22] Therefore, the EHR defaults must be targeted precisely for low-value prescriptions to avoid unintended consequences, such as GI bleeding, that might have been prevented by PPIs.[22,23]

This study has important limitations. First, findings from this single-institution study may not generalize to other health systems. Second, the lack of a documented indication does not exclude the possibility that there was an undocumented evidenced-based indication. Prompting clinicians to document an indication for long-term prescriptions can mitigate this clinical uncertainty while simultaneously improving documentation and the quality of care.[12,24]

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