Passive ‘Choosing Wisely’ advice fails to curb PPI overuse

GI tract

By Michael Woodhead

31 Oct 2019

Stricter curbs on proton pump inhibitor use may be needed because ‘passive’ interventions by GESA and NPS MedicineWise have failed to curb widespread overuse, researchers say.

Simply disseminating advice and information through Choosing Wisely recommendations has had only minimal impact of prescribing of PPIs since 2015, according to a new analysis.

In a study published in BMJ Quality & Safety, NSW researchers described how PBS data from 2012 to 2018 were used to assess the before and after trends in PPI use around a year-long educational initiative led by NPS MedicineWise from April 2015 and Choosing Wisely recommendations released in 2015/2016 by GESA and the RACGP.

One of GESA’s five Choosing Wisely recommendations was: “Do not use PPIs long-term in patients with uncomplicated disease without regular attempts at reducing dose or ceasing.”

Similarly the RACGP advised GPs not to continue prescribing long-term PPI medication to patients “without attempting to reduce the medication down to the lowest effective dose or cease the therapy altogether.”

However the campaigns resulted in only a 1.7% decrease in monthly PBS dispensing of standard dose PPIs, and no change in dispensing of high dose or low dose PPIs.

Similarly there was no change in the rates of switching to lower PPI strengths or discontinuation rates for PPI treatment.

Study author Claudia Bruno, from UNSW Medicine’s Centre for Big Data Research in Health,  said experience with previous ‘deprescribing’ campaigns in areas such as antibiotic prescribing showed that  ‘active’ interventions such as face-to-face doctor visits were needed to change prescribing behaviour.

“We had no expectations of large-scale, national change because the campaigns we studied mostly disseminated the information. This is necessary to drive change, but generally successful interventions have more active measures including educational visits to doctors,” she said.

The PPI de-escalation initiative may also have been doomed to fail because they were not supported by PBS prescribing criteria in place at the time, she added.

“Until May 2019, the PBS PPI restrictions did not align with treatment guidelines, [and] this may have undermined the efforts of the national initiatives under study,” she wrote.

“Additionally, esomeprazole is the most commonly prescribed PPI in Australia, but interestingly no low strength formulation (ie, 10 mg tablets) of this PPI is publicly subsidised, with only 10 mg sachets available on the Australian market. We observed very few step-down attempts from standard strength esomeprazole in our data, indicating that the absence of a low strength esomeprazole may have discouraged the step down of PPIs to the lowest effective dose and potentially diminished the impact of the initiatives on low strength PPI uptake.”

She said imposing tighter restrictions on subsidised use of PPIs may be more effective in discouraging overuse, and the effects of recent restrictions should be monitored.

According to NPS MedicineWise, the May 2019 restrictions on PPIs included:

  • Terminology for PPI doses changed from highest, high and low, to high, standard and low.
  • Restriction level for esomeprazole 40 mg (1 repeat) increased from Restricted Benefit to Authority Required (Telephone).
  • Restriction levels for all standard dose PPIs increased from Restricted Benefit to Authority Required (Streamlined).
  • New item numbers added for standard dose PPIs for long-term maintenance treatment of GORD in patients with symptoms inadequately controlled by a low dose PPI.
  • GORD indication  removed from item numbers for standard dose PPIs used to treat patients with other gastrointestinal acid-related disorders.

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