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Low-Value Proton Pump Inhibitor Prescriptions Among Older Adults at a Large Academic Health System.
J Am Geriatr Soc. 2019 12; 67(12):2600-2604.JA

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. J Am Geriatr Soc 67:2600-2604, 2019.

Authors+Show Affiliations

Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California. RAND Corporation, Santa Monica, California.Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California.Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California. RAND Corporation, Santa Monica, California.Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California.Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California.Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California.Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California.Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California.Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California.Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California.RAND Corporation, Santa Monica, California.Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California.Division of Geriatrics, David Geffen School of Medicine at UCLA and Veterans Affairs (VA) Greater Los Angeles Healthcare System Geriatric Research Education and Clinical Center, Los Angeles, California.

Pub Type(s)

Journal Article
Research Support, N.I.H., Extramural

Language

eng

PubMed ID

31486549

Citation

Mafi, John N., et al. "Low-Value Proton Pump Inhibitor Prescriptions Among Older Adults at a Large Academic Health System." Journal of the American Geriatrics Society, vol. 67, no. 12, 2019, pp. 2600-2604.
Mafi JN, May FP, Kahn KL, et al. Low-Value Proton Pump Inhibitor Prescriptions Among Older Adults at a Large Academic Health System. J Am Geriatr Soc. 2019;67(12):2600-2604.
Mafi, J. N., May, F. P., Kahn, K. L., Chong, M., Corona, E., Yang, L., Mongare, M. M., Nair, V., Reynolds, C., Gupta, R., Damberg, C. L., Esrailian, E., & Sarkisian, C. (2019). Low-Value Proton Pump Inhibitor Prescriptions Among Older Adults at a Large Academic Health System. Journal of the American Geriatrics Society, 67(12), 2600-2604. https://doi.org/10.1111/jgs.16117
Mafi JN, et al. Low-Value Proton Pump Inhibitor Prescriptions Among Older Adults at a Large Academic Health System. J Am Geriatr Soc. 2019;67(12):2600-2604. PubMed PMID: 31486549.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Low-Value Proton Pump Inhibitor Prescriptions Among Older Adults at a Large Academic Health System. AU - Mafi,John N, AU - May,Folasade P, AU - Kahn,Katherine L, AU - Chong,Michelle, AU - Corona,Edgar, AU - Yang,Liu, AU - Mongare,Margaret M, AU - Nair,Vishnu, AU - Reynolds,Courtney, AU - Gupta,Reshma, AU - Damberg,Cheryl L, AU - Esrailian,Eric, AU - Sarkisian,Catherine, Y1 - 2019/09/05/ PY - 2019/06/15/received PY - 2019/07/11/revised PY - 2019/07/12/accepted PY - 2019/9/6/pubmed PY - 2020/5/28/medline PY - 2019/9/6/entrez KW - deprescribing KW - geriatrics KW - high-value care KW - quality improvement KW - quality of care SP - 2600 EP - 2604 JF - Journal of the American Geriatrics Society JO - J Am Geriatr Soc VL - 67 IS - 12 N2 - 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. J Am Geriatr Soc 67:2600-2604, 2019. SN - 1532-5415 UR - https://www.unboundmedicine.com/medline/citation/31486549/Low-Value_Proton_Pump_Inhibitor_Prescriptions_Among_Older_Adults_at_a_Large_Academic_Health_System L2 - https://doi.org/10.1111/jgs.16117 DB - PRIME DP - Unbound Medicine ER -