John N Mafi1,2, Folasade P May3, Katherine L Kahn1,2, Michelle Chong4, Edgar Corona3, Liu Yang3, Margaret M Mongare4, Vishnu Nair4, Courtney Reynolds3, Reshma Gupta1, Cheryl L Damberg2, Eric Esrailian3, Catherine Sarkisian5. 1. Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California. 2. RAND Corporation, Santa Monica, California. 3. Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California. 4. Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California. 5. 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.
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.
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: Mitesh S Patel; Susan C Day; Scott D Halpern; C William Hanson; Joseph R Martinez; Steven Honeywell; Kevin G Volpp Journal: JAMA Intern Med Date: 2016-06-01 Impact factor: 21.873
Authors: John N Mafi; Kyle Russell; Beth A Bortz; Marcos Dachary; William A Hazel; A Mark Fendrick Journal: Health Aff (Millwood) Date: 2017-10-01 Impact factor: 6.301
Authors: Taline A Boghossian; Farah Joy Rashid; Wade Thompson; Vivian Welch; Paul Moayyedi; Carlos Rojas-Fernandez; Kevin Pottie; Barbara Farrell Journal: Cochrane Database Syst Rev Date: 2017-03-16
Authors: John N Mafi; Rachel O Reid; Lesley H Baseman; Scot Hickey; Mark Totten; Denis Agniel; A Mark Fendrick; Catherine Sarkisian; Cheryl L Damberg Journal: JAMA Netw Open Date: 2021-02-01
Authors: Jacob E Kurlander; Joel H Rubenstein; Caroline R Richardson; Sarah L Krein; Raymond De Vries; Brian J Zikmund-Fisher; Yu-Xiao Yang; Loren Laine; Arlene Weissman; Sameer D Saini Journal: Am J Gastroenterol Date: 2020-05 Impact factor: 12.045