Lead/Presenter: Jacob Kurlander, COIN - Ann Arbor
All Authors: Kurlander JE (VA Ann Arbor Center for Clinical Management Research), Rubenstein, JH (Veterans Affairs Ann Arbor Center for Clinical Management Research), Richardson, CR (Department of Family Medicine, University of Michigan) Krein, SL (Veterans Affairs Ann Arbor Center for Clinical Management Research) De Vries, R (Department of Learning Health Sciences, University of Michigan) Zikmund-Fisher, B (Department of Health Behavior and Health Education, School of Public Health, University of Michigan) Yang, YX (Department of Medicine, University of Pennsylvania) Laine, L (Veterans Affair Connecticut Healthcare System) Weissman, A (Research Center, American College of Physicians) Saini, SD (Veterans Affairs Ann Arbor Center for Clinical Management Research)
To determine how providers perceive the risks and benefits of proton pump inhibitors (PPIs), and the impact of these perceptions on prescribing, ahead of an upcoming VA nationwide PPI deprescribing program.
We surveyed members of the American College of Physicians' Internal Medicine Insider research panel in 2018. We queried knowledge and perceptions of PPI adverse effects (AEs), and usual practice for PPI management for GERD or prevention of upper gastrointestinal (GI) bleeding at low/moderate/high risk. For the high-risk scenario, we used logistic regression to examine the effects of perceived PPI effectiveness for bleeding prevention, concern about AEs, age, and gender on stopping omeprazole.
Among 440 participants (61% response rate), 64% were male, mean age was 48 years, 72% were general internists, and 1% were gastroenterologists. Seventy percent were somewhat/very concerned about PPI AEs. For 6 of 12 AEs queried, a majority believed PPIs directly increase the risk, most often bone loss or fracture (89%) and C difficile infection (82%). Forty-seven percent believed PPIs are not at all/slightly effective at preventing upper GI bleeding. Respondents were 1.5-2.2 times more likely to recommend stopping PPI when used for bleeding prevention vs. GERD (p < 0.001). In the high-risk scenario, multivariable analysis showed that perceived effectiveness of PPI for bleeding prevention was strongly inversely associated with stopping omeprazole (OR 0.07-0.28 for slightly-very effective, p < 0.005), but concern about AEs had no effect.
Amidst widespread concern about PPIs, internists frequently recommend stopping PPIs when used for GI bleeding prevention, in contradiction to professional guidance statements. Misunderstanding of the substantial evidence of PPI effectiveness for bleeding prevention appears to be a significant contributor to the underuse of PPIs for bleeding prevention.
VA's efforts to reduce PPI overuse must be attentive to the possible unintended consequence of causing inappropriate underuse, which could be a significant patient safety issue.