Study Examines Possible Overuse of Proton Pump Inhibitors to Treat Veterans with Gastroesophageal Reflux Disease
Proton pump inhibitors (PPIs) are the mainstay of treatment for gastroesophageal reflux disease (GERD) and account for more than 50% of prescriptions for all digestive diseases, resulting in more than $11 billion in annual direct healthcare costs in the U.S. In the case of persistent symptoms despite empiric and escalated PPI therapy, efforts should be made to evaluate other potential causes of symptoms and alternative approaches to therapy. Long-term use should be titrated to the lowest effective dose to control symptoms. This approach is recommended by both the American Board of Internal Medicine and the American Gastroenterology Association in order to reduce potential risks and side effects of PPIs. This study sought to determine how PPIs are initially prescribed for Veterans diagnosed with GERD — and to characterize subsequent PPI use over two years after the initial prescription. Using VA administrative data, investigators identified 1,621 Veterans who had received a diagnosis of GERD as an outpatient at one VAMC from 2003 to 2007, and who also had received a new PPI prescription within 30 days of the diagnosis. Investigators examined PPI dosage (standard vs. high daily dose) and refill data during the two years after initial prescriptions. Evidence of step-up and step-down therapy was determined by evaluating changes in total daily doses for Veterans with at least one refilled prescription of the same PPI.
- Many Veterans received high total daily dose PPI prescriptions as initial therapy for GERD, but few patients had evidence of cessation or reduction of therapy.
- Of the Veterans in this study, 378 (23%) had high daily dose initial PPI prescriptions, and 1,243 (77%) had standard daily dose initial prescriptions.
- The majority of Veterans (66%) received a 90-day or greater initial prescription. Over two years, 13% of patients with initial standard daily dose prescriptions had evidence of step-up therapy. Only 7% of patients with initial high daily dose prescriptions had evidence of step-down therapy.
- The authors suggest that efforts should be made to ensure that VA providers prescribe the minimum effective PPI dose and prevent unnecessary PPI prescriptions. This could include decision support in the electronic health record via automatic alerts, as well as the need for justification when physicians attempt to prescribe high daily doses of PPIs.
- Results rely on administrative data from one VAMC.
- Veterans were identified as having GERD using ICD-9 codes, which may have been inaccurate due to symptoms that are sometimes attributed incorrectly to GERD.
This study was funded by HSR&D. Drs. Gawron and LaVela and Mr. Miskevics are part of HSR&D's Center for Management of Complex Chronic Care located in Hines, IL.
Gawron A, Pandolfino J, Miskevics S, and LaVela S. Proton Pump Inhibitor Prescriptions and Subsequent Use in U.S. Veterans Diagnosed with Gastroesophageal Reflux Disease. Journal of General Internal Medicine February 12, 2013;Epub ahead of print.