Passing the acid test? Evaluating the impact of national education initiatives to reduce proton pump inhibitor use in Australia

Abstract

Background: Proton pump inhibitor (PPI) use is widespread. There have been increasing concerns about overuse of high-dose PPIs for durations longer than clinically necessary.

Objective: To evaluate the impact of national education initiatives on reducing PPI use in Australia.

Design: Population-based, controlled interrupted time series analysis of PPI dispensing claims data for Australian adults from July 2012 to June 2018; we used statin dispensing as a control.

Interventions: A year-long educational initiative led by NPS MedicineWise (previously the National Prescribing Service) from April 2015. Simultaneously, Choosing Wisely released recommendations in April 2015 and May 2016. Both promoted review of prolonged PPI use and encouraged stepping down or ceasing treatment, where appropriate.

Measurements: We examined monthly changes in PPI (and statin) dispensing (stratified by high, standard and low tablet strength), rates of switching from higher to lower strength PPIs and rates of PPI (and statin) discontinuation.

Results: We observed 12 040 021 PPI dispensings to 579 594 people. We observed a sustained -1.7% (95% CI: -2.7 to -0.7%) decline in monthly dispensing of standard strength PPIs following the initiatives until the end of the study period. There were no significant changes in high or low strength PPI (or statin) dispensings, switching to lower strength PPIs, or PPI (and statin) treatment discontinuation.

Conclusion: Our findings suggest that these educational initiatives alone were insufficient in curbing overuse of PPIs on a national level. Concerted efforts with policy levers such as imposing tighter restrictions on subsidised use of PPIs may be more effective. Noting low strength esomeprazole is not publicly subsidised in Australia, availability of these preparations may also facilitate more appropriate practice.

Keywords: health policy; health services research; healthcare quality improvement; pharmacoepidemiology.

Figure 1

(A) Monthly unadjusted and seasonally adjusted (dashed line) dispensing counts of PPIs and statins; (B) dispensing counts of PPIs by strength: high, standard and low, from July 2012 to June 2018. NPS MedicineWise’s PPI program start and end and Choosing Wisely Australia recommendations 1 and 2 marked at April 2015 and may 2016. Standard strength PPI esomeprazole was made available over the counter in February 2016. PPIs, proton pump inhibitors

Figure 2

(A) Monthly unadjusted and seasonally adjusted (dashed line) rate (%) of PPI and statin discontinuation among those covered by treatment; (B) rate of switching to a lower strength PPI among those dispensed standard or high strength PPIs each month, from January 2013 to May 2018. NPS MedicineWise’s PPI program start and end and Choosing Wisely Australia recommendations 1 and 2 marked at April 2015 and May 2016. Standard strength PPI esomeprazole was made available over the counter in February 2016. PPI, proton pump inhibitor.

Figure 3

(A) Monthly unadjusted and seasonally adjusted (dashed line) concessional beneficiaries’ dispensing counts of PPIs and statins (B) concessional beneficiaries’ dispensing counts of PPIs by strength: high, standard and low, from July 2012 to May 2018. NPS MedicineWise’s PPI programme start and end and Choosing Wisely Australia recommendations 1 and 2 marked at April 2015 and May 2016. Standard strength PPI esomeprazole was made available over the counter in February 2016. PPI, proton pump inhibitors.