Deprescribing of proton pump inhibitors in older patients: A cost-effectiveness analysis

Abstract

Over-prescribing of proton-pump inhibitors (PPIs) is widely observed in older patients. Clinical findings have showed that deprescribing service significantly decreased inappropriate PPIs utilization. We aimed to examine the cost-effectiveness of PPI deprescribing service from the perspective of Hong Kong public healthcare provider. A decision-analytic model was constructed to examine the clinical and economic outcomes of PPI deprescribing service (deprescribing group) and usual care (UC group) in a hypothetical cohort of older PPI-users aged ≥65 years in the ambulatory care setting. The model inputs were retrieved from literature and public data. The model time-frame was one-year. Base-case analysis and sensitivity analysis were performed. Primary model outcomes were direct medical cost and quality-adjusted life-years (QALYs) loss. In base-case analysis, the deprescribing service (versus UC) reduced total direct medical cost by USD235 and saved 0.0249 QALY per PPI user evaluated. The base-case results were robust to variation of all model inputs in one-way sensitivity analysis. In probabilistic sensitivity analysis, the deprescribing group was accepted as cost-effective (versus the UC group) in 100% of the 10,000 Monte Carlo simulations. In conclusion, the PPI deprescribing service saved QALYs and reduced total direct medical cost in older PPIs users, and showed a high probability to be accepted as the cost-effective option from the perspective of public healthcare provider in Hong Kong.

Fig 1. Simplified decision-analytical model of proton pump inhibitor (PPI) deprescribing service versus usual care in older PPIs users.

AE: adverse event; GERD: gastroesophageal reflux disease; H2RAs: Histamine-2 receptor antagonists; PPIs: proton-pump inhibitors.

Fig 2. Tornado diagram of top 5 influential factors in one-way sensitivity analysis on incremental cost-effectiveness ratio (ICER) of the proton pump inhibitors deprescribing service versus usual care.

Fig 3. Scatter plot of the incremental cost against QALY gained by the proton pump inhibitors deprescribing service versus usual care in 10,000 Monte Carlo simulations.