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Current Practices of Proton-Pump Inhibitor Prescribing in a Large Resident-Run Ambulatory Setting: Targets for Intervention


Louissaint, Jeremy MD; Sninsky, Jared MD; Ciesielski, Thomas MD

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American Journal of Gastroenterology: October 2018 - Volume 113 - Issue - p S656
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Introduction: Gastroesophageal Reflux Disease (GERD) is the most common gastrointestinal diagnosis in the ambulatory setting. The prevalence of GERD has been estimated to be at least 10-15%. As the frequency of GERD diagnoses increases, so too has the use of acid reducing agents; notably, proton pump inhibitors (PPIs). Coupled with a large cost burden are several possible diseases associated with long-term PPI use, including chronic kidney disease, bone disease, and possibly cardiac disease. The American College of Gastroenterology recommends an eight-week course of once-daily PPI treatment for symptomatic GERD followed by a trial of discontinuation in those with uncomplicated GERD who have achieved symptom relief.

Methods: This retrospective study was performed using patient data from a medicine resident ambulatory clinic database. Inclusion criteria: age > 18 years, ICD-9 or ICD-10 codes for GERD, first prescription of PPI occurring between 6/21/2015 to 6/21/2017, and prescribing primary care physician an internal medicine resident. Chart review was conducted to exclude patients with endoscopic findings or recommendations for PPI therapy (including esophagitis, gastritis, PUD, bleeding), H. pylori, and a prior history of PPI use. Nominal data was compared using Chi-Square tests and ordinal data was computed using Student's t-tests.

Results: A total of 175 patients met full inclusion criteria with baseline characteristics listed in Table 1. The average length of the first PPI prescription was 5.84 months with 20 (11.4%) patients receiving a twice-daily prescription. There was no significant difference in months prescribed between postgraduate years one and two, one and three, and two and three with p = 0.126, p= 0.386, and p = 0.546, respectively. There were 25 patients given an initial prescription for two months or less; however, only 11 (44%) had documentation that the short course was a trial for symptomatic improvement.

Conclusion: In this study using the first prescription length as a surrogate of adherence to ACG PPI prescribing guidelines, we have illustrated a wide deviation from the recommended 8-week trial. Low familiarity with ACG guidelines likely explains prolonged PPI use, which increases cost, pill burden, and risk of conditions potentially associated with long-term PPI use. Prospective studies evaluating the impact of physician education regarding these guidelines may serve to reduce the first prescription length and lead to structured attempts at PPI deprescribing.

1143_A Figure 1. Baseline characteristics of patient population and year of prescribing residents
1143_B Figure 2. Frequency of initial prescription length of PPIs by internal medicine residents
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