Proton Pump Inhibitor Prescriptions and Subsequent Use in US Veterans Diagnosed with Gastroesophageal Reflux Disease

ABSTRACT

BACKGROUND

Empiric proton pump inhibitor use is common for gastroesophageal reflux disease (GERD), but initial proton pump inhibitor (PPI) prescription patterns in Veterans are unknown.

OBJECTIVE

The study aims were to determine initial PPI prescriptions in Veterans diagnosed with GERD, and to characterize subsequent PPI use over the 2 years following initial prescription.

DESIGN

We conducted a retrospective study using Veteran’s Administration (VA) administrative data and chart review.

STUDY POPULATION

Patients diagnosed with GERD and provided an initial PPI prescription at Hines VA Hospital from 2003 to 2007, with 2 year follow-up for each patient (through 2009).

MEASURES and OUTCOMES

Initial PPI prescriptions were categorized as standard total daily dose or high total daily dose, and accuracy was confirmed by manual chart review. Descriptive statistics were calculated and bivariate analyses were used to assess for differences in demographics, prescriptions, and subsequent use by initial PPI dosage category.

RESULTS

Of the 1,621 patients included in the study, 378 (23.3 %) had high total daily dose initial PPI prescriptions and 1,243 (76.7 %) patients had standard total daily dose initial prescriptions. The majority of patients (65.8 %) received a 90-day or greater initial prescription. Over the 2 years following the initial PPI prescription, 13.0 % of patients with initial standard daily dose prescriptions had evidence of step-up therapy. Only 7.1 % of patients with initial high daily dose PPI prescriptions had evidence of step-down therapy. A large majority of patients (83.8 %) had at least one refill over 2 years, and the overall medication possession ratio was 0.86.

CONCLUSIONS

Many Veterans receive high total daily dose PPI prescriptions as initial therapy for a GERD diagnosis, and few patients have evidence for cessation or reduction of therapy. These results provide detailed data on prescribing and use of PPIs to help guide efforts for optimal PPI use in US Veterans.

This is a preview of subscription content, access via your institution.

Figure 1.

Abbreviations

GERD:

Gastroesophageal reflux disease

PPI:

Proton pump inhibitor

H2RA:

Histamine receptor 2 antagonists

VA:

Veteran’s administration

NSAID:

Non-steroidal anti-inflammatory drug

DSS:

Decision support system

NDE:

National data extracts

MPR:

Medication possession ratio

CCR:

Computerized clinical reminders

ABIM:

American Board of Internal Medicine

AGA:

American Gastroenterology Association

REFERENCES

  1. 1.

    Everhart JE, Ruhl CE. Burden of digestive diseases in the United States part I: overall and upper gastrointestinal diseases. Gastroenterol. 2009;136:376–386.

    Article  Google Scholar 

  2. 2.

    Caro JJ, Salas M, Ward A. Healing and Relapse Rates in Gastroesophageal Reflux Disease Treated with the Newer Proton-Pump Inhibitors Lansoprazole, Rabeprazole, and Pantoprazole Compared with Omeprazole, Ranitidine, and Placebo: Evidence from Randomized Clinical Trials. Clin Ther. 2001;23:998–1017.

    PubMed  Article  CAS  Google Scholar 

  3. 3.

    Weijenborg PW, Cremonini F, Smout AJ, et al. PPI therapy is equally effective in well-defined non-erosive reflux disease and in reflux esophagitis: a meta-analysis. Neurogastroenterol Motil. 2012;24:747–57.

    PubMed  Article  CAS  Google Scholar 

  4. 4.

    Kahrilas PJ, Shaheen NJ, Vaezi MF, et al. American Gastroenterological Association Medical Position Statement on the management of gastroesophageal reflux disease. Gastroenterol. 2008;135:1383–1391.

    Article  Google Scholar 

  5. 5.

    Heidelbaugh JJ, Goldberg KL, Inadomi JM, Suppl. Overutilization of proton pump inhibitors: a review of cost-effectiveness and risk [corrected]. Am J Gastroenterol. 2009;104(Suppl):S27–32.

    PubMed  Article  CAS  Google Scholar 

  6. 6.

    Naunton M, Peterson GM, Bleasel MD. Overuse of proton pump inhibitors. J Clin Pharm Ther. 2000;25:333–340.

    PubMed  Article  CAS  Google Scholar 

  7. 7.

    Heidelbaugh JJ, Goldberg KL, Inadomi JM. Magnitude and economic effect of overuse of antisecretory therapy in the ambulatory care setting. Am J Manag Care. 2010;16:e228–34.

    PubMed  Google Scholar 

  8. 8.

    Linsky A, Gupta K, Lawler EV, et al. Proton pump inhibitors and risk for recurrent Clostridium difficile infection. Arch Intern Med. 2010;170:772–778.

    PubMed  Article  Google Scholar 

  9. 9.

    Howell MD, Novack V, Grgurich P, et al. Iatrogenic gastric acid suppression and the risk of nosocomial Clostridium difficile infection. Arch Intern Med. 2010;170:784–90.

    PubMed  Article  Google Scholar 

  10. 10.

    Gray SL, LaCroix AZ, Larson J, et al. Proton pump inhibitor use, hip fracture, and change in bone mineral density in postmenopausal women: results from the Women’s Health Initiative. Arch Intern Med. 2010;170:765–771.

    PubMed  Article  Google Scholar 

  11. 11.

    Kahrilas P. Clinical practice. Gastroesophageal reflux disease. N Engl J Med. 2008;359:1700–1707.

    PubMed  Article  CAS  Google Scholar 

  12. 12.

    American Gastroenterological Association. Choosing Wisely: Five Things Physicians and Patients Should Question. 2012. Available at: http://www.choosingwisely.org/ [Accessed April 6, 2012].

  13. 13.

    Pandolfino JE, Vela MF. Esophageal-reflux monitoring. Gastrointest Endosc. 2009;69:917–30. 930 e1.

    PubMed  Article  Google Scholar 

  14. 14.

    George CJ, Korc B, Ross JS. Appropriate proton pump inhibitor use among older adults: a retrospective chart review. Am J Geriatr Pharmacother. 2008;6:249–254.

    PubMed  Article  CAS  Google Scholar 

  15. 15.

    Heidelbaugh JJ, Inadomi JM. Magnitude and economic impact of inappropriate use of stress ulcer prophylaxis in non-ICU hospitalized patients. Am J Gastroenterol. 2006;101:2200–2205.

    PubMed  Article  Google Scholar 

  16. 16.

    Bradley MC, Fahey T, Cahir C, et al. Potentially inappropriate prescribing and cost outcomes for older people: a cross-sectional study using the Northern Ireland Enhanced Prescribing Database. Eur J Clin Pharmacol 2012.

  17. 17.

    Hollingworth S, Duncan EL, Martin JH. Marked increase in proton pump inhibitors use in Australia. Pharmacoepidemiol Drug Saf. 2010;19:1019–1024.

    PubMed  Article  Google Scholar 

  18. 18.

    Gosselin A, Luo R, Lohoues H, et al. The impact of proton pump inhibitor compliance on health-care resource utilization and costs in patients with gastroesophageal reflux disease. Value Health. 2009;12:34–39.

    PubMed  Article  Google Scholar 

  19. 19.

    Hungin APS, Hill C, Molloy-Bland M, et al. Systematic review: Patterns of proton pump inhibitor use and adherence in gastroesophageal reflux disease. Clin Gastroenterol Hepatol. 2012;10:109–16.

    PubMed  Article  Google Scholar 

  20. 20.

    Pillans PI, Kubler PA, Radford JM, et al. Concordance between use of proton pump inhibitors and prescribing guidelines. Med J Aust. 2000;172:16–18.

    PubMed  CAS  Google Scholar 

  21. 21.

    Abraham NS, Hartman C, Castillo D, et al. Effectiveness of national provider prescription of PPI gastroprotection among elderly NSAID users. Am J Gastroenterol. 2008;103:323–32.

    PubMed  Article  Google Scholar 

  22. 22.

    El-Serag HB, Wieman M, Richardson P. The use of acid-decreasing medication in veteran patients with gastro-oesophageal reflux disorder with and without Barrett’s oesophagus. Aliment Pharmacol Ther. 2008;27:1293–1299.

    PubMed  Article  CAS  Google Scholar 

  23. 23.

    El-Serag HB. Temporal trends in new and recurrent esophageal strictures in Department of Veterans Affairs. Am J Gastroenterol. 2006;101:1727–33.

    PubMed  Article  Google Scholar 

  24. 24.

    Yang Y-X, Lewis JD, Epstein S, et al. Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA. 2006;296:2947–53.

    PubMed  Article  CAS  Google Scholar 

  25. 25.

    Ngamruengphong S, Leontiadis GI, Radhi S, et al. Proton pump inhibitors and risk of fracture: a systematic review and meta-analysis of observational studies. Am J Gastroenterol. 2011;106:1209–18. quiz 1219.

    PubMed  Article  CAS  Google Scholar 

  26. 26.

    Abraham NS, El-Serag HB, Johnson ML, et al. National adherence to evidence-based guidelines for the prescription of nonsteroidal anti-inflammatory drugs. Gastroenterol. 2005;129:1171–1178.

    Article  Google Scholar 

  27. 27.

    Gurbel PA, Tantry US. Antiplatelet therapy: Clopidogrel-PPI interaction, an ongoing controversy. Nat Rev Cardiol. 2011;8:7–8.

    PubMed  Article  CAS  Google Scholar 

  28. 28.

    Van Soest EM, Siersema PD, Dieleman JP, et al. Persistence and adherence to proton pump inhibitors in daily clinical practice. Aliment Pharmacol Ther. 2006;24:377–385.

    PubMed  Article  Google Scholar 

  29. 29.

    El-Serag HB, Fitzgerald S, Richardson P. The extent and determinants of prescribing and adherence with acid-reducing medications: a national claims database study. Am J Gastroenterol. 2009;104:2161–2167.

    PubMed  Article  Google Scholar 

  30. 30.

    Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83.

    PubMed  Article  CAS  Google Scholar 

  31. 31.

    Gadzhanova SV, Roughead EE, Mackson JM. Initiation and duration of proton pump inhibitors in the Australian veteran population. Intern Med J 2010.

  32. 32.

    Inadomi J, McIntyre L, Bernard L, et al. Step-down from multiple- to single-dose proton pump inhibitors (PPIs): a prospective study of patients with heartburn or acid regurgitation completely relieved with PPIs. Am J Gastroenterol. 2003;98:1940–1944.

    PubMed  Article  CAS  Google Scholar 

  33. 33.

    Ostini R, Jackson C, Hegney D, et al. How is medication prescribing ceased? A Systematic Review. Medical Care. 2011;49:24–36.

    PubMed  Article  Google Scholar 

  34. 34.

    Hershcovici T, Fass R. An algorithm for diagnosis and treatment of refractory GERD. Best Pract Res Clin Gastroenterol. 2010;24:923–936.

    PubMed  Article  Google Scholar 

  35. 35.

    Dickman R, Boaz M, Aizic S, et al. Comparison of clinical characteristics of patients with gastroesophageal reflux disease who failed proton pump inhibitor therapy versus those who fully responded. J Neurogastroenterol Motil. 2011;17:387–94.

    PubMed  Article  Google Scholar 

  36. 36.

    Kahrilas PJ, Shaheen NJ, Vaezi MF. American Gastroenterological Association Institute technical review on the management of gastroesophageal reflux disease. Gastroenterol. 2008;135:1392–1413.

    Article  Google Scholar 

Download references

Acknowledgements

We would like to acknowledge Dr. Elizabeth Tarlov, Ph.D. (VA Information Resource Center (VIReC), Edward Hines Jr. VA) for her assistance with defining measures from the VA pharmacy data set.

This work was directly funded by a VA HSR&D grant (LIP#42-131) provided through the Center for Management of Complex Chronic Care (co-PIs: Drs. Gawron and LaVela). Dr. Gawron is a National Research Service Award postdoctoral fellow at the Center for Healthcare studies under an institutional award from the Agency for Healthcare Research and Quality, T-32 HS 000078 (PI: Jane L. Holl, MD MPH).

Portions of this work were previously presented in abstract form (oral presentation) at Digestive Disease Week (May 2012, San Diego, CA).

Conflict of Interest

This material is based on work supported by the Office of Research and Development, Health Services Research and Development of the Department of Veterans Affairs. This paper reflects only the authors’ opinions and does not necessarily reflect the official position of the Department of Veterans Affairs. Dr. Pandolfino serves as a consultant for Given, Sandhill, and Shire, and on the advisory board for Crospon. None of the authors have a financial or other relationship that might signify a direct conflict of interest.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Andrew J. Gawron MD, PhD.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Gawron, A.J., Pandolfino, J.E., Miskevics, S. et al. Proton Pump Inhibitor Prescriptions and Subsequent Use in US Veterans Diagnosed with Gastroesophageal Reflux Disease. J GEN INTERN MED 28, 930–937 (2013). https://doi.org/10.1007/s11606-013-2345-0

Download citation

KEY WORDS

  • drug
  • GERD
  • prescriptions
  • Veteran Health Affairs