One of the biggest studies ever conducted on the subject of deprescribing medications demonstrates the potential benefits and drawbacks of a significant effort to reduce the overuse of a common type of heartburn medications called proton pump inhibitors (PPIs). It also suggests that some of the feared risks associated with PPIs may be exaggerated. Many health systems and clinics have begun working on strategies to encourage deprescribing of medications that patients may not require, whether to minimize costs, safety risks, or alleviate “pill fatigue.” The findings of a recent study published in the BMJ highlight the potential promise and challenges of this initiative.The study explores the potential benefits and risks of a large-scale initiative to reduce the unnecessary use of proton pump inhibitors (PPIs) for heartburn.
Results suggest that some of the perceived dangers of PPIs may be exaggerated.
The intervention focused on limiting the size and refills of PPI prescriptions for patients without a valid medical need, discontinuing old prescriptions, and providing education on alternative treatments to both patients and healthcare providers.
This initiative was implemented in VISN 17, a specific region of the Veterans Health Administration system, and involved a quarter of the population.The study involved a large number of patients, making it one of the largest ever conducted on deprescribing.
Important discoveries
Overall, the intervention resulted in a significant decrease in PPI use: a nearly 30% decrease in PPI prescriptions compared to other VA regions.
However, the effort to reduce potentially unnecessary PPI use had an unintended outcome: a decrease in prescriptions for veterans who actually need to take PPIs because their other medications pose a high risk of gastrointestinal bleeding. There is strong evidence that PPIs are effective in preventing gastrointestinal bleeding.The use of PPIs is recommended in clinical guidelines. It is reassuring to note that regardless of the reason for taking PPIs, the effort to discontinue their use did not result in an increase in healthcare visits for gastrointestinal diagnoses. Additionally, there was no increase in gastrointestinal bleeding in high-risk patients, suggesting that the deprescribing initiative itself was safe. Interestingly, the rate of reported negative effects of PPIs, such as kidney disease, stroke, heart attack, or pneumonia, did not decrease in VISN17 compared to other regions. The risk of hip fractures, which has been linked to PPI use in previous studies, only decreased by a small percentage.The evidence suggests that PPIs may indicate patients at risk for certain adverse outcomes, although they are not likely to be the direct cause. Therefore, the main advantages of discontinuing PPIs are related to cost and the inconvenience of taking multiple pills, rather than reducing clinical risks. The VA-funded study utilized data from before and after VISN 17 implemented its PPI deprescribing program for veterans in Texas, New Mexico, and Oklahoma. The study was led by a multi-inThe team involved in the study includes researchers from the University of Michigan and the VA Center for Clinical Management Research (CCMR) in Ann Arbor; the University of Pennsylvania and the VA Center for Health Equity Research and Promotion (CHERP) in Philadelphia; and the Yale School of Medicine and VA Center for Pain Research, Informatics, Multi-morbidities, and Education (PRIME).
According to Jacob Kurlander, M.D., M.S., who is the first author of the study and a gastroenterologist, the intervention was successful because it required some level of patient involvement – refills for the medication could no longer be received automatically without a clear indication for it.The quote is from a doctor at Michigan Medicine, U-M’s academic medical center, and the Lieutenant Colonel Charles S. Kettles VA Ann Arbor Medical Center. According to the doctor, patients who benefit from PPIs for bleeding prevention, which is sometimes overlooked by doctors, also got impacted by deprescribing efforts. This suggests that deprescribing efforts need to be more careful to ensure that providers don’t unintentionally take a patient off the drug if they need it, says Kurlander. Additionally, the doctor adds that their findings suggest that PPIs may not be as harmful as some people have feared. Before the VISN 17 program started, about 26% of veterans who received primary care from a VA provider were given a prescription for a PPI within a six-month period. By the end of 2019, only 15% of veterans in VISN 17 had a PPI prescription, while about 22% of veterans in other regions had one. This means that PPI prescribing decreased by 30% within VISN 17, and there was a 7% absolute reduction in PPI use between VISN 17 and other regions by the end of the study period. The researchers also linked veterans’ VA records with their Medicare data to account for care received outside the VA, and utilized information from death certificates.The study focused on examining the death certificates of veterans in different regions to identify the causes of cardiovascular-related deaths. Results showed no significant differences between the VISN 17 region and other areas.
Kurlander and Saini, who are members of the VA Center for Clinical Management Research directed by co-senior author Sameer Saini, M.D., M.S., are part of the U-M Institute for Healthcare Policy and Innovation. They also serve as faculty members in the Division of Gastroenterology at the U-M Medical School’s Department of Internal Medicine.
The study’s co-senior author, Yu-Xiao Yang, M.D., M.S.C.E., from the University of Pennsylvania and the VA CHERP in Philadelphia, also contributed to the research.CMR researchers Hyungjin Myra Kim, Sc.D., Darcy Saffar, Aimee Myers, Robert Holleman, Yuqing Gao, Jane Forman, and Sarah L Krein, Ph.D. along with Loren Laine, M.D., from the Yale School of Medicine and VA Connecticut; Christopher B Roberts from CHERP, Michelle Shank, who served as the pharmacy executive of VISN 17 during the study period, Richard Nelson, Ph.D. from the University of Utah and Salt Lake City VA Center for Informatics, Decision Enhancement, & Analytics Sciences (IDEAS); and Christian Helfrich, Ph.D. from the Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care were part of the study. The research was funded by the Department of Veterans Affairs.Veterans Affairs Health Services Research and Development Service (HX002693-01) supports Kurlander’s work. Additionally, the National Institute of Diabetes and Digestive and Kidney Diseases, part of the National Institutes of Health (DK118179), also funds his work.
