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 27 May 2018

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The right idea for the wrong patient: results of a national survey on stopping PPIs

The Right Idea for the Wrong Patient: Results of a National Survey on Stopping PPIs

News image

Recent studies have linked proton pump inhibitor use to serious adverse effects, including bone fracture, chronic kidney disease, dementia, and ischemic stroke.

Although it remains unclear whether proton pump inhibitors truly cause these adverse effects, this potential has forced physicians to carefully consider the safety 
and utility of long-term PPI use in their patients, a topic included in the American Board of Internal Medicine Foundation’s Choosing Wisely campaign.

Using case vignettes, Dr Jacob Kurlander and colleagues from Michigan, USA evaluated internists’ willingness to stop proton pump inhibitor varies according to drug indication.

In 2013, the reseachers conducted an online, cross-sectional survey of a representative sample of the American College of Physicians using their Internal Medicine Insider Research Panel.
Respondents shown the high-risk vignette were 1.93 times more likely to stop proton pump inhibitor
Clinical Gastroenterology & Hepatology

Physicians spending 25% of their time in direct patient care were invited.

The research team developed 3 patient vignettes, all featuring a 70-year-old woman prescribed omeprazole, 20 mg daily, and recently diagnosed with osteopenia,  increasing her risk of bone fracture, a reported PPI adverse effect.

The vignettes differed in proton pump inhibitor indication:  gastroesophageal reflux disease  well controlled for years with normal upper endoscopy;  prevention of 
upper gastrointestinal bleeding  while on low-dose aspirin  and warfarin, otherwise asymptomatic; or  prevention of upper gastrointestinal bleeding while on low-dose 
aspirin alone with a history of nonsteroidal anti-inflammatory drug–related peptic ulcer disease 10 years prior, otherwise asymptomatic.

The 3 vignettes represented low-, moderate-, and high-risk for upper gastrointestinal bleeding, respectively, and bleeding risk was not explicitly stated in the vignettes.

Respondents were presented at random with 2 of the 3 patient vignettes to minimize respondent fatigue.

For each vignette, the researchers asked respondents how likely they would be to stop proton pump inhibitor on a 1–7 Likert-type scale.

The researchers also asked participants how concerned they were about long-term pump inhibitor indication adverse effects on a 1–7 Likert-type scale.

The reserchers hypothesized that physicians would be most likely to recommend proton pump inhibitor stopping in the patient with gastroesophageal reflux disease.

A total of 487 of 914 invited participants completed the survey. 

The team found that the median age was in the 5th decade of life, and 30% were female.

The researchers noted that a total of 22% were trainees, 58% practiced general medicine, 2% gastroenterology, and 18% another subspecialty.

The team observed that on a 1–7 scale, most physicians reported moderate concern about PPI adverse effects.

For the patient vignette with high risk for upper gastrointestinal bleeding , 62% of respondents would stop the proton pump inhibitor, compared with 47% for the 
moderate-risk vignette, and only 32% for the low-risk vignette.

The team noted that respondents shown the moderate-risk vignette were 1.47 times  more likely to stop proton pump inhibitor relative to the low-risk vignette, whereas respondents shown the high-risk vignette were 1.93 times more likely to stop proton pump inhibitor relative to the low-risk.

Dr Kurlander's team concludes,  "For every 1-point increase on the 7-point scale of concern about proton pump inhibitor adverse effects, probability of stopping proton pump inhibitor increased by 11%."

"Older physician age  and being a current trainee  were both independently associated with a lower probability of stopping." 

Clin Gastroenterol Hepatol 2017: 15: 1475–1476
14 September 2017

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