美国密歇根大学Jacob E Kurlander团队研究了减少质子泵抑制剂（PPI）过度使用的干预措施对医疗保健以及患者预后的影响。2024年4月11日，《英国医学杂志》发表了这一成果。

为了确定减少质子泵抑制剂（PPI）过度使用的大规模、多组分、基于药物的干预措施如何影响处方模式、医疗保健利用率和临床结局，研究组利用美国退伍军人事务医疗保健系统的数据，其中一个地区网络实施了过度使用干预，其他17个网络作为对照来进行差异研究。参与者为2009年至2019年接受初级保健的所有个人。

干预措施为对没有长期使用适应证的患者重新使用PPI限制，最近未开具PPI处方无效，促进H2受体拮抗剂的电子处方，以及对患者和临床医生的教育。主要结局是每6个月开具PPI处方的患者百分比。次要结局包括上消化道出血高危患者服用PPI胃保护的天数百分比、服用PPI或H2受体拮抗剂处方的患者百分比、适合PPI胃防护的老年人酸性消化性疾病入院、上消化道诊断的初级保健就诊、上内镜检查和PPI相关临床状况。

每个间隔分析的患者数量在干预机构为192607至250349人，在对照机构为3775953至4360868人，26%的患者在干预前接受PPI。干预措施与服用PPI处方的患者绝对减少7.3%（95%置信区间7.6%至7.0%）、适合胃保护的患者PPI使用绝对减少11.3%（12.0%至10.5%）以及服用PPI或H2受体拮抗剂处方的患者绝对减少5.72%（6.08%至5.36%）有关。在适合胃保护的老年患者中，上消化道诊断、上内镜检查或酸性消化性疾病住院的初级保健就诊没有增加。在任何PPI相关的临床条件下均未发现临床显著变化。

研究结果表明，多组分干预与PPI的总体使用减少有关，但也适用于适合胃保护的患者，临床益处或危害的证据很少。

附：英文原文

Title: Impact of large scale, multicomponent intervention to reduce proton pump inhibitor overuse in integrated healthcare system: difference-in-difference study

Author: Jacob E Kurlander, Loren Laine, Hyungjin Myra Kim, Christopher B Roberts, Darcy Saffar, Aimee Myers, Robert Holleman, Yuqing Gao, Michelle Shank, Richard Nelson, Jane Forman, Christian D Helfrich, Sarah L Krein, Sameer D Saini, Yu-Xiao Yang

Issue&Volume: 2024/04/11

Abstract:

Objective To determine how a large scale, multicomponent, pharmacy based intervention to reduce proton pump inhibitor (PPI) overuse affected prescribing patterns, healthcare utilization, and clinical outcomes.

Design Difference-in-difference study.

Setting US Veterans Affairs Healthcare System, in which one regional network implemented the overuse intervention and all 17 others served as controls.

Participants All individuals receiving primary care from 2009 to 2019.

Intervention Limits on PPI refills for patients without a documented indication for long term use, voiding of PPI prescriptions not recently filled, facilitated electronic prescribing of H2 receptor antagonists, and education for patients and clinicians.

Main outcome measures The primary outcome was the percentage of patients who filled a PPI prescription per 6 months. Secondary outcomes included percentage of days PPI gastroprotection was prescribed in patients at high risk for upper gastrointestinal bleeding, percentage of patients who filled either a PPI or H2 receptor antagonist prescription, hospital admission for acid peptic disease in older adults appropriate for PPI gastroprotection, primary care visits for an upper gastrointestinal diagnosis, upper endoscopies, and PPI associated clinical conditions.

Results The number of patients analyzed per interval ranged from 192607 to 250349 in intervention sites and from 3775953 to 4360868 in control sites, with 26% of patients receiving PPIs before the intervention. The intervention was associated with an absolute reduction of 7.3% (95% confidence interval 7.6% to 7.0%) in patients who filled PPI prescriptions, an absolute reduction of 11.3% (12.0% to 10.5%) in PPI use among patients appropriate for gastroprotection, and an absolute reduction of 5.72% (6.08% to 5.36%) in patients who filled a PPI or H2 receptor antagonist prescription. No increases were seen in primary care visits for upper gastrointestinal diagnoses, upper endoscopies, or hospital admissions for acid peptic disease in older patients appropriate for gastroprotection. No clinically significant changes were seen in any PPI associated clinical conditions.

Conclusions The multicomponent intervention was associated with reduced PPI use overall but also in patients appropriate for gastroprotection, with minimal evidence of either clinical benefits or harms.

DOI: 10.1136/bmj-2023-076484

Source: https://www.bmj.com/content/385/bmj-2023-076484