NHS Fylde & Wyre
PPI use is now so prevalent that a prescribing audit across three GP practices found these drugs were being prescribed for over 8% of all patients. With high levels of polypharmacy, this a prime target group for a novel approach to medicines optimisation.
Using a multi-faceted approach, including educational sessions for primary care teams, production of supporting materials for both clinicians and patients and patient centred polypharmacy reviews, medication use was successfully reduced with high levels of patient satisfaction.
This example was originally submitted to demonstrate implementation of CG17. The guidance has been updated and replaced by CG184. The example has been assessed and continues to align to the new guidance.
Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?
Aims and objectives
Use of PPIs was, until 2012, one of the national QIPP therapeutic areas for review by medicines management teams, however this was in relation to generating efficiency savings by increasing the use of generic versus branded PPIs. The reviews often did not address the ever increasing level of usage or whether patients were managed in line with NICE dyspepsia guidelines i.e. with regular reviews and the aim of returning to self-management without PPIs.
Added to this recent safety concerns regarding PPI usage raised the importance of reviewing this therapeutic area across our 3 practices in order to:
- assess the scale of PPI usage
- the indications for prescribing
- how this linked with other medications prescribed.
The audit results demonstrated that together with high usage (5-11%) the majority of patients were also prescribed 4 or more medications & should thus be having their PPI use reviewed annually in line with QoF.
The majority were also seen by practice nurses in chronic disease clinics & this provided an opportunity to review PPI use in these settings.
Our aim was therefore to use a multifaceted approach to:
-embed the review of PPIs as part of regular medication reviews
-provide healthcare professionals with the means to overcome barriers to reducing PPI use e.g. by managing rebound hyperacidity & patient perceptions of self-management
-raise awareness of the safety concerns around PPI usage & management in line with NICE CG17 in order to affect a change in future prescribing behaviour.
Reasons for implementing your project
As previously stated, PPI reduction was no longer high on our agenda until we realised that their use had continued to increase significantly. Across England and Wales in 2011 more than 40 million items were dispensed; with omeprazole and lansoprazole achieving 5th and 10th position respectively in the list of most dispensed items in the community. In North West England, where this project was based PPI use has been steadily rising at approximately 10% year on year.
The recent safety concerns around long-term use and high doses i.e. increased risk of fractures, C. difficile infection & hypomagnesemia together with the high levels of prescribing added to our belief that we needed to review our use of PPIs.
NICE guidance recommends reviewing PPIs taken for dyspepsia at least annually with a return to self-care with antacids and/or alginates but in reality stopping PPIs can be difficult due to symptom recurrence resulting from rebound acid hypersecretion.
A baseline audit of PPI usage in our 3 practices in Fleetwood, Lancashire revealed not only that PPIs were taken by up to 11% of the population, but also that this was in conjunction with high numbers of other medications. These patients made up 25% of all those requiring medication reviews under QoF due to their taking 4 or more medicines.
The plan was to put together & implement a package of support to encourage healthcare professionals to review PPI use as part of a full medication review and embed this into on-going patient management. Patient experience was to be measured to ensure an improvement in patient centred care whilst also measuring any efficiency savings released.
How did you implement the project
There were many challenges that had to be overcome in order to successfully fulfill this project.
To overcome GPs perceptions that PPI prescribing was not a significant clinical issue, we presented the audit results together with safety concerns around the use of PPI's and gained agreement that medication reviews to discuss reducing PPI use with patients were needed.
The next issue was lack of GP time to hold face to face reviews. It was agreed to make use of existing nurse led clinic appointments to review patients already attending chronic disease management clinics and to use practice pharmacists to see remaining patients.
Another decision was to use external gastro-nurses to see patients who would not be attending chronic disease clinic appointments during the 4 month period chosen to do the reviews in order to ensure a sufficient number of patients had been seen to verify the effectiveness of the approach. These gastro-nurses attended a practice nurse education session to discuss how to review PPI use with patients and address any concerns the nurses had about advising patients to reduce or stop PPI's.
A GP education session with a consultant gastroenterologist was held to raise awareness of rebound hyperacidity and how it could be managed with use of licensed alginate preparations.
Evidence based management guidelines for PPIs together with patient information leaflets on PPIs and lifestyle modification were developed in order to help in discussing appropriate long-term management with patients as it was perceived that patients would be unwilling to stop PPIs.
As the audit had shown that many patients were taking PPIs for gastro-protection due to use of NSAIDs or SSRIs, guidelines for prescribing and stopping these were also produced together with patient information leaflets to encourage stopping these where appropriate with subsequent stopping of the associated PPI.
The initial audit also found a large number of patients who were prescribed aspirin for primary prevention of cardiovascular disease contrary to current guidance. A separate audit was conducted to review the risks of continuing treatment in these patients.
A patient satisfaction questionnaire was developed to gather patients' views on the review process and materials.
After 4 months of patient reviews, a re-audit took place to assess any changes that had been made and to look at patients' opinions of the review process together with feedback from healthcare professionals involved.
Evaluation of the work to date has been by feedback from healthcare professionals, re-audit of prescribing and analysis of patient questionnaires.
GP & nurse education sessions were well attended. Feedback showed the sessions very useful in highlighting issues around PPI use & techniques to manage them. The patient information leaflets were helpful when discussing issues with patients. Those around SSRIs have also been used with good feedback from the community mental health team.
During the 4 month period a total of 862 patients taking PPIs attended the practices. Of these:
-18% reduced their PPI dose
-19% stopped their PPI
-At re-audit only 17 patients had reverted to previous higher dose PPIs and 75% remained off treatment
-Medications prescribed reduced by 111 items with annualised prescribing savings of £5,641 taking into account the cost of acute alginate prescribing
-284 patients had aspirin stopped for primary prevention patients (where risks outweighed benefits)
110 patients returned satisfaction questionnaires with overall satisfaction rates being high at 79%. Patients said they welcomed a face to face review & would like them to occur more regularly. They were happy with the information received & any changes suggested.
These results show that the approach we took was successful in promoting change in patients such that they were willing & able to manage their symptoms with less reliance on prescribed PPIs. Patients were willing to reduce their use of PPIs & by explaining about managing rebound symptoms, patients were able to continue with these changes. Although PPIs are low cost medications, significant prescribing savings were made by reviewing patients in line with NICE CG17 & using the opportunity to review & optimise other treatments.
A further re-audit is planned 12 months after initial review period to assess if the results of these interventions have been maintained & long-term changes in prescribing behaviour achieved. Projected 12 month savings for all patients would be around £16,000 and, if extrapolated to the wider CCG, would amount to approximately £97,000.
The project has exceeded expectations as it has not only delivered efficiency savings and enhanced the knowledge and skills of the primary care multi-disciplinary team but also uncovered a range of clinical issues with other medications that have been tackled to enhance patient safety. This has reduced the risk of harm, particularly in an elderly, polypharmacy population.
Key learning points
A number of factors have contributed to the success of this project.
- The baseline audit proved an excellent means of highlighting issues around PPI use at a local level & in gaining buy-in from GPs for the review process.
- Education sessions for healthcare professionals benefitted from the inclusion of gastro-nurses who were experienced in PPI reviews & could answer questions about the practicalities of seeing patients. The consultant gastro-enterologist was able to answer wider questions around diagnosis, referral & management & helped to validate the need for better review & management in primary care.
- Piloting the reviews over an initial 4 month period allowed for prompt feedback on how the process was working & was able to demonstrate benefits at an early stage to encourage continued involvement.
- Feedback from patients helped dispel the perception that patients would be unwilling to consider coming off PPIs & encouraged regular discussion around self-management & lifestyle modification in future.
- Raising awareness of rebound hyperacidity encouraged prescribers to inform patients about this & how it could be effectively managed & thus contributed to high success rates when stopping treatment.
This multifaceted approach to the implementation of recommendations in the NICE dyspepsia guideline has demonstrated benefits for patients & healthcare professionals & could readily be reproduced in other settings.
Chris Roberts & Diane McGinn
CCG Practice Pharmacist, Medicines Management Pharmacist
NHS Fylde & Wyre
Is the example industry-sponsored in any way?
Reckitt Benckiser Healthcare UK Ltd sponsored nurse & pharmacist support for this project together with speaker fees for a consultant gastroenterologist & printing of materials. The project was facilitated by external consultants, Jackel Solutions.