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期刊来源：BMJ

原文链接：https://doi.org/10.1136/bmj-2023-076484

摘要内容如下：

客观

确定减少质子泵抑制剂（PPI）过度使用的大规模、多组分、基于药物的干预如何影响处方模式、医疗保健利用和临床结果。

设计

差异中的差异研究

设置

美国退伍军人事务医疗保健系统，其中一个区域网络实施了过度使用干预，所有其他17个作为对照。

参与者

2009年至2019年接受初级保健的所有个人。

干预

对没有记录的长期使用适应症的患者补充PPI的限制，近期未配药的PPI处方的作废，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。

主要结果指标

主要结果是每6个月使用PPI处方的患者百分比。次要转归包括上消化道出血高危患者使用PPI胃保护的天数百分比、使用PPI或H2受体拮抗剂处方的患者百分比、适合PPI胃保护的老年人因酸性消化性疾病入院、上消化道诊断的初级保健就诊、上消化道内镜检查和PPI相关的临床状况。

结果

在干预点，每间隔分析的患者数量从192607到250349不等，在对照点，每间隔分析的患者数量从3775953到4360868不等，26%的患者在干预前接受了质子泵抑制剂治疗。在服用PPI处方的患者中，干预的绝对减少了7.3%（95%置信区间-7.6%至-7.0%），在适合胃保护的患者中，PPI的使用绝对减少了11.3%（-12.0%至-10.5%），在服用PPI或H2受体拮抗剂处方的患者中，绝对减少了5.72%（-6.08%至-5.36%）。在适合胃保护的老年患者中，因上消化道诊断、上消化道内窥镜检查或酸性消化性疾病住院的初级保健就诊人数没有增加。在任何与PPI相关的临床状况中均未观察到临床上显著的变化。

结论

多组分干预与总体PPI使用减少有关，但在适合胃保护的患者中也是如此，临床益处或危害的证据极少。

英文原文如下：

Abstracts

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 192 607 to 250 349 in intervention sites and from 3 775 953 to 4 360 868 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.

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