Identifying patients who may benefit from “stepping down” omeprazole treatment

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Background

Proton pump inhibitors (PPIs) are among the most widely used medicines in New Zealand; in 2013 omeprazole was the third most dispensed medicine in the community. PPIs are highly effective at providing symptom relief for patients affected by gastric acid, and they are generally well tolerated. However, PPIs should not be prescribed indefinitely without review.

PPIs have been associated with adverse effects, e.g. an increased risk of interstitial nephritis, a small increase in fracture risk and rarely an increased risk of gastrointestinal or respiratory infection. PPIs should therefore be prescribed at the lowest effective dose for the shortest period of time. Gastro-oesophageal reflux disease (GORD) is one of the most common indications for the use of PPIs with 15 – 20% of all adults experiencing heartburn, the cardinal symptom of GORD, at least once a week. Patients with uncomplicated GORD can generally be effectively managed in a primary care setting with a regimen of omeprazole 20 mg, daily (or lower). Prescribing higher doses of omeprazole to patients with uncomplicated GORD is unlikely to provide any benefit and increases the risk of adverse effects in patients’ taking long-term treatment.

Because GORD is very prevalent there is likely to be a number of patients in every practice who are being treated with higher doses of omeprazole than is necessary; these patients may benefit from “stepping down” to a lower dose. In 2013, over one-quarter of omeprazole dispensed from community pharmacies was for omeprazole 40 mg capsules, the highest dose formulation available.

For patients taking PPIs long-term the need for ongoing treatment should be reassessed at every consultation. Many patients, depending on the initial indication for treatment, will continue to have control of symptoms on a reduced dose of PPI, e.g. reducing from 40 mg to 20 mg, or 20 mg to 10 mg, daily, or changed to “as needed” dosing. Lifestyle changes can also help with symptom control.

There will be some patients taking PPIs long-term for whom withdrawal of the PPI is inappropriate, e.g. patients with Barrett’s oesophagus. In other patients, e.g. with a history of severe erosive oesophagitis, withdrawal of PPIs should only be considered after discussion with an appropriate specialist.

Plan

Summary

Patients in the practice who are currently taking omeprazole can be audited to assess whether their indication for treatment remains and if they are taking the lowest effective dose. If “stepping down” is appropriate, this can be flagged in the patients clinical record for discussion at each consultation.

Criteria for a positive result

For a positive result for the audit, the patient’s notes should contain one of the following:

  • A record of a discussion with the patient about “stepping down” to a lower dose of omeprazole, and the reason why this was or was not achieved

OR

  • An indication for continued high-dose omeprazole, e.g. severe erosive oesophagitis, Barrett’s oesophagus

As an extra aspect of the audit, record the current dose of omeprazole the patient is taking, and calculate the average daily dose among your sample. In the second cycle of the audit, the average dose among your sample should have reduced

Recommended audit standards

A recommended standard would be for 90% of patients to have the recommended information recorded in the patient notes. In addition, there should be an improvement in the achieved percentage between the first and second audit cycles.

Data

Eligible people

All patients within the practice currently prescribed omeprazole are eligible for this audit.

Identifying patients

You will need to have a system in place that allows you to identify eligible patients. Many practices will be able to identify patients by running a ‘query’ through their PMS system. Identify all patients who have received a prescription for omeprazole in the last six months.

Sample size

The number of eligible patients will vary according to your practice demographic. If you identify a large number of patients, take a random sample of 30 patients whose notes you will audit (the first 30 results returned is sufficiently random for the purposes of this audit).

Data analysis

Use the data sheet provided to record your data.

A positive result is any patient who has a tick in either column A or B. The percentage achievement can be calculated by dividing the number of patients with a positive result by the total number of patients audited.

Identifying opportunities for CQI

Taking action

The first step to improving medical practice is to identify where gaps exist between expected and actual performance and then to decide how to change practice.

Decide on a set of priorities for change and develop an action plan to implement any changes.

It may be useful to consider the following points when developing a plan for action.

Problem solving process

  • What is the problem or underlying problem(s)?
  • Change it to an aim
  • What are the solutions or options?
  • What are the barriers?
  • How can you overcome them?

Overcoming barriers to promote change

  • What is achievable – find out what the external pressures on the practice are and discuss ways of dealing with them in the practice setting
  • Identify the barriers
  • Develop a priority list
  • Choose one or two achievable goals

Effective interventions

  • No single strategy or intervention is more effective than another, and sometimes a variety of methods are needed to bring about lasting change
  • Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance and behaviour

Review

Monitoring change and progress

It is important to review the action plan at regular intervals. It may be helpful to review the following questions:

  • Is the process working?
  • Are the goals for improvement being achieved?
  • Are the goals still appropriate?
  • Do you need to develop new tools to achieve the goals you have set?

Following the completion of the first cycle, it is recommended that practitioners complete the first part of the CQI activity summary sheet (Appendix 1).

Undertaking a second cycle

In addition to regular reviews of progress, a second audit cycle should be completed in order to quantify progress on closing the gaps in performance.

It is recommended that the second cycle be completed within 12 months of completing the first cycle. The second cycle should begin at the data collection stage. Following the completion of the second cycle it is recommended that practitioners complete the remainder of the CQI activity summary sheet.

Claiming MOPS credits

This audit has been endorsed by the RNZCGP as an Audit of Medical Practice activity (previously known as Continuous Quality Improvement - CQI) for allocation of MOPS credits; 10 credits for a first cycle and 10 credits for a second cycle. General practitioners taking part in this audit can claim credits in accordance with the current MOPS programme.

To claim points go to the RNZCGP website: www.rnzcgp.org.nz

Record your completion of the audit on the MOPS Online credit summary, under the Audit of Medical Practice section. From the drop down menu, select the audit from the list or select “Approved practice/PHO audit” and record the audit name in “Notes”, the audit date and 10 credits.

General practitioners are encouraged to discuss the outcomes of the audit with their peer group or practice.

As the RNZCGP frequently audit claims you should retain the following documentation, in order to provide adequate evidence of participation in this audit:

  1. A summary of the data collected
  2. An Audit of Medical Practice (CQI) Activity summary sheet (included as Appendix 1).