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I write in response to the article published in your journal “Passing the acid test? Evaluating the impact of national education initiatives to reduce proton pump inhibitor use in Australia” (Bruno C et al., BMJ Qual Saf 2019). I am writing as NPS MedicineWise evaluation found a significant impact on general practitioner prescribing of proton pump inhibitors (PPIs) following their educational programs in 2009 and 2015. I acknowledge that the article is well written, the methods are well described, and the approach includes a number of sensitivity analyses. However, I would like to highlight some key points on the analysis methods used that differ from the approach taken by NPS MedicineWise and about which I have some concerns.
The 2015 NPS MedicineWise educational program on PPIs was part of a larger educational strategy over a decade to support best-practice prescribing of PPIs by general practitioners (GPs) and included Pharmaceutical Benefits Scheme (PBS) feedback to GPs in Australia. This consists of a letter that includes information of the individual GP’s prescribing of PPIs compared to their peers. Programs launched in 2009 and 2018 on PPI prescribing for GPs also included face-to-face educational visits to GP practices. The 2015 campaign, which did not include these face-to-face visits, aimed to reinforce the impact of the earlier 2009 campaign.
NPS MedicineWise has conducted an evaluation of the 2009 and 2015 education programs on GP prescribing o...
NPS MedicineWise has conducted an evaluation of the 2009 and 2015 education programs on GP prescribing of PPIs and found a significant decrease in the volume of high and standard PPIs prescribed to concessional patients.
There are a number of ways in which our analysis differs to that described in the Bruno et al. article:
• Our analysis found a reduction in high/standard PPI dispensed volumes from GP prescriptions for concessional patients over four times that found in the Bruno et al. article. Our analysis was focussed on GP prescribing, as they were the target prescribers for our education programs. In contrast, the Bruno et al. article includes all dispensed prescriptions including those by specialists. Specialists may be prescribing PPIs more frequently for people with more complicated conditions for which long-term PPI use is appropriate.
• The authors of the Bruno et al. article have used a novel approach by looking at a sample of 10% of individual longitudinal PBS patient data and used novel data analysis methods. In contrast, we use the complete PBS data for concessional patients and analyse dispensing volumes using best practice time series analysis.
• We analyse trends over multiple years, whereas the Bruno et al. analysis used data from one year before and after the 2015 NPS MedicineWise program, although they did adjust for seasonality. Benefits of a multiple year analysis include taking into account additional factors such as the impacts of previous programs, consumers stockpiling medicines once they reach the PBS safety net and other environmental factors.
• In the Bruno et al. article they only assessed a change in the dispensing levels after the interventions although there is a clear upward trend in PPI prescriptions over the years prior to the intervention. They did not assess a change in slope (i.e. change in trend) which NPS MedicineWise considers in evaluation work using time series analysis. One possible reason for an upward trend is a continual increase in the size of the population with gastro-oesophageal reflux disease (GORD) due to population growth, and this is particularly strong in older populations. I would recommend assessing total dispensing over time as an age-standardised or age-specific population rate to control for change in the size of the population at risk of being prescribed PPIs.
Since NPS MedicineWise launched the Choosing Wisely Australia initiative in April 2015, three recommendations from medical colleges and societies about the use of PPIs have been published – from the Royal Australian College of General Practitioners (RACGP) in April 2015, the Gastroenterological Society of Australia (GESA) in October 2016 and the Royal Australasian College of Physicians’ Paediatrics & Child Health Division in September 2017. The 2018 NPS MedicineWise educational program included recommendations on PPIs from RACGP and GESA. One of the program’s aims was to grow GP awareness of the RACGP recommendation and GPs were encouraged to regularly review patients with GORD on PPIs, with the aim of reducing or ceasing PPIs altogether.
A GP survey conducted in February 2019 asked GPs to rate their agreement with the RACGP statement before and after participating in the NPS MedicineWise program. The result was a significant 13% increase in GP awareness of the RACGP recommendation after participating, demonstrating that educational activities do have an important role in behaviour change.
There is a need for further research into the impact of reducing PPI use on GORD symptom control. Further evaluation is planned and the MedicineInsight dataset provides a unique opportunity to explore the reasons general practitioners prescribe PPIs to patients. MedicineInsight, managed by NPS MedicineWise with support funding from the Australian Government Department of Health, is a large-scale national general practice dataset that extracts and collates longitudinal, de-identified patient health records from general practice clinical information systems.