K. Pollock et J. Grime, Strategies for reducing the prescribing of proton pump inhibitors (PPIs): patient self-regulation of treatment may be an under-exploited resource, SOCIAL SC M, 51(12), 2000, pp. 1827-1839
Escalating costs of proton pump inhibitor (PPI) prescribing are a source of
increasing concern. To reduce costs, GPs in the UK have been coming under
pressure to restrict PPI prescribing in primary care, e.g. by raising the p
rescribing threshold for new patients, and encouraging established patients
to accept a reduced dose, if not stop taking PPIs altogether. The need to
reduce prescribing costs impacts on patients by redefining, i.e. reducing,
the boundaries of clinical need for which PPI prescribing is deemed appropr
iate. This may be rationalised by the assumptions that much existing prescr
ibing is inappropriate, is applied to relatively minor and trivial afflicti
ons, and that patients put pressure on their doctors to initiate prescribin
g of PPIs, after which they are very reluctant to give them up. The researc
h involved extended interviews to elicit GP and patient Views and experienc
e of PPI prescribing. A particular focus was a comparison of the views of p
atients and GPs, and the understanding and articulation of the patient pers
pective on PPIs, which has been largely absent from the discussion to date.
The research identified six distinct strategies used by GPs in their effor
ts to reduce PPI prescribing. Contrary to what GPs often assumed to be the
case? patients were generally quite receptive to changes to their medicatio
n, provided they had the security of knowing that their original prescripti
on would be restored if necessary. Most doctors assessed their rationing st
rategies as having some impact, but acknowledged the difficulties in achiev
ing a significant and sustained reduction in PPIs. In the study sample near
ly half of the patients who had experienced a prescribing switch or step do
wn had drifted back to their former brand, and, especially, higher dose. Ho
wever, far from being overly and unreflectively dependent on PPIs, patients
were often keen to reduce their medicine taking to a minimum. A number of
respondents had taken the initiative in experimenting to find the lowest ef
fective dose of PPIs required to control their symptoms. GPs varied in thei
r attitudes to this form of treatment self-management, but less than half a
ctively encouraged patients to regulate their treatment in this way. Our fi
ndings suggest that there is considerable scope for encouraging patients to
self-regulate with PPIs, and that many patients would be willing to do thi
s if the practice was sanctioned by their doctors. The anticipated benefits
of increased self-regulation include an overall reduction in PPI prescribi
ng and associated costs, and an increase in patient autonomy and control wh
ich is in line with the concordance model of the ideal relationship between
patients and doctors. (C) 2000 Elsevier Science Ltd. All rights reserved.