Strategies for reducing the prescribing of proton pump inhibitors (PPIs): patient self-regulation of treatment may be an under-exploited resource

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.