Proton pump inhibitors: perspectives of patients and their GPs

Background: There is growing concern with the rapid increase in prescribing proton pump inhibitor drugs (PPIs) for a variety of gastrointestinal disor ders, and the escalating costs associated with this trend. Explanations hav e included that general practitioners (GPs) prescribe PPIs inappropriately and that patients demand PPIs and use them as a way of avoiding having to m ake lifestyle changes, Aim. To compare the perspectives of GPs and their patients on the need for PPIs, to examine the pressure to prescribe, and to examine the effect of PP Is on lifestyle. Design of study. Qualitative comparative study based on semistructured inte rviews. Setting. Twenty-six GPs in seven practices in the West Midlands and 82 ef t heir patients on repeat prescriptions for PPIs. Method. Interviews were conducted coveting a wide range of topics, includin g., experience, cause, course, and outcome of stomach problems, effectivene ss of PPIs,. and role of lifestyle in controlling symptoms The transcripts were studied repeatedly to look-for the occurrence and distribution of mate rial relating to these issues, as well as other responder-driven issues. Co debooks were devised to enable a simple categorisation and systematic compa rison of cases. Results. GPs and patients agreed about the severity and unpleasantness of s tomach symptoms for which PPIs were prescribed While GPs and patients regar ded PPIs as a very effective treatment, GPs rated their efficacy more highl y than patients. Half of the GP interviews reproduced the stereotype of the demanding patient and of patients using PPIs to support unhealthy lifestyl es. There was little evidence from patient interviews to support either ste reotype. Doctors underestimated patient concerns about side-effects, safety , and long-term use of PPIs, and the willingness ef patients to achieve the minimum effective dose by experimenting with their treatment. GPs felt tha t the pressure to prescribe PPIs was out-weighed by the pressure not to pre scribe, and most GPs had responded to the call to cut the prescribing of PP Is. Different strategies were employed to cut prescribing, including the wh olesale switching of patients on a treatment dose ef one brand of PPI to a maintenance dose of a cheaper brand of PPI known as 'double switching'. Conclusion. The stereotypes ef 'profligate prescriber,, 'demanding patient' , and 'adverse lifestyle', as explanations for the increase in the prescrib ing of PPIs, were not upheld. The stereotype of patients demanding PPIs may arise from GPs' internal pressure to prescribe being externalised onto pat ients. The extent to which health behaviour contributes to gastric disorder s needs to be established empirically. Labelling PPI patients as having a p oor lifestyle may be used as a means of reducing legitimate need for PPIs. Current policy relating to switching of dose and brand of PPI should he rev iewed.