6.3 Proton pump inhibitor medicines dispensing, 75 years and over

Proton pump inhibitor (PPI) medicines are one of the most commonly used medicines in Australia, particularly among older people. Find out about variations in PPI prescription dispensing in the Fourth Australian Atlas of Healthcare Variation 2021.

At a glance

Proton pump inhibitor (PPI) medicines are used to reduce stomach acid production and are effective in managing gastro-oesophageal reflux disease
They are commonly used in older people, often for periods longer than they are actually needed
After standardising to remove age and sex differences between populations, the rate of dispensing of PPI medicines to people aged 75 years and over in 2018–19 was 6 times as high in the area with the highest rate compared with the area with the lowest rate. Almost half of people aged 75 years and over had at least one prescription dispensed for a PPI medicine.
Targeted interventions are needed to prompt clinicians to regularly review the need for PPI medicines in older people.

Why is this important?

Proton pump inhibitor (PPI) medicines are one of the most commonly used medicines in older people in Australia. PPI medicines reduce stomach acid production. They are mainly used to manage gastro-oesophageal reflux disease (GORD).

Guidelines recommend 4–8 weeks of treatment with a standard dose of a PPI medicine for most people with GORD. PPI medicines are often used for longer periods and sometimes at high doses without checking if the person still needs them. Harms from long-term use include:

Unnecessary complexity in medicine regimens
Unnecessary costs
Rare but serious adverse effects.

Life-style measures are important for managing GORD, and intermittent reflux. Over-the-counter medicines, such as antacids, histamine 2 receptor antagonists or a PPI medicine are useful for treating intermittent reflux that cannot be managed with life-style measures alone.

What did we find?

In 2018–19:

More than 7.1 million Pharmaceutical Benefits Scheme (PBS) prescriptions were dispensed for a PPI medicine for people aged 75 years and over. This represents 418,360 prescriptions per 100,000 people aged 75 years and over (the Australian rate)
The number of prescriptions dispensed for PPI medicines across 328 local areas ranged from 131,393 to 777,098 per 100,000 people aged 75 years and over
The prescribing rate was 5.9 times as high in the area with the highest rate compared with the area with the lowest rate
47% of people aged 75 years and over had at least one PBS prescription dispensed for a PPI medicine
38% had at least four prescriptions dispensed, suggesting long-term PPI medicine use
Prescribing rates increased with socioeconomic disadvantage, and were higher in inner regional areas than other areas
There was substantial variation in rates of dispensing of high-dose PPI medicines among Primary Health Networks (PHNs) – from 15,746 per 100,000 people aged 75 years and over in the Northern Territory to 96,557 per 100,000 people aged 75 years and over in Tasmania.

Rates are standardised to remove age and sex differences between populations.

What does it mean?

Variation in rates of PPI medicine dispensing is likely to be due to differences in:

Rates of underlying disease – higher rates of PPI medicine use may be appropriate in areas that have higher rates of
- GORD and its risk factors, including obesity, smoking, poor diet and alcohol intake
- arthritis and cardiovascular disease and so higher NSAID use and low-dose aspirin use
- untreated Helicobacter pylori infection and peptic ulcer disease
Clinical decision-making – clinicians may not follow guidelines for a range of reasons
Access to clinicians and services – this includes availability of general practitioners and gastroenterologists, and the number of clinicians providing services to people living in the area
Ability to afford over-the-counter medicines – PPI medicine dispensing rates are lower in areas of socioeconomic advantage
Changes to the PBS listings for PPI medicines – these might be expected to have a bigger impact in areas in which adherence to guidelines has been low.

What can be done?

Actively encourage clinicians to regularly review the need for PPI medicines in older people.

Educate consumers about:

Lifestyle measures to reduce reflux
When to take their PPI medicines, which can help improve treatment effectiveness and reduce their need for higher doses or long-term use.

Changes to the PBS restrictions for prescribing PPI medicines for GORD were introduced in May 2019. These changes should help to reduce inappropriate long-term use.

Recommendations

The Commission consulted widely, but is solely responsible for making the recommendations; as such, the recommendations may not reflect the views of all contributors to the Atlas.

6a. The Commission, in collaboration with the Australian Government Department of Health, the Aged Care Quality and Safety Commission, NPS MedicineWise and relevant groups, to develop nationally consistent:

i. Guidance for people taking multiple medicines

ii. Guidance about the communication of reports to medical practitioners from Residential Medication Management Reviews and Home Medicines Reviews

iii. Measures for aged care homes to compare the percentage of residents who have received Residential Medication Management Reviews and the percentage of pharmacists’ recommendations, in line with the Commonwealth’s development of the National Aged Care Mandatory Quality Indicator Program

iv. Guidance for the establishment, governance, composition and operation of Medication Advisory Committees within aged care homes.

6b. The Australian Government Department of Health to investigate ways of collecting patient-level data on the supply of PBS medicines through the S100 Remote Area Aboriginal Health Services Program to gather accurate information about the use of medicines in rural and remote Aboriginal communities.

Download full chapter for more detail

Download the proton pump inhibitor medicines dispensing, 75 years and over section of the Atlas to read more about context, data, key findings, interpretation and addressing variation:

Fourth Atlas 2021 - 6.3 Proton pump inhibitor medicines dispensing, 75 years and over

2021

Publication, report or update

Contents:

Context

Previous Atlas findings on PPI medicine use
Why revisit this topic for people aged 75 years and over?
PBS changes

About the data

What do the data show?

Magnitude of variation
Analysis by remoteness and socioeconomic status
Analysis by people dispensed at least one prescription for a PPI medicine by state and territory
Analysis by people dispensed at least four prescriptions for a PPI medicine by state and territory
Analysis by defined daily dose by state and territory
Analysis by Primary Health Network
Analysis by dose (high, standard and low*) and PHN
PBS changes

Interpretation

Rates of underlying disease
Clinical decision-making
Access to medical care
Uptake of PBS changes
Over-the-counter use of PPI medicines

Addressing variation

Regulatory changes
Reviewing the need for PPI use
Consumer and clinician education
Lifestyle factors
Optimising effectiveness of PPI medicines
Other initiatives

Resources

Australian initiatives

References

Interactive maps, graphs and data

Data show variation in rates by geographic location of patient residence. To use the interactive maps and graphs:

Hover or click on maps and graphs for details of data points
Use the dropdown boxes at the bottom of graphs to select states and territories, SA3s or PHNs

Learn more about using the interactive Atlas or how to interpret the data.

Map of rates across Australia

Rates by local area

//viz.aihw.gov.au/t/Public/views/Histogram_PPI_PBS/Histogram?%3Aiid=1&%3Aembed=y#1

Rates by state and territory

//viz.aihw.gov.au/t/Public/views/SOP_PPI_PBS/Stateandterritory?%3Aiid=1&%3Aembed=y#1

Rates by remoteness and SES

//viz.aihw.gov.au/t/Public/views/SOP_PPI_PBS/RemotenessandSES?%3Aiid=1&%3Aembed=y#1

About the data

About the data - Proton pump inhibitor medicines dispensing, 75 years and over

Data are sourced from the PBS dataset, which includes all prescriptions dispensed under the PBS and the Repatriation Pharmaceutical Benefits Scheme (RPBS), including under co-payment prescriptions.

Data used in this report exclude doctors’ bag items and any programs with alternative supply arrangements (section 100 of the National Health Act 1953) where patient level details are not available, such as direct supply to remote Aboriginal health services.

The PBS and RPBS do not cover medicines supplied to public hospital inpatients, over-the-counter medicines or private prescriptions.

The dataset does not allow analysis by Aboriginal and Torres Strait Islander status.

Rates are based on the number of prescriptions dispensed for PPI medicines per 100,000 people aged 75 years and over in 2018–19, unless otherwise indicated. For defined daily dose (DDD), the rate is calculated per 1,000 people per day. Patient counts reflect the number or unique patients, regardless of the number of prescriptions the patient may have received in the year.

The data do not include PPI medicines in fixed-dose combinations with antibiotics.

The analysis and maps are based on the patient’s postcode recorded in their Medicare file and not the location of the prescriber or the dispensing pharmacy.

Rates are age and sex standardised to allow comparisons between populations with different age and sex structures.

Some data have been suppressed to manage volatility and confidentiality. This process takes into account the Australian Government Department of Health’s requirements for reporting PBS data (see the Technical Supplement). Data suppression for this item (indicated on the maps in grey) has been particularly marked for remote areas of the Northern Territory.

About the Atlas and how to interpret the data visualisations

This document outlines how to interpret the data correctly and explains the limitations of the data prior to using the Atlas:

Fourth Atlas 2021 - About the Atlas