VA Center for Clinical Management Research
Randomized PPI De-Prescribing (RaPPID) Program Evaluation
Sameer Saini, MD, MS (PI)
Darcy Saffar, MPH
Aimee Myers, BS
Jane Forman, ScD
Jacob Kurlander, MD, MS
Sarah Krein, PhD, RN
11/1/2018 – 10/31/2021
VA Pharmacy Benefits Management Services
Background: Proton pump inhibitors (PPIs) are among the most commonly prescribed medications in the VHA, accounting for over 11 million 30-day prescriptions and nearly $50 million in medication costs annually. Though effective for treatment of acid-related disorders such as gastroesophageal reflux disease, PPIs have been associated with a number of potential harms in observational studies (e.g., dementia, chronic kidney disease, fractures), and increased mortality in Veterans. Nonetheless, PPIs continue to be used without an appropriate indication or for longer and at higher doses than necessary. Accordingly, VHA Pharmacy Benefits Management Services (PBM) recently deployed RaPPID – a national Randomized PPI De-prescribing program, targeting patients for whom a short course of PPI is likely sufficient. This program comprises activation of Clinical Pharmacy Specialists, provider education and academic detailing, and patient education.
Objectives: This study will evaluate RaPPID through a phased, cluster-randomized trial of PPI de-prescribing involving every VA Medical Center and Community-Based Outpatient Clinic (CBOC) in the United States. In Aim 1, we will identify system-, provider-, and patient-level barriers and facilitators to implementation of RaPPID at three VA Healthcare Systems (Ann Arbor, Philadelphia, and West Haven). Using formative evaluation approaches, we will pilot and refine RaPPID prior to national randomization and deployment. In Aim 2, we will assess the impact of RaPPID on important clinical outcomes. We will assess the impact of RaPPID on PPI use (primary outcome) using a cluster randomized design (cluster = healthcare system). We will also assess a variety of unintended effects (impact of reduced PPI use on upper GI symptoms and complications, such as upper GI bleeding) and PPI-related harms (e.g., enteric infections, pneumonia). Finally, we will use process evaluation approaches to understand why and how the program was effective or ineffective in specific contexts. In Aim 3, we will assess the economic effects of RaPPID. We will use data from Aim 2 to estimate the budget impact of RaPPID, taking into account the impact of the program on VHA and non-VHA healthcare use.