Patient attitudes towards and experiences with an intervention programme to reduce chronic acid-suppressing drug intake in primary care

Abstract

Objective: Many patients are using acid-suppressing drugs (ASD) unnecessary. An insurance company initiated intervention programme aiming at reduction of chronic ASD use, was introduced in primary care-practices. We evaluated the attitude and experiences of the participating patients. Methods: A survey was conducted among a random sample of 2376 long-term ASD users using a validated questionnaire that combined CAHPS and QUOTE methodology. Using a psychometric principal component analysis we assessed the role of GPs in three scales: quality of support; communication and conduct; involvement in decisions. Both the importance of and experiences with quality items, transformed into quality impact indices, were measured. Results: Of 2376 questionnaires distributed, 1808 (76%) were returned, 1270 (54%) were valid. 188 were of patients that participated in the programme. The majority was dissatisfied with the GPs’ support: no information about rebound side effects (76%), lifestyle habits (68%), and reasons to stop (50%). Compared to the non-participants 9% more participants stopped ASD use (P = 0.04).

Conclusion: A majority of patients on chronic ASD was prepared to participate in the drug-reduction programme. Although 16% succeeded in stopping ASD use, the majority was dissatisfied with the role of the GP. Improved GP support might have make more patients stop using ASD.

Key words::

• Patient attitudes
• intervention programme
• acid-suppressing drug
• primary health care

Introduction

Dyspepsia is very prevalent in the community and acid-suppressing drug treatment accounts for 10% of the pharmacy budget. Three percent of all patients using acid-suppressive drugs (ASD) are long-term consumers (1–3). Most prescriptions are for Proton-Pump Inhibitors, and the number of these prescriptions increases annually by 5% (4–6). Many patients, in particular those with recurrent complaints who have been referred to a specialist, believe they have to use medication for the rest of their lives (7,8). Actually, the indications for chronic ASD use are limited and many of the present consumers could stop or taper their use to either on demand or intermittent use (9–13). In order to increase the efficient use of health care resources antacid drug reduction programmes, based on evidence based guidelines are implemented in general practice (14). Patients, however, have little motivation to reduce ASD use, because the treatment is very effective in suppressing dyspeptic symptoms. In general, patients do have concerns about safety and side effects of drugs, but most of them do not perceive the need for cost-effectiveness (15–19). The effectiveness of most ASD cessation programmes is limited, mainly due to the fact that the patient's perspective is inadequately considered in the intervention. Patients will use behavioural strategies to influence the prescribing physician not to change the successful drug regimen (20,21). Active multiple-intervention methods, that focus on doctor-patient communication and pay attention to the patients’ requirements and expectations, are necessary (22–27). If GPs were more aware of the patients’ need for counselling on the background and rationale of chronic ASD use and the need for cost-effectiveness, they could encourage patients to experiment with ASD use to find the lowest effective dose, thus contributing to effective drug use (28–30).

Agis, a major public health insurance company in The Netherlands, conducted a regional managed care project to stimulate rational ASD prescription, combining guideline implementation with active support of patients. Participating GPs received a ‘stop protocol’ based on Dutch dyspepsia guidelines, together with a list of patients on chronic ASD in their practice (31–34). The GPs selected the patients they considered eligible for the programme, and counselled and supported them in their cessation process. Every three months the GPs received feedback on the ASD consumption among their patients (stop/success rate). As compensation the GPs were allowed to charge additional consultation fees for their efforts.

We evaluated the effect of the ASD reduction programme from the patients’ point of view, and analysed the attitude of participants towards the initiative and their experiences with the implementation of the programme.

Methods

Design

In a postal survey questionnaires were sent to long-term ASD users.

Patients

Long-term ASD users were selected from the Agis prescription data warehouse, which contains information of 1.5 million patients in the central region of the Netherlands. A random sample of 2376 long-term ASD users was taken from all practices in the region where the reduction programme was implemented. Eligibility criteria were: resident in Agis’ primary region, using at least 180 daily defined doses (DDD) of ASD in the last year, and no chronic NSAID co-medication. All eligible patients received a postal questionnaire analysing their attitudes towards the intervention programme and their experience with the cessation process (35–37).

Questionnaire development

An ´ASD questionnaire´ was developed based on an existing general questionnaire, the CAHPS (consumer assessment of health plan survey) combined with elements of the QUOTE (quality of care through the patient's eyes) surveys (38–41). The questionnaire contained general items about dyspepsia, taken from the CAPS questionnaire and of subjective-specific items about perceived importance of quality in care, derived from the QUOTE methodology. In addition, interviews were held with patients who participated in the programme, as well as with a few key coordinators of the programme. Based on these interviews, questions about quality aspects from the patient's perspective about reduction of ASD were formulated and added to the questionnaire. In two successive sections respondents were asked to indicate the importance of quality aspects and their experiences in the programme.

In the questions about experiences ASD consumers were asked about the frequency with which quality criteria had been met, using a four-point Likert scale (never, sometimes, usually and always). Finally, statements were formulated about the role of the GP and the health insurer in the managed care project. On a scale from zero to ten, (0 being lowest and 10 the best possible), they could rate their satisfaction with their GP and the health insurer.

Questionnaire validation

To validate the questionnaire a psychometric analysis was performed. As a result of the principal component analyses with varimax rotation, three scales were constructed, based on the experiences with quality aspects. After validation of the three scales, the major themes in the questionnaire were: support given by the GP; information from and conduct of the GP; involvement of patients in the process. These themes refer, within the framework of the ASD reduction programme, to the GP's intervention activities.

Analyses

The average score for both the experience and the importance items were analysed. The multiplication of both factors (using the importance scores as weighting factors) provides a figure which indicates the improvement score of important areas in the intervention; the quality impact index (42). In general, high impact indices coincide with bad experiences and, with scales ranging from one to four, the worst impact indices will be 4 × 4. A score of eight or above was arbitrarily regarded as indicating a need for improvement.

Chi-square tests were used to compare the characteristics of the participants in the reduction programme with those of non-participants. The percentage of respondents who agreed with the statements about the role of the GP and the health insurer was calculated. Agreement was achieved when respondents indicated that they either ‘completely agreed’ or ‘agreed’. Analyses were done using SPSS 14.0.

Results

Respondents

Of the 2376 questionnaires randomly sent to eligible patients 1808 (76%) were returned. Of these 420 questionnaires were returned incomplete, 53 of the respondents were not insured with Agis, 20 had not used PPI in the last two years and 45 questionnaires were filled out by a third person. Of the 1270 (54% of total) remaining valid questionnaires, 229 (18%) patients actively participated in the ASD reduction programme. Some of them did not answer all the questions about their ASD consumption, which left 188 (16%) valid questionnaires of patients that participated in the programme for analyses and 977 valid questionnaires of ASD users that did not participate in the programme.

Patients’ gender, age and education in the two groups were comparable (Table I). In the participating group, the ASD medication was more often prescribed by the GP than the specialist (P <0.001) and 11% more of them (P <0.01) experienced their health as good or very good compared to the non-participating group. In both groups about 80% used PPIs, and 20% had had an endoscopy in the past.

Table I. Characteristics of study population in %.

	ASD users (n = 977)	ASD users in the reduction programme (n = 188)
Gender
Male	40.7	41.7
Age
25–54	25.6	30.1
55–74	51.9	47.7
75+	22.3	22.5
ASD prescribed by^a
GP	66.7	87.5
Specialist	29.1	10.9
Other	4.2	1.6
Education level
Low	64.7	63.3
Moderate	25.4	28.3
High	9.5	8.3
General health^b
Very good	5.9	11.4
Good	39.6	45.1
Acceptable	45.1	36.4
Bad	9.4	7.1
Antacid use
PPI	82.1	79.3
H2RA	17.9	20.7
Endoscopy	21.4	19.6
Health compared to the previous year
Better	16.3	20.0
Same	54.1	56.2
Worse	29.6	23.8

^aP <0.001.

^bP <0.01.

ASD, acid-suppressing drug.

Outcome of the intervention programme

After completion of the reduction programme 30/188 (16%) of those who participated completely stopped ASD (Figure 1). In the non participating group 65/977 (7%) completely stopped ASD (diff. 9%, P = 0.04). Participants that stopped ASD intake and those who did not, were comparable in gender and age. Both groups used the same proportion of PPI and H2RA. Whether they stopped using ASD or not, more than half of the participants indicated that they were in reasonable or good health. Of those who stopped, 33% felt that they were healthier than a year before.

Figure 1. Diagram of respondents with chronic ASD use and the number that participated or did not in the ASD reduction programme

Attitude towards the programme

More than 70% of the patients indicated that they neither had a problem with being approached for the reduction programme, nor with the participatory role of the health insurance company in it. Of the patients included in the ASD cessation programme 72% was approached during consultation with the GP. After they agreed to participate and stop ASD, 11% of the participants did not consult their GP again and 48% visited their GP only once more. Patients participating in the programme also stated that their GP rarely or never elaborated on the reasons to stop ASD (50%), did not promote dietary or lifestyle changes to support ASD cessation (68%), and did not discuss the possibility of rebound effects after cessation (76%).

When asked to rate their satisfaction with the role of the different parties in the programme, the respondents gave the GP an average score of 8.0 (SD = 1.7) and the health insurer an average score of 7.5 (SD = 1.8).

Evaluation of the programme

The patients who participated in the reduction programme were asked about their experiences and to evaluate various quality aspects. Of the 188 participants 173 (92%) answered all the sub-questions on these items. The first column in Table II demonstrates that ‘quality of GP support during the attempt’ scored 2.9 which is a low score indicating a general negative experience. From the patient's perspective, ‘quality of GP support’ is more important than ‘communication and conduct by the GP’ and ‘patient involvement in decisions’. The latter aspects scored respectively 1.5 and 1.6 on a scale from 1 (good experience) to 4 (bad experience). The ‘importance’ score of those two scales in column two demonstrates relatively minor differences (±3.2). Combining the two scores of experience and importance of quality gave an ‘improvement’ score of 8.6 for the first scale ‘Quality of GP support during the intervention’. The ‘experience’ score in contrast to the importance score of the second scale ‘Communication by conduct of the GP’ and the third scale ‘Patient involvement in decisions’ were relatively low and resulted in an average improvement score of 5.

Table II. Experience and importance scores of patients on ASD that participated in the reduction programme and the quality impact indices on the three scales. (n = 173).

	Experience	Importance	Improvement
	score^a	score^b	score^c
Quality of GP support during the intervention	2.89	2.98	8.6
Communication by and conduct of the GP	1.52	3.23	4.9
Patient involvement in decisions	1.59	3.25	5.2

^a1 = very good experience, 4 = very bad experience.

^b1 = not important, 4 = of the utmost importance.

^cMaximum score is 16.

ASD, acid-suppressing drugs

Discussion and conclusions

Summary of results

In contrast to the general opinion there seems to be sufficient public support for insurance company initiated ASD reduction programmes, implemented in cooperation with GPs. The majority of long-term ASD users were happy to be approached and were willing to cooperate in a drug reduction programme. In this study 16% of the ASD users who were invited to participate in the programme, succeeded in stopping ASD use. However, the majority of patients were dissatisfied with the support of the GP. One third of those patients who managed to stop using ASD reported that their health had become better than in the previous year.

Discussion

The results of this study demonstrate that the group of patients on ASD that participated in the programme was only a smaller subgroup of those eligible. Compared to the non participants the participating group more often received treatment from the GP and did experience a better health (see Table I). Possibly GPs selected mainly those patients for whom they thought it would be less difficult for them to cease ASD use, without intensive GP support. This implies that a larger group of long-term ASD users could succeed in stopping ASD use with an increased supportive effort of GP's. In our evaluation many patients experienced a lack of adequate support from their GP after entering the programme; they did not receive sufficient follow-up consultations (over 50% had only one extra consultation) and were not optimally informed about the benefits of reducing ASD.

Focusing on the practical aspects of the programme, the results demonstrate a clear need to combine optimal motivation of the patients with strong GP support. Patients should not only be encouraged to try to reduce ASD use, but they also need support to help them to continue to reduce dependence on ASD (lifestyle habits and rebound side effects) and to sustain their independency of ASD use (on demand or intermittent use) thereafter. The fact that GPs fail to provide that support, could simply be due to poor time management by GPs, but it is more likely that the GPs do not have adequate tools to provide the necessary level of support. In any future reduction programmes, GPs should be provided with specific tools to support their patients during the process of reducing drug intake.

From this point of view the limitations of the intervention programme become clear. Instead of approaching any patient who met the eligibility criteria for the programme, the selection was completely left to the GPs clinical judgement. The GP may have anticipated on the chance of successful reduction by including fewer “difficult” patients, knowing that lack of patient cooperation and lack of time to monitor patients actively could lead to failures or relapses. GPs’ own assessments of their patients, therefore, may have had a biased influence on the outcome.

Practice implications

The practical conclusion is that patients need more supportive interaction with the physician during the drug rationalisation programmes. This kind of support however, could also be provided by others. A nurse practitioner or pharmacist, for example, could act as intermediary in the programme to provide more support in the reduction process (43,44). This intervention strategy would extend the role of the insurance company, which in the present design only offered passive and financial support for enrolling ASD users in the programme. The question remains what better instruments GP's should be given to support their patients actively. Should the insurance company include preconditions for these instruments when introducing programmes for disease management in order to improve success rates?

In conclusion, the managed care reduction programme will be successful for a percentage of long-term ASD users. This percentage might increase if patients received better support from their GPs. Better conditions and tools for disease management should be developed and offered to GPs to help them to encourage their patients to stop or reduce ASD use.

Funding

The costs to carry out the postal survey as well as the data collection was funded by Agis Health Insurance Company.

Acknowledgement

The authors thank Jolanda Groenendijk for providing a validated data collection and her assistance with the data analyses.

Conflict of interest: At the time the study was carried out the author HS was employed by Agis Health Insurance Company. The authors declare that they have no competing interests.