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      Proton Pump Inhibitor Use in the U.S. Ambulatory Setting, 2002–2009

      1 , 2 , 3 , *

      PLoS ONE

      Public Library of Science

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          Background and Aims

          Anecdotal reports and studies of select populations suggest that the use of proton pump inhibitors (PPIs) has increased since their introduction. We sought to determine recent trends in PPI use in the U.S. outpatient setting and characteristics of patients and physicians that may predict their use.


          We used data from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) to estimate the prevalence of visits in which patients used PPIs from 2002 to 2009. We tested for associations between PPI use and patient, physician, and practice characteristics using data from 2009. We also estimated the prevalence of visits in which PPIs were used by patients without gastrointestinal complaints, diagnoses, or other indications for their use and tested for associations between patient and physician characteristics and PPI use in patients with no documented indication.


          PPIs were used in 4.0% of visits in 2002 and 9.2% in 2009 (p<0.001 for trend across years). The use of omeprazole (0.9% in 2002 to 3.9% in 2009, p<0.001), esomeprazole (0.9% in 2002 to 2.3% in 2009, p<0.001), and pantoprazole (0.6% in 2002 to 1.6% in 2009, p<0.001) increased significantly over the study period. Among visits by patients using PPIs, 62.9% documented no gastrointestinal complaints, gastrointestinal diagnoses, or other indicated reason for their use.


          We found that PPI use increased significantly from 2002 to 2009 as did documented indications for their use. Newly-prescribed PPI use did not change from 2006 to 2009. More research is needed to determine whether PPIs are overused in the U.S. outpatient setting.

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          Most cited references 15

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          Acid-suppressive medication use and the risk for hospital-acquired pneumonia.

          The use of acid-suppressive medication has been steadily increasing, particularly in the inpatient setting, despite lack of an accepted indication in the majority of these patients. To examine the association between acid-suppressive medication and hospital-acquired pneumonia. Prospective pharmacoepidemiologic cohort study. All patients who were admitted to a large, urban, academic medical center in Boston, Massachusetts, from January 2004 through December 2007; at least 18 years of age; and hospitalized for 3 or more days were eligible for inclusion. Admissions with time spent in the intensive care unit were excluded. Acid-suppressive medication use was defined as any order for a proton-pump inhibitor or histamine(2) receptor antagonist. Traditional and propensity-matched multivariable logistic regression were used to control for confounders. Incidence of hospital-acquired pneumonia, defined via codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), in patients exposed and unexposed to acid-suppressive medication. The final cohort comprised 63 878 admissions. Acid-suppressive medication was ordered in 52% of admissions and hospital-acquired pneumonia occurred in 2219 admissions (3.5%). The unadjusted incidence of hospital-acquired pneumonia was higher in the group exposed to acid-suppressive medication than in the unexposed group (4.9% vs 2.0%; odds ratio [OR], 2.6; 95% confidence interval [CI], 2.3-2.8). Using multivariable logistic regression, the adjusted OR of hospital-acquired pneumonia in the group exposed to acid-suppressive medication was 1.3 (95% CI, 1.1-1.4). The matched propensity-score analyses yielded identical results. The association was significant for proton-pump inhibitors (OR, 1.3; 95% CI, 1.1-1.4) but not for histamine(2) receptor antagonists (OR, 1.2; 95% CI, 0.98-1.4). In this large, hospital-based pharmacoepidemiologic cohort, acid-suppressive medication use was associated with 30% increased odds of hospital-acquired pneumonia. In subset analyses, statistically significant risk was demonstrated only for proton-pump inhibitor use.
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            Proton pump inhibitors and risk of fractures: a meta-analysis of 11 international studies.

             Paul Bain,  D Bauer,  Wei Yu (2011)
            Concerns have been raised about the risk of fractures with acid-suppressive medications, such as proton pump inhibitors and histamine(2)-receptor antagonists. This meta-analysis evaluated the association between proton pump inhibitor or histamine(2)-receptor antagonist use and fractures. We performed a systematic search of published literature (1970 to October 10, 2010) in MEDLINE, EMBASE, and other sources. Ten publications reporting 11 studies were considered eligible for analysis. All studies were observational case-control or cohort studies and primarily evaluated older adults. The summary effect estimate for risk of hip fracture increased modestly among individuals taking proton pump inhibitors (relative risk [RR] 1.30, 95% confidence interval [CI], 1.19-1.43). There also was an increase in spine (RR 1.56, 95% CI, 1.31-1.85) and any-site fractures (RR 1.16, 95% CI, 1.04-1.30) among proton pump inhibitor users. These findings were similar in both men and women and after stratification by duration of use. In contrast, histamine(2)-receptor antagonist use was not significantly associated with increased risk of hip fracture (RR 1.12, 95% CI, 0.97-1.30). In this meta-analysis of observational studies, proton pump inhibitors modestly increased the risk of hip, spine, and any-site fractures, whereas histamine(2)-receptor antagonists were not associated with fracture risk. The possibility of residual confounding cannot be excluded. Further skeletal evaluation should be considered for patients who are taking proton pump inhibitors and also at risk for osteoporotic fracture. Copyright © 2011 Elsevier Inc. All rights reserved.
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              Prices don't drive regional Medicare spending variations.

              Per capita Medicare spending is more than twice as high in New York City and Miami than in places like Salem, Oregon. How much of these differences can be explained by Medicare's paying more to compensate for the higher cost of goods and services in such areas? To answer this question, we analyzed Medicare spending after adjusting for local price differences in 306 Hospital Referral Regions. The price-adjustment analysis resulted in less variation in what Medicare pays regionally, but not much. The findings suggest that utilization-not local price differences-drives Medicare regional payment variations, along with special payments for medical education and care for the poor.

                Author and article information

                Role: Editor
                PLoS One
                PLoS ONE
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                13 February 2013
                : 8
                : 2
                [1 ]Department of Medicine, New York Presbyterian Hospital, New York, New York, United States of America
                [2 ]Division of Outcomes and Effectiveness, Department of Public Health, Weill Cornell Medical College, New York, New York, United States of America
                [3 ]Department of Medicine, Weill Cornell Medical College, New York, New York, United States of America
                University of Colorado, United States of America
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: TFB SRR. Analyzed the data: TFB SRR. Wrote the paper: TFB SRR.


                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                Pages: 8
                TFB is supported by a National Institute On Aging Career Development Award (K23AG043499) and in by funds provided to her as a Nanette Laitman Clinical Scholar in Public Health at Weill Cornell Medical College. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Research Article
                Clinical Research Design
                Survey Research
                Drugs and Devices
                Behavioral Pharmacology
                Gastroenterology and Hepatology
                Non-Clinical Medicine
                Health Care Policy
                Health Statistics
                Health Care Quality
                Public Health
                Behavioral and Social Aspects of Health
                Social and Behavioral Sciences
                Health Economics



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