PrescQIPP

Reducing High-Dose and Inappropriate PPI Prescribing Across Mid and South Essex PCNs (2025)

Mid and South Essex ICB

Project summary

MSE ICB has higher than average prescribing rate of PPIs per 1000 patients when compared to ICBs with a similar demographic, also, among the highest use of high dose PPIs as a proportion of all PPI prescribing. According to NICE guidance [CG184], the lowest effective dose should be used to treat symptoms.

PPIs are cost-effective when used appropriately, research indicates that up to 70% of prescriptions do not have a clear medical reason. Although the individual risk associated with PPI use is relatively low, their extensive and prolonged use can lead to adverse effects that have a substantial negative impact on public health. Over the past decade, numerous adverse effects linked to PPI therapy have been documented. The most extensively studied is Clostridium difficile infection. Additional adverse effects include increased mortality risk, heightened fracture risk, pneumonia, acute interstitial nephritis, chronic kidney disease, hypomagnesemia, vitamin B12 deficiency, cardiovascular events, subacute cutaneous lupus erythematosus, and gastric cancer. Furthermore, nationally over £128 million is spent on PPIs annually, illustrating the potential for both clinical and financial gains.

To ensure that prescribing supports the ICB’s medicines optimisation objectives as well as being compliant with CG184, the ‘Reducing High-Dose and Inappropriate PPI Prescribing Audit’ focused on reviewing high-dose PPI prescribing and assessing the appropriateness of ongoing PPI use in accordance with NICE recommendations. Guidance was also provided on cost effective forms of PPIs to guide decision making process.

A SystmOne search tool was created, practices identified adults prescribed PPIs long-term, then reviewed a sample representing 0.5% of their population (minimum 50 patients per practice). The audit assessed appropriateness of therapy, opportunities for dose reduction, deprescribing, or switching to lower-cost alternatives. A structured data tool was shared with the practices, with a summary of interventions being submitted at PCN level.

All 26 PCNs participated in the audit with 7,768 patients audited:

  • 2,152 (28%) had their dose reduced
  • 768 (10%) stepped down to PRN (‘as needed’) use
  • 355 (5%) were switched to lower-cost alternatives
  • 293 (4%) had PPI use stopped or moved to OTC

These interventions led to safer prescribing, reduced polypharmacy, improved adherence to national guidelines. Cost efficiencies were also seen with an estimated saving of £1 million in the ICB.