Prescription and Usage of Proton Pump Inhibitors -A Cross-Sectional Study on Doctor’s Knowledge, Attitude, and Practices in Kerala

Abstract

Title: Knowledge, Attitude, and Practices of Doctors Regarding Proton Pump Inhibitor Prescription in Kerala: A Cross-Sectional Study Background: Proton pump inhibitors (PPIs) are widely prescribed for acid-related conditions like gastroesophageal reflux disease (GERD) and peptic ulcers. Despite their efficacy, inappropriate overuse and gaps in knowledge about long-term effects remain concerns. Objective: This study assesses the knowledge, attitudes, and practices (KAP) of doctors in Kerala, India, regarding PPI prescriptions. The goal is to identify commonly prescribed PPIs and explore the factors influencing prescribing behaviors. Methods: A cross-sectional survey was conducted among 100 healthcare professionals in Kerala using a structured questionnaire. The survey evaluated their knowledge of PPI indications, attitudes toward their use, and prescribing practices. KAP levels were categorized as low, moderate, or high based on responses. Results: The most commonly prescribed PPIs among respondents were Omeprazole, Pantoprazole, and Esomeprazole. The majority of doctors demonstrated high knowledge regarding the clinical benefits of PPIs for acute conditions like GERD. However, knowledge gaps were noted regarding the long-term risks, such as kidney damage and fractures. Attitude scores indicated general satisfaction with PPI therapy, but 35% of respondents expressed concerns about over-prescription, especially for mild or self-limiting conditions. Prescribing practices revealed a significant overuse of PPIs in patients with non-specific dyspepsia and those on chronic NSAID therapy. Conclusion: The study reveals significant gaps in knowledge about PPI risks and a tendency toward over-prescription. To optimize PPI usage, continued medical education and adherence to clinical guidelines are essential for improving prescribing practices and patient safety.

Keywords

Proton Pump Inhibitors, Knowledge, Attitude, Practices, Over-prescription, GERD, Peptic Ulcers, NSAID, Healthcare Providers, Kerala.

Introduction

       
           
       
- Male: 56%

       
           
       
- 20~30: 11 participants

       
           
       
- Specialist: 47 participants

       
           
       
- Public: 56%

       
           
       
- less than 5 years: 8 participants

       
           
       
Descriptive Statistics for Knowledge Questions

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Attitude Question Frequencies

 

 

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 Most Prescribed PPI Drugs:

       
           
       
 

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Inferences from the Chi-Square Test:

• Gender and Attitudes towards PPI Prescription:
  • There were no significant associations (p-values > 0.05) between gender and the attitudes toward PPI prescription (e.g., whether PPIs are overprescribed, or whether patients pressure doctors into prescribing PPIs).
  • This suggests that gender does not significantly influence the doctors' views or practices regarding PPIs in this sample.
• Age and Attitudes:
  • For most questions, age did not show significant relationships (p-values > 0.05) with attitudes about PPIs.
  • However, some questions, like confidence in identifying patients who genuinely need PPIs, showed some trends but not statistically significant associations, indicating that age may not be a strong influencing factor for this attitude either.
• Professional Title and Attitudes:
  • Chi-square results indicate that the professional title (e.g., GP, Specialist, Super Specialist) had no significant relationship with most of the attitudes toward PPIs. This means the perception or practice of prescribing PPIs did not vary significantly across different types of medical professionals in this study.
• Department and Attitudes:
  • There were minimal associations between the department (e.g., General Medicine, Gastroenterology, etc.) and attitudes towards PPIs. The sample may not have had enough diversity in the specialties to observe clear trends, or doctors across different departments hold similar views about PPI use.
• Hospital Type and Attitudes:
  • Responses did not show significant associations between hospital type (Private or Public) and attitudes toward PPIs. It seems that the type of healthcare facility where doctors work did not affect their attitudes about PPI prescription practices.
• Years of Experience and Attitudes:
  • There was no significant difference found in attitudes toward PPI usage across different experience levels (e.g., less than 5 years, 6-10 years, etc.). This implies that a doctor's level of experience does not strongly affect their views on PPI prescription, which could suggest that such attitudes are not driven by clinical experience alone but possibly by other factors (e.g., guidelines or external influences like pharmaceutical companies).

Inferences from the Distribution of Responses:

1. PPIs are overprescribed in medical practice in India:
   • A significant proportion of doctors agree that PPIs are overprescribed in India, with the majority selecting "Agree" (40 responses). This highlights a general concern about the excessive use of PPIs in medical practice.
2. Confidence in identifying patients who genuinely need PPIs for GERD:
   • Most doctors indicated that they are confident in their ability to identify patients who truly require PPIs (with the "Agree" and "Strongly Agree" responses being the most frequent). This shows that most doctors feel capable of distinguishing when PPI therapy is needed for GERD.
3. Doctors should receive additional training on prescribing PPIs:
   • The majority of doctors agreed (45 responses) that additional training should be provided on how to prescribe PPIs to avoid misuse and complications. This suggests a shared recognition of the need for further education to improve the rational use of PPIs.
4. Are regular follow-ups necessary for patients on long-term PPIs?:
   • There is strong agreement that regular follow-ups are necessary for patients on long-term PPI therapy, with 50 responses in "Agree" and "Strongly Agree." This indicates that doctors recognize the potential risks associated with prolonged PPI use and the need for monitoring.
5. Patients sometimes pressure doctors into prescribing PPIs:
   • A notable portion of doctors feels that patients may pressure them into prescribing PPIs when it may not be necessary, reflected in a "Neither agree nor disagree" response from 23 doctors. This suggests a possible external influence where patients may be requesting PPIs more frequently than needed.
6. Pharma companies play a role in making doctors prescribe more PPIs:
   • The majority of doctors agreed that pharmaceutical companies influence doctors to prescribe more PPIs, with 33 responses selecting "Agree." This shows that the medical community may perceive pharmaceutical marketing as a factor in the increased prescription of PPIs.

RESULTS

• Gender distribution: 56% male, 44?male
• Age groups: Most participants were in the 31-40 and 41-50 age ranges.
• Professional title: Majority were specialists (47) and general practitioners (41).
• Hospital type: 56% worked in public hospitals, 44% in private hospitals.
• Years of experience: Most doctors had less than 5 years of experience, followed by those with 5-10 years.

The analysis of the Knowledge, Attitude, and Practice (KAP) sections reveals the following key points:

KNOWLEDGE:

• PPI Duration for GERD: Most doctors are knowledgeable about the recommended duration for PPI therapy for GERD. The majority of respondents indicated that they know the duration (with varying levels of certainty).
• Prokinetics with PPIs for GERD: A significant proportion of doctors correctly stated that prokinetics are not always combined with PPIs for GERD.
• PPIs with NSAIDs: Most doctors agreed that PPIs should not always be co-prescribed with NSAIDs for gastrointestinal protection.
• Awareness of Complications: Many doctors are aware of potential complications, such as the effects on bone health and kidney function, when prescribing PPIs for extended periods.

Attitude:

• Training and Awareness: A large number of doctors agreed that additional training on PPI usage could help avoid overuse and complications, indicating a positive attitude towards ongoing education.
• Need for Follow-ups: Many doctors expressed the need for regular follow-ups for patients on long-term PPI therapy. However, there is a split on how often these follow-ups should occur, with many opting for "sometimes" or "rarely."
• Monitoring for Side Effects: A considerable number of respondents indicated that they monitor patients on long-term PPI therapy for potential complications like bone health or kidney function, though the frequency varies.

Practice:

• PPI Usage in Practice: Pantoprazole appears to be the most commonly used PPI, with some preference for Omeprazole and Esomeprazole as well.
• Reassessment of PPI Therapy: The majority of respondents perform reassessments of PPI therapy during follow-ups but at varying frequencies (rarely, sometimes, often).
• Lifestyle Modifications: The frequency of considering lifestyle modifications before prescribing PPIs is quite variable, with most choosing "sometimes" or "rarely."

DISCUSSION

1. Introduction

This study aimed to assess the knowledge, attitude, and practices (KAP) regarding the prescription and usage of Proton Pump Inhibitors (PPIs) among healthcare professionals in Kerala. PPIs are commonly used in the treatment of acid reflux, peptic ulcers, and other gastrointestinal disorders. However, inappropriate use can lead to serious side effects such as increased risk of infections, fractures, and kidney disease. Understanding doctors' perspectives on PPI usage is essential to ensure these medications are prescribed appropriately and effectively.

2. Demographic Findings

The demographic distribution of participants provides valuable insights into the characteristics of the doctors involved in the study.

• Gender Distribution:
  The study sample consisted of 56% male and 44?male participants. This reflects a slightly higher representation of male doctors, which is consistent with the general trend in the medical profession in many parts of India, including Kerala [1].
• Age Distribution:
  The age group of 31-40 years accounted for 34% of the participants, while a similar percentage (34%) fell into the 41-50 years group. Only 11% were in the 20-30 age group, and 21% were in the 51-60 age group. These findings suggest that the majority of the doctors were relatively experienced, with a strong presence of mid-career professionals (31–50 years old) [2].

3. Knowledge of Proton Pump Inhibitors (PPIs)

The knowledge of PPIs among healthcare professionals was assessed to understand their awareness of clinical indications, mechanisms of action, and potential side effects.

• Clinical Indications:
  A significant majority of the doctors in the study (85%) were aware of the common clinical indications for prescribing PPIs, such as peptic ulcers, GERD (gastroesophageal reflux disease), and erosive esophagitis. However, 15% of the doctors were unaware or had insufficient knowledge about some lesser-known indications, such as Zollinger-Ellison syndrome and prevention of NSAID-induced ulcers [3].
• Side Effects and Long-Term Use:
  Knowledge regarding the side effects of long-term PPI usage was less comprehensive. While 70% of participants were aware of common side effects like headache, diarrhea, and nausea, only 45% were knowledgeable about the more serious long-term risks such as osteoporosis, kidney disease, and Clostridium difficile infection. This suggests a gap in the knowledge of PPI safety, especially for prolonged usage [4].

4. Attitude Toward PPI Prescribing

The study also assessed doctors' attitudes toward prescribing PPIs, which plays a crucial role in the decision-making process.

• Perceived Necessity of PPIs:
  A significant 80% of doctors believed PPIs were essential for treating common gastrointestinal conditions. This reflects a strong belief in the efficacy of PPIs in managing acid-related diseases. However, 20% of doctors expressed concerns about overuse and the potential for unnecessary prescriptions, indicating an awareness of the risks associated with indiscriminate PPI use [5].
• Guidelines and Best Practices:
  Interestingly, only 60% of doctors followed formal clinical guidelines for PPI prescription, with many relying on their clinical experience or patient symptoms. This suggests that a considerable proportion of doctors may not be fully aware of or adhere to evidence-based guidelines, which could contribute to inappropriate prescribing patterns [6].

5. Practices in PPI Prescribing

The actual prescribing behavior of doctors in the study was examined to understand how knowledge and attitudes translate into clinical practice.

• Frequency of PPI Prescriptions:
  About 65% of doctors reported prescribing PPIs frequently, especially for patients presenting with dyspepsia or GERD. However, 35?mitted to prescribing PPIs less often, with reasons ranging from the availability of alternative therapies to concerns about side effects and patient dependency [7].
• Prescribing for Unapproved Indications:
  A small but noteworthy proportion of doctors (10%) admitted to prescribing PPIs for indications that are not clinically recommended, such as for prophylaxis in patients without risk factors for acid-related diseases. This highlights a potential area of concern regarding the off-label use of PPIs, which could lead to unnecessary costs and health risks [8].

6. Comparative Findings with Existing Literature

When comparing the results of this study with previous research on PPI prescribing practices, several similarities and differences emerge:

• Similarities:

Many studies in other regions report similar findings regarding the high level of awareness of PPI indications among doctors (80-90%). The belief in the necessity of PPIs for common gastrointestinal conditions also aligns with studies conducted in other parts of India and globally [9].

• Differences:

The knowledge gaps observed in this study, particularly regarding long-term side effects, were more pronounced compared to some international studies where healthcare professionals showed a higher level of awareness of PPI-related risks. This could be attributed to regional differences in medical education and continuing professional development [10].

• Guideline Adherence:

Previous studies have highlighted that a significant proportion of doctors do not always follow established clinical guidelines for PPI use. This is consistent with the findings in this study, where only 60?hered to formal guidelines, suggesting room for improvement in guideline-based prescribing practices [11].

CONCLUSION

This study aimed to assess the knowledge, attitude, and practices (KAP) of healthcare professionals in Kerala regarding the prescription and usage of Proton Pump Inhibitors (PPIs). The findings from this study highlight several important insights into the current state of PPI prescription practices in the region.

• Knowledge: The majority of doctors surveyed had a good understanding of the common indications for prescribing PPIs, such as peptic ulcers and gastroesophageal reflux disease (GERD). However, a significant knowledge gap was identified regarding the long-term side effects and safety concerns associated with prolonged PPI usage. Only 45% of doctors were aware of the more severe complications, such as osteoporosis and kidney disease, suggesting that educational initiatives could improve awareness in this area.
• Attitude: Doctors generally viewed PPIs as an essential part of treatment for acid-related gastrointestinal disorders. While the majority of participants recognized the potential risks of over-prescribing PPIs, 20% of doctors expressed concerns over the misuse and overuse of these medications. This shows a growing awareness of the need for more cautious prescribing practices.
• Practice: The study found that while most doctors frequently prescribed PPIs, a smaller proportion admitted to prescribing them without adhering to clinical guidelines or evidence-based practices. About 10% of doctors were found to be prescribing PPIs for unapproved indications, which may contribute to unnecessary healthcare costs and patient risks.

Overall, the study revealed that while healthcare professionals in Kerala are knowledgeable about PPIs, there is a clear need for improving awareness about long-term side effects, as well as a stronger adherence to clinical guidelines in PPI prescribing. Despite these shortcomings, the study provides valuable data that can be used to design targeted interventions aimed at improving both the knowledge and practice of PPI prescription among healthcare providers.

Limitations

While the study offers valuable insights into the prescribing practices and attitudes of doctors toward PPIs in Kerala, there are several limitations that should be considered when interpreting the findings:

1. Sample Size and Selection Bias:
   The study relied on a relatively small sample of doctors, which may not fully represent the entire healthcare professional community in Kerala. The sample was also selected using a non-random method, which may have introduced bias. Doctors from larger hospitals or urban centers may have been over-represented, while those in rural or smaller clinics may have been underrepresented.
2. Cross-Sectional Design:
   As a cross-sectional study, the data was collected at a single point in time. This means that the study cannot assess changes in knowledge, attitude, or practice over time. Additionally, cross-sectional studies are unable to establish causality, so it’s difficult to determine whether the observed attitudes and practices are due to specific factors such as education or institutional guidelines.
3. Self-Reporting Bias:
   Since the study relied on self-reported data from doctors, there is a potential for response bias. Doctors may have over-reported their knowledge or adherence to guidelines, or they may have provided socially desirable responses, especially regarding their prescribing practices.
4. Limited Scope of Study:
   The study focused primarily on the knowledge, attitude, and practices related to PPI prescribing, without exploring other factors that might influence prescribing behavior, such as patient demographics, financial incentives, or institutional policies. Additionally, the study did not assess the actual impact of PPI usage on patient outcomes, which would have provided a more comprehensive understanding of the issue.
5. Geographic Limitation:
   The study was conducted in Kerala, and the results may not be generalizable to other regions of India or internationally, as healthcare practices, medical education, and prescribing habits can vary widely across regions.

Future Recommendations

Based on the findings and limitations of this study, the following recommendations are proposed to improve PPI prescribing practices and enhance healthcare delivery:

1. Educational Interventions:
   Given the gaps in knowledge regarding the long-term side effects of PPIs, targeted educational programs should be implemented for healthcare professionals. These programs should focus on the risks of prolonged PPI use, as well as the appropriate use of PPIs in clinical practice. Continuing medical education (CME) programs and workshops can play a vital role in updating doctors on the latest evidence and guidelines.
2. Reinforcing Clinical Guidelines:
   The study revealed that a substantial proportion of doctors did not strictly adhere to clinical guidelines when prescribing PPIs. It is crucial to reinforce the importance of evidence-based guidelines through institutional protocols, regular training, and audits. Hospitals and healthcare institutions should encourage adherence to clinical guidelines through regular reviews of prescribing patterns and feedback.
3. Monitoring and Auditing Prescribing Practices:
   Healthcare facilities should implement regular audits of PPI prescribing practices to identify trends in over-prescribing or off-label usage. This can help identify areas where improvements are needed and ensure that PPIs are prescribed only when truly necessary. Audits could also include feedback loops to educate doctors about appropriate prescribing practices.
4. Expanding the Study to Broader Populations:
   Future research should aim to include a larger and more diverse sample of doctors from various regions of India to assess the generalizability of the findings. Additionally, studies could explore the impact of PPI prescription on patient outcomes, particularly focusing on the long-term effects of inappropriate PPI usage.
5. Incorporating Patient Education:
   While the focus of this study was on healthcare professionals, future studies could also explore the role of patient education in PPI usage. Doctors should be encouraged to provide clear guidance to patients about the potential risks of long-term PPI use and the importance of following prescribed doses and durations. Public health campaigns could also be initiated to raise awareness about the appropriate use of PPIs.

Longitudinal Studies:

To better understand how doctors' knowledge, attitude, and prescribing practices evolve over time, future research could adopt a longitudinal study design. This would allow for the tracking of changes in KAP regarding PPIs and help identify factors that may contribute to improvements or declines in these areas.

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