Controlled trial of interventions to increase testing and treatment for Helicobacter pylori and reduce medication use in patients with chronic acid‐related symptoms

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Abstract
Background : Many symptomatic patients take proton pump inhibitors or histamine‐2 blockers for years and those without gastro‐oesophageal reflux disease might benefit from Helicobacter pylori eradication. Aim : To increase testing and treatment of H. pylori and reduce chronic use of proton pump inhibitors and histamine‐2 blockers. Methods : We conducted a three‐armed controlled trial in 14 managed care practices. We included adults who used proton pump inhibitors or histamine‐2 blockers for >1 year and excluded those with gastro‐oesophageal reflux disease or previous endoscopy. We compared usual care (n = 312 patients from 6 practices) to low‐intensity (n = 147 from 3 practices) and high‐intensity (n = 122 from 5 practices) interventions. Low‐intensity intervention consisted of guidelines, patient‐lists, and a ‘toolkit’; high‐intensity intervention added academic group detailing by a gastroenterologist with reinforcement by pharmacists. Results : Compared with usual care, the high‐intensity intervention increased H. pylori test‐ordering (29% versus 9% at 12 months, P = 0.02). About half (23 of 58) of patients tested positive and 22 received eradication treatments. The high‐intensity intervention decreased proton pump inhibitor use by 9% per year (P = 0.028), but did not alter histamine‐2 blocker use. The low intensity intervention was ineffective. Conclusions : Providing guidelines, patient‐lists, and toolkits was no better than usual care. Adding group detailing and pharmacist reinforcements led to improvements in H. pylori management and decreases in proton pump inhibitor use.