Potentially Inappropriate Medication Use in Primary Care in Switzerland.

Importance: Potentially inappropriate medication (PIM) exposes patients to an increased risk of adverse outcomes. Many lists of explicit criteria provide guidance on identifying PIM and recommend alternative prescribing, but the complexity of available lists limits their applicability and the amount of data available on PIM prescribing. Objective: To determine PIM prevalence and the most frequently prescribed PIMs according to 6 well-known PIM lists and to develop a best practice synthesis for clinicians. Design, Setting, and Participants: This cross-sectional study used anonymized electronic health record data of Swiss primary care patients aged 65 years or older with drug prescriptions from January 1, 2020, to December 31, 2021, extracted from a large primary care database in Switzerland, the FIRE project. Data analyses took place from October 2022 to September 2023. Exposure: PIM prescription according to PIM criteria operationalized for use with FIRE data. Main Outcomes and Measures: The primary outcomes were PIM prevalence (percentage of patients with 1 or more PIMs) and PIM frequency (percentage of prescriptions identified as PIMs) according to the individual PIM lists and a combination of all 6 lists. The PIM lists used were the American 2019 Updated Beers criteria, the French list by Laroche et al, the Norwegian General Practice Norwegian (NORGEP) criteria, the German PRISCUS list, the Austrian list by Mann et al, and the EU(7) consensus list of 7 European countries. Results: This study included 115 867 patients 65 years or older (mean [SD] age, 76.0 [7.9] years; 55.8% female) with 1 211 227 prescriptions. Among all patients, 86 715 (74.8%) were aged 70 years or older, and 60 670 (52.4%) were aged 75 years or older. PIM prevalence among patients 65 years or older was 31.5% (according to Beers 2019), 15.4% (Laroche), 16.1% (NORGEP), 12.7% (PRISCUS), 31.2% (Mann), 37.1% (EU[7]), and 52.3% (combined list). PIM prevalence increased with age according to every PIM list (eg, according to Beers 2019, from 31.5% at age 65 years or older to 37.4% for those 75 years or older, and when the lists were combined, PIM prevalence increased from 52.3% to 56.7% in those 2 age groups, respectively). PIM frequency was 10.3% (Beers 2019), 3.9% (Laroche), 4.3% (NORGEP), 2.4% (PRISCUS), 6.7% (Mann), 9.7% (EU[7]), and 19.3% (combined list). According to the combined list, the 5 most frequently prescribed PIMs were pantoprazole (9.3% of all PIMs prescribed), ibuprofen (6.9%), diclofenac (6.3%), zolpidem (4.5%), and lorazepam (3.7%). Almost two-thirds (63.5%) of all PIM prescriptions belonged to 5 drug classes: analgesics (26.9% of all PIMs prescribed), proton pump inhibitors (12.1%), benzodiazepines and benzodiazepine-like drugs (11.2%), antidepressants (7.0%), and neuroleptics (6.3%). Conclusions and Relevance: In this cross-sectional study of adults aged 65 or older, PIM prevalence was high, varied considerably depending on the criteria applied, and increased consistently with age. However, only few drug classes accounted for the majority of all prescriptions that were PIM according to any of the 6 PIM lists, and by considering this manageable number of drug classes, clinicians could essentially comply with all 6 PIM lists. These results raise awareness of the most common PIMs and emphasize the need for careful consideration of their risks and benefits and targeted deprescribing.

Perceived dilemma between protective measures and social isolation in nursing homes during the COVID-19 pandemic: a mixed methods study among Swiss nursing home directors.

Background: Coronavirus pandemic (COVID-19) particularly affected older adults, with the highest risks for nursing home residents. Stringent governmental protective measures for nursing homes unintendedly led to social isolation of residents. Nursing home directors (NDs) found themselves in a dilemma between implementing protective measures and preventing the social isolation of nursing home residents. Objectives: The objectives of this study were to describe protective measures implemented, to investigate NDs' perception of social isolation and its burden for nursing home residents due to these measures, and to explore experiences of NDs in the context of the dilemma. Methods: Cross-sectional embedded mixed-method study carried out by an online survey between April 27 and June 09, 2022, among NDs in the German-speaking part of Switzerland. The survey consisted of 84 closed-ended and nine open-ended questions. Quantitative findings were analyzed with descriptive statistics and qualitative data were evaluated using content analysis. Results: The survey was completed by 398 NDs (62.8% female, mean age 55 [48-58] years) out of 1'044 NDs invited.NDs were highly aware of the dilemma. The measures perceived as the most troublesome were restrictions to leave rooms, wards or the home, restrictions for visitors, and reduced group activities. NDs and their teams developed a variety of strategies to cope with the dilemma, but were burdened themselves by the dilemma. Conclusion: As NDs were burdened themselves by the responsibility of how to deal best with the dilemma between protective measures and social isolation, supportive strategies for NDs are needed.

Patient leaflets on respiratory tract infections did not improve shared decision making and antibiotic prescriptions in a low-prescriber setting.

Patient information leaflets can reduce antibiotic prescription rates by improving knowledge and encouraging shared decision making (SDM) in patients with respiratory tract infections (RTI). The effect of these interventions in antibiotic low-prescriber settings is unknown. We conducted a pragmatic pre-/post interventional study between October 2022 and March 2023 in Swiss outpatient care. The intervention was the provision of patient leaflets informing about RTIs and antibiotics use. Main outcomes were the extent of SDM, antibiotic prescription rates, and patients' awareness/knowledge about antibiotic use in RTIs. 408 patients participated in the pre-intervention period, and 315 patients in the post- intervention period. There was no difference in the extent of SDM (mean score (range 0-100): 65.86 vs. 64.65, p = 0.565), nor in antibiotic prescription rates (no prescription: 89.8% vs. 87.2%, p = 0.465) between the periods. Overall awareness/knowledge among patients with RTI was high and leaflets showed only a small effect on overall awareness/knowledge. In conclusion, in an antibiotic low-prescriber setting, patient information leaflets may improve knowledge, but may not affect treatment decisions nor antibiotic prescription rates for RTIs.

[Why Switzerland needs evidence-based guidelines for its general practice medicine].

INTRODUCTION: Medical guidelines summarize evidence based knowledge and give helpful recommendations for diagnostics and therapy in daily practice. Most Swiss medical societies therefore adapt international guidelines for the Swiss setting. In primary care this adaption must not only take into account the specific Swiss healthcare system, but also the specific setting of primary care, which is characterized by a low prevalence of most diseases as well as by chronic conditions and multimorbidity. Exactly these multimorbid patients are underrepresented in the studies, which underline the current guidelines of medical societies. The institute of primary care at the university of Zurich, IHAMZ, therefore creates evidence based guidelines according to international established quality criteria for the Swiss primary care setting.

Impact of a deprescribing tool on the use of sedative hypnotics among older patients: study protocol for a cluster randomised controlled trial in Swiss primary care (the HYPE trial).

INTRODUCTION: Benzodiazepines and other sedative hypnotics (BSH) are potentially inappropriate and harmful medications in older people due to their higher susceptibility for adverse drug events. BSH prescription rates are constantly high among elderly patients and even increase with higher age and comorbidity. Deprescribing BSH can be challenging both for healthcare providers and for patients for various reasons. Thus, physicians and patients may benefit from a supportive tool to facilitate BSH deprescribing in primary care consultations. This study intends to explore effectiveness, safety, acceptance and feasibility of such a tool. METHODS AND ANALYSIS: In this prospective, cluster randomised, controlled, two-arm, double-blinded trial in the ambulatory primary care setting, we will include general practitioners (GPs) from German-speaking Switzerland and their BSH consuming patients aged 65 years or older, living at home or in nursing homes. GPs will be randomly assigned to either intervention or control group. In the intervention group, GPs will participate in a 1-hour online training on how to use a patient support tool (decision-making guidance plus tapering schedule and non-pharmaceutical alternative treatment suggestions for insomnia). The control group GPs will participate in a 1-hour online instruction about BSH epidemiology and sleep hygiene counselling. This minimal intervention aims to prevent unblinding of control group GPs without jeopardising their 'usual care'.The primary outcome will be the percentage of patients who change their BSH use (ie, stop, reduce or switch to a non-BSH insomnia treatment) within 6 months from the initial consultation. EXPECTED BENEFIT: Based on the results of the study, we will learn how GPs and their patients benefit from a supportive tool that facilitates BSH deprescribing in primary care consultations. The study will emphasise on exploring barriers and facilitators to BSH deprescribing among patients and providers. Positive results given, the study will improve medication safety and the quality of care for patients with sleeping disorders. ETHICS AND DISSEMINATION: The study has been approved by the Ethics Committee of the Canton of Zurich (KEK-ZH Ref no. 2023-00054, 4 April 2023). Informed consent will be sought from all participating GPs and patients. The results of the study will be publicly disseminated. TRIAL REGISTRATION NUMBER: ISRCTN34363838.

[Choosing Wisely in Patients with Polypharmacy]. / Choosing Wisely bei Patientinnen und Patienten mit Polypharmazie.

Choosing Wisely in Patients with Polypharmacy Abstract. Polypharmacy and potentially inappropriate medication have a negative impact on health. For reducing or stopping medication (deprescribing) patient benefits are crucial. The following stepwise approach has turned out to be successful: a. ask patients to bring along all their medication and compare them with the current medication list; b. offer shared decision making; c. evaluate every drug for indication, balance between benefit and harm, side effects and dose; d. prioritize benefit and harm according to values, preferences and goals of the patient; e. decide together about deprescribing; f. track changes in the medication plan und arrange a follow-up consultation. We illustrate this approach by the example of an older, frail female patient with polypharmacy. Deprescribing is just as important for patients' well-being as is prescribing!

Comparison of Motivational Short Interventions to Improve Smokers' Health Behavior (The COSMOS Study): A Pragmatic Cluster-Randomized Two-Arm Trial in General Practice.

INTRODUCTION: Helping smokers to quit is an important task of general practitioners (GPs). However, achieving tobacco abstinence is difficult, and smokers who fail may still want to improve their health in other ways. Therefore, Swiss GPs developed a multithematic coaching concept that encourages health behavior changes beyond smoking cessation alone. AIMS AND METHODS: To compare the effectiveness of such coaching with state-of-the-art smoking cessation counseling, we conducted a pragmatic cluster-randomized two-arm trial with 56 GPs in German-speaking Switzerland and 149 of their cigarette smoking patients. GPs were instructed in either multithematic health coaching or smoking cessation counseling. After 12 months, we compared their patients' improvements in cigarette consumption, body weight, physical inactivity, alcohol consumption, stress, unhealthy diet, and a health behavior of their own choice, using hierarchical logistic regression models and Fisher's exact and t tests. RESULTS: Over 95% of all participants achieved clinically relevant improvements in at least one health behavior, with no difference between study arms (health coaching vs. smoking cessation counseling: aOR = 1.21, 95% CI = [0.03-50.76]; and aOR = 1.78, 95% CI = [0.51-6.25] after non-responder imputation). Rates of clinically relevant improvements in the individual health behaviors did not differ between study arms either (they were most frequent in physical activity, achieved by 3 out of 4 patients), nor did the extent of the improvements. CONCLUSIONS: Multithematic health coaching and state-of-the art smoking cessation counseling were found to be comparable interventions, both in terms of smoking cessation success and, quite unexpectedly, their effects on other health behaviors. IMPLICATIONS: The findings of our study suggest that in general practice, multithematic health coaching is an effective smoking cessation intervention, and conversely, monothematic smoking cessation counseling also achieves the beneficial effects of a multithematic health behavior intervention. This opens up the possibility for GPs to support their smoking patients in improving their health behavior in additional and more flexible ways.

Medication Review and Enhanced Information Transfer at Discharge of Older Patients with Polypharmacy: a Cluster-Randomized Controlled Trial in Swiss Hospitals.

BACKGROUND: Medication safety in patients with polypharmacy at transitions of care is a focus of the current Third WHO Global Patient Safety Challenge. Medication review and communication between health care professionals are key targets to reduce medication-related harm. OBJECTIVE: To study whether a hospital discharge intervention combining medication review with enhanced information transfer between hospital and primary care physicians can delay hospital readmission and impact health care utilization or other health-related outcomes of older inpatients with polypharmacy. DESIGN: Cluster-randomized controlled trial in 21 Swiss hospitals between January 2019 and September 2020, with 6 months follow-up. PARTICIPANTS: Sixty-eight senior physicians and their blinded junior physicians included 609 patients ≥ 60 years taking ≥ 5 drugs. INTERVENTIONS: Participating hospitals were randomized to either integrate a checklist-guided medication review and communication stimulus into their discharge processes, or follow usual discharge routines. MAIN MEASURES: Primary outcome was time-to-first-readmission to any hospital within 6 months, analyzed using a shared frailty model. Secondary outcomes covered readmission rates, emergency department visits, other medical consultations, mortality, drug numbers, proportions of patients with potentially inappropriate medication, and the patients' quality of life. KEY RESULTS: At admission, 609 patients (mean age 77.5 (SD 8.6) years, 49.4% female) took a mean of 9.6 (4.2) drugs per patient. Time-to-first-readmission did not differ significantly between study arms (adjusted hazard ratio 1.14 (intervention vs. control arm), 95% CI [0.75-1.71], p = 0.54), nor did the 30-day hospital readmission rates (6.7% [3.3-10.1%] vs. 7.0% [3.6-10.3%]). Overall, there were no clinically relevant differences between study arms at 1, 3, and 6 months after discharge. CONCLUSIONS: The combination of a structured medication review with enhanced information transfer neither delayed hospital readmission nor improved other health-related outcomes of older inpatients with polypharmacy. Our results may help researchers in balancing practicality versus stringency of similar hospital discharge interventions. STUDY REGISTRATION: ISRCTN18427377, https://doi.org/10.1186/ISRCTN18427377.

[New/direct oral anticoagulants (DOAK)].

INTRODUCTION: Due to their advantageous benefit-risk-profile, direct oral anticoagulants (DOACs) are preferred over vitamin-K-antagonists for stroke prevention in atrial fibrillation as well as therapy and secondary prevention of venous thromboembolism. This guideline provides information on the practical use of DOACs, their advantages and disadvantages and limitations. It is based on recommendations from international guidelines (ESC, EHRA, DGA) and adapts them for the general practitioner setting in Switzerland.

[Shared Decision-Making in Preventive Activities]. / Shared Decision-Making in der Prävention.

Shared Decision-Making in Preventive Activities Abstract. Shared Decision-Making (SDM) is particularly useful in conditions where decisions are preference-sensitive, i.e., where preferences and values of patients are crucial for the further proceeding. This typically applies to conditions where the potential benefit and the potential harm are similar. Preventive activities are characterized by the fact that there is no current burden of disease and the benefit to expect is far in the future. Therefore, it is preference-sensitive if the current effort really pays off. The procedure of SDM in (preventive) counselling can be classified into three steps: Team Talk, Option Talk and Decision Talk. For every step, we present examples of how to talk. After an overview of the current evidence, we present four examples of how to apply SDM in preventive conditions: quit-smoking counselling, lifestyle coaching, vaccination counselling and screening for cancer. Finally, we focus on the role of activated patients and point out the opportunity for SDM during check-up examinations. For all these implementation issues useful tools and links are presented. In summary, important elements of SDM, such as patient centeredness, clarifying needs/goals and shared responsibility, are crucial for the entire spectre of caring for patients, not only for prevention.

The Swiss Approach - feasibility of a national low-dose CT lung cancer screening program.

BACKGROUND: Lung cancer is the leading cause of cancer-related deaths in Switzerland. Despite this, there is no lung cancer screening program in the country. In the United States, low-dose computed tomography (LDCT) lung cancer screening is partially established and endorsed by guidelines. Moreover, evidence is growing that screening reduces lung cancer-related mortality and this was recently shown in a large European randomized controlled trial. Implementation of a lung cancer screening program, however, is challenging and depends on many country-specific factors. The goal of this article is to outline a potential Swiss lung cancer screening program. FRAMEWORK: An exhaustive literature review on international screening models as well as interviews and site visits with international experts were initiated. Furthermore, workshops and interviews with national experts and stakeholders were conducted to share experiences and to establish the basis for a national Swiss lung cancer screening program. SCREENING APPROACH: General practitioners, pulmonologists and the media should be part of the recruitment process. Decentralisation of the screening might lead to a higher adherence rate. To reduce stigmatisation, the screening should be integrated in a "lung health check". Standardisation and a common quality level are mandatory. The PLCOm2012 risk calculation model with a threshold of 1.5% risk for developing cancer in the next six years should be used in addition to established inclusion criteria. Biennial screening is preferred. LUNG RADS and NELSON+ are applied as classification models for lung nodules. CONCLUSION: Based on data from recent studies, literature research, a health technology assessment, the information gained from this project and a pilot study the Swiss Interest Group for lung cancer screening (CH-LSIG) recommends the timely introduction of a systematic lung cancer screening program in Switzerland. The final decision is for the Swiss Cancer Screening Committee to make.

The Role of Point-of-Care C-Reactive Protein Testing in Antibiotic Prescribing for Respiratory Tract Infections: A Survey among Swiss General Practitioners.

Understanding the decision-making strategies of general practitioners (GPs) could help reduce suboptimal antibiotic prescribing. Respiratory tract infections (RTIs) are the most common reason for inappropriate antibiotic prescribing in primary care, a key driver of antibiotic resistance (ABR). We conducted a nationwide prospective web-based survey to explore: (1) The role of C-reactive protein (CRP) point-of-care testing (POCT) on antibiotic prescribing decision-making for RTIs using case vignettes; and (2) the knowledge, attitudes and barriers/facilitators of antibiotic prescribing using deductive analysis. Most GPs (92-98%) selected CRP-POCT alone or combined with other diagnostics. GPs would use lower CRP cut-offs to guide prescribing for (more) severe RTIs than for uncomplicated RTIs. Intermediate CRP ranges were significantly wider for uncomplicated than for (more) severe RTIs (p = 0.001). Amoxicillin/clavulanic acid was the most frequently recommended antibiotic across all RTI case scenarios (65-87%). Faced with intermediate CRP results, GPs preferred 3-5-day follow-up to delayed prescribing or other clinical approaches. Patient pressure, diagnostic uncertainty, fear of complications and lack of ABR understanding were the most GP-reported barriers to appropriate antibiotic prescribing. Stewardship interventions considering CRP-POCT and the barriers and facilitators to appropriate prescribing could guide antibiotic prescribing decisions at the point of care.

Swiss GPs' preferences for antidepressant treatment in mild depression: vignette-based quantitative analysis.

BACKGROUND: GPs frequently prescribe antidepressants in mild depression. The aim of this study was to examine, how often Swiss GPs recommend antidepressants in various clinical presentations of mild depression and which factors contribute to antidepressant treatment recommendations. METHODS: We conducted an online survey among Swiss GPs with within-subject effect analysis. Alternating case vignettes described a typical female case of mild depression according to International Classification of Diseases, 10th edition criteria, with and without anxiety symptoms and sleep problems. GPs indicated for each vignette their preferred treatments (several recommendations were possible). Additionally, we assessed GP characteristics, attitudes towards depression treatments, and elements of clinical decision-making. RESULTS: Altogether 178 GPs completed the survey. In the initial description of a case with mild depression, 11% (95%-CI: 7%-17%) of GPs recommended antidepressants. If anxiety symptoms were added to the same case, 29% (23%-36%) recommended antidepressants. If sleep problems were mentioned, 47% (40%-55%) recommended antidepressants, and if both sleep problems and anxiety symptoms were mentioned, 63% (56%-70%) recommended antidepressants. Several factors were independently associated with increased odds of recommending antidepressants, specifically more years of practical experience, an advanced training in psychosomatic and psychosocial medicine, self-dispensation, and a higher perceived effectiveness of antidepressants. By contrast, a higher perceived influence of patient characteristics and the use of clinical practice guidelines were associated with reduced odds of recommending antidepressants. CONCLUSIONS: Consistent with depression practice guidelines, Swiss GPs rarely recommended antidepressants in mild depression if no co-indications (i.e., sleep problems and anxiety symptoms) were depicted. However, presence of sleep problems and anxiety symptoms, many years of practical experience, overestimation of antidepressants' effectiveness, self-dispensation, an advanced training in psychosomatic and psychosocial medicine, and non-use of clinical practice guidelines may independently lead to antidepressant over-prescribing.

Achieving higher performing primary care through patient registration: A review of twelve high-income countries.

BACKGROUND: Patient registration with a primary care providers supports continuity in the patient-provider relationship. This paper develops a framework for analysing the characteristics of patient registration across countries; applies this framework to a selection of countries; and identifies challenges and ongoing reform efforts. METHODS: 12 jurisdictions (Denmark, France, Germany, Ireland, Israel, Italy, Netherlands, Norway, Ontario [Canada], Sweden, Switzerland, United Kingdom) were selected for analysis. Information was collected by national researchers who reviewed relevant literature and policy documents to report on the establishment and evolution of patient registration, the requirements and benefits for patients, providers and payers, and its connection to primary care reforms. RESULTS: Patient registration emerged as part of major macro-level health reforms linked to the introduction of universal health coverage. Recent reforms introduced registration with the aim of improving quality through better coordination and efficiency through reductions in unnecessary referrals. Patient registration is mandatory only in three countries. Several countries achieve high levels of registration by using strong incentives for patients and physicians (capitation payments). CONCLUSION: Patient registration means different things in different countries and policy-makers and researchers need to take into consideration: the history and characteristics of the registration system; the use of incentives for patients and providers; and the potential for more explicit use of patient-provider agreements as a policy to achieve more timely, appropriate, continuous and integrated care.

["Smarter Medicine" in ambulatory general internal medicine, at present and in future]. / Smarter Medicine in der ambulanten Allgemeinen Inneren Medizin.

"Smarter Medicine" in ambulatory general internal medicine, at present and in future Abstract. Overuse and inappropriate care resulting in potential harm and unwarranted waste of healthcare resources were leading to the international "Choosing Wisely" campaign (CWC) almost a decade ago. In Switzerland, the movement started 2014 / 15 under the label "Smarter Medicine", with a top-5 list of interventions better to avoid in ambulatory general internal medicine (GIM). Yet from the beginning of the international CWC campaign, its effectiveness has been questioned, and we don't know if the "Smarter Medicine" top-5 list for ambulatory GIM efficiently is reducing overuse and inappropriate care, as there is almost no evaluation data available. The prerequisites for an efficient reduction of overuse and inappropriate care are a. the scientific evidence for the recommendations, b. the recommendations coming from a trusted source, c. reliable data for the evaluation, d. the active role of patients, the public, professional healthcare societies and politicians. Another key factor for a successful implementation is the involvement of the final users at an early stage of recommendation development. Keeping this in mind, we recently developed new suggestions for interventions better to avoid, in collaboration with 538 general practitioners. These suggestions lead to a next top-5 list for the ambulatory GIM.

Time trends in general practitioners' home visits for older patients: a retrospective cross-sectional study from Switzerland.

WHAT IS KNOWN ON THE SUBJECT, AND WHAT THE STUDY ADDS: The number of home visits by general practitioners (GPs) has decreased in recent years, in contrast to the increasing number of frail and older patients in western countries. Current data on GP home visit numbers and rates are lacking for Switzerland. Our study provides new data on GP home visit numbers and rates, and their associations with patient characteristics. AIM: Our study aimed at investigating the time trend of GP home visits to older patients from 2014 to 2018 in Switzerland, and associations between GP home visits and patient characteristics including healthcare utilisation and living situation. METHODS: Retrospective cross-sectional study of insurance claims data from 2014 to 2018 among patients aged ≥65 years (Nextrapolated = 2,095,102; Nraw = 339,301). We compared patient characteristics between patients with and without GP home visits using descriptive statistics. We performed logistic regression analyses to detect associations between patient characteristics and GP home visits, including subgroups of patients aged ≥80 and patients living in a nursing home. Regression models were adjusted for age and sex. RESULTS: The yearly GP home visit rate declined from 10.7% to 9.3% from 2014 to 2018 (p <0.0001). Among patients aged ≥80, the rate declined from 26.1% to 23.1% (p <0.0001), and among patients living in a nursing home from 68.7% to 65.8% (p <0.0001). Regression analyses revealed increased health care utilisation and a higher burden of morbidity and mortality in patients receiving GP home visits. CONCLUSION: There is an ongoing decline of GP home visits over the past years, with a potentially negative impact on the quality of care for older and frail patients.

Potentially inappropriate proton-pump inhibitor prescription in the general population: a claims-based retrospective time trend analysis.

BACKGROUND: Proton-pump inhibitors (PPI) are among the most prescribed drugs worldwide, and a large body of evidence raises concerns about their inappropriate use. Previous estimates of inappropriate use varied due to different definitions and study populations. AIMS: We aimed to measure the population-based incidence and time trends of PPI and potentially inappropriate PPI prescriptions (PIPPI) with a novel method, continuously assessing excessive cumulative doses based on clinical practice guidelines. We also assessed association of patient characteristics with PPI prescriptions and PIPPI. METHODS: This was an observational study based on a large insurance claims database of persons aged >18 years with continuous claims records of ⩾12 months. The observation period was January 2012 to December 2017. We assessed the incidence and time trends of PPI prescriptions and PIPPI based on doses prescribed, defining ⩾11.5 g of pantoprazole dose equivalents during any consecutive 365 days (average daily dose >31 mg) as inappropriate. RESULTS: Among 1,726,491 eligible persons, the annual incidence of PPI prescriptions increased from 19.7% (2012) to 23.0% (2017), (p = <0.001), and the incidence of PIPPI increased from 4.8% (2013) to 6.4% (2017), (p = <0.001). Age, male gender, drugs with bleeding risk and multimorbidity were independent determinants of PIPPI (p = <0.001 for all). CONCLUSIONS: This study provides evidence that one of the most prescribed drug groups is commonly prescribed inappropriately in the general population and that this trend is increasing. Multimorbidity and drugs with bleeding risks were strong determinants of PIPPI. Addressing PPI prescriptions exceeding guideline recommendations could reduce polypharmacy and improve patient safety.