Educational program for physicians to reduce use of non-steroidal anti-inflammatory drugs among community-dwelling elderly persons: a randomized controlled trial.
BACKGROUND
Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most frequently prescribed drugs for patients 65 years of age or older, primarily for musculoskeletal symptoms of osteoarthritis. Because NSAIDs frequently cause serious gastrointestinal (GI) and other complications among elderly patients, expert guidelines for osteoarthritis recommend acetaminophen-based regimens, which are safer and often as effective as NSAIDs.


OBJECTIVE
Evaluate a physician education program that communicated guidelines for management of osteoarthritis in elderly patients that emphasized avoidance of NSAIDs when possible. The program reviewed NSAID risks and benefits and recommended: re-evaluating continuous NSAID users, considering substitution of up to 4 g/d of acetaminophen for the NSAID, and trying topical agents and nonpharmacologic measures.


METHODS
Randomized controlled trial among community-dwelling Tennessee Medicaid enrollees.


METHODS
Study physicians had 5 or more patients who: were community-dwelling Medicaid enrollees 65 years of age or older; had used NSAIDs regularly for at least 180 days; had had no medical care encounters during this period suggesting an indication other than osteoarthritis; and had 1 year of baseline and follow-up data. The study thus included 209 physicians (103 intervention/106 control) with 1,566 qualifying regular NSAID users (768/798).


METHODS
Face-to-face visit to study physicians by another physician, and reminder placements in the charts of patients eligible to have NSAID use reevaluated.


RESULTS
Change between baseline and follow-up years in: days of prescribed NSAIDs, acetaminophen, other drugs for musculoskeletal disorders, and GI drugs; outpatient visits and inpatient days of stay; SF36 measures of general health, physical function, and bodily pain (from 40% random patient sample); and over-the-counter NSAIDs (from the sample).


RESULTS
Intervention-attributable reduction of 7% (95% CI, 3% to 11%) in days of prescribed NSAIDs use with concomitant increase in acetaminophen use. No significant changes in other study endpoints. The intervention effect was greater among 75 physicians with a completed study visit, whose 564 patients had a 10% (95% CI, 6% to 14%) attributable reduction in NSAID use.


CONCLUSIONS
The educational program modestly reduced NSAID exposure in community-dwelling elderly patients without undesirable substitution of other medications or detectable worsening of musculoskeletal symptoms.
Ray
W A
WA
Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232, USA. wayne.ray@mcmail.vanderbilt.edu
Stein
C M
CM
Byrd
V
V
Shorr
R
R
Pichert
J W
JW
Gideon
P
P
Arnold
K
K
Brandt
K D
KD
Pincus
T
T
Griffin
M R
MR
D000082:Acetaminophen / Q000627:therapeutic use*; D000368:Aged; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000009:adverse effects / Q000627:therapeutic use; D004363:Drug Utilization / Q000706:statistics & numerical data*; D004502:Education, Medical, Continuing / Q000458:organization & administration*; D005260:Female; D005500:Follow-Up Studies; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008484:Medicaid; D010003:Osteoarthritis / Q000188:drug therapy*; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D015397:Program Evaluation; D013714:Tennessee
D000894:Anti-Inflammatory Agents, Non-Steroidal; D000082:Acetaminophen