Approximately 70 million non-steroidal anti-inflammatory drug (NSAID) prescriptions are dispensed every year in the U.S.
And every year in the U.S., an estimated 7,600 people (mostly the elderly) die from the effects of NSAIDs: gastrointestinal bleeding and perforation (one death for every 9,210 prescriptions). Another 76,000 end up in the hospital (one hospitalization for every 921 prescriptions).
In addition, "NSAID-related gastrointestinal side effects account for one third of the cost for arthritis therapy." Obviously, these risk factors increase for patients receiving multiple prescriptions.
To determine the extent of unnecessary NSAID prescribing, researchers used standardized elderly arthritic patients who visited the offices of 112 medical physician volunteers. The MDs were blinded as to who the standardized patients were. Each physician saw two to four patients over a 6-8 month period. The physicians varied by specialty:
- 33 community-based general practitioners
- 24 academically affiliated general practitioners
- 32 family medicine residents
- 23 internal medicine residents
In the first part of the study, standardized patients made their visits complaining of chronic hip pain. For this part of the study, 139 blinded visits were made. In each case, the management decisions of the particular MD for the particular standardized patient were graded: optimal, acceptable, suboptimal or unsafe. This is how the scores fell:
|Quality of Management||Visits (%)|
The study also revealed other interesting tendencies:
"Slightly more than half of patients (51.9%) who were prescribed an NSAID were not prescribed gastroprotective therapy, despite the history of peptic ulcer disease and intolerance of acetylsalicylic acid.
"Nonpharmacologic therapy was recommended in 34.5% of visits; the most commonly recommended therapies were physiotherapy and non-weight-bearing exercise.
"Nonpharmacologic therapy was less likely to be recommended in visits during which an NSAID was prescribed (nondrug therapy was recommended in 21% of visits) than in visits during which either acetaminophen (nondrug therapy was recommended in 48.9% of visits) or no drug (nondrug therapy was recommended in 33.3% of visits) was prescribed (P=0.02; chi-square test)."
In the second part of the study, "137 blinded visits were completed for the case of NSAID-related gastropathy." Using the same scale, the visits were graded as follows:
|Quality of Management||Visits|
Again, some interesting observations by the investigators:
"The main difference between academic general practitioners and internal medicine residents was in the likelihood that they would prescribe an NSAID (residents, 58% of visits; academic physicians, 25% of visits), not in whether they would prescribe gastroprotective therapy with an NSAID."Practice style" appeared to have a significant effect on the quality and type of care patients receive:
"The likelihood of obtaining a relevant history was increased by threefold to fourfold during visits that lasted longer than 15 minutes."
"Practice style also seems to influence drug prescribing. Shorter visits are associated with higher prescribing rates and more inappropriate prescribing. Moreover, a controversial Canadian study found that general practitioners who saw more patients per day and billed for more services per patient were more likely to prescribe NSAIDs and other drugs, and that higher rates of NSAID prescribing were associated with higher rates of hospitalization and death. These researchers speculated that physicians who prescribed more medication spent less time with their patients and delivered worse quality of care; as a result, their patients were sicker."The results of this study are important to patients who may ultimately see a medical physician for conditions that are likely to be addressed by a prescription. But these results may be understated:
"Our results probably underestimate the extent of unnecessary NSAID prescribing because physicians who refuse to participate in studies of medical practice have been shown to have lower examination scores than those who participate, and lower examination scores have been linked to higher rates of NSAID prescribing."------------------ 1. Tamblyn R, Berkson L, Dauphinee WD, et al. Unnecessary prescribing of NSAIDs and the management of NSAID-related gastropathy in medical practice. Ann Intern Med, 1997;127:429-438.