UNNECESSARY PRESCRIBING OF NSAIDS AND THE MANAGEMENT OF NSAID-RELATEDGASTROPATHY IN MEDICAL-PRACTICE

Background: Use of nonsteroidal anti-inflammatory drugs (NSAIDs) incre ases the risk for hospitalization and death from gastrointestinal blee ding and perforation. Objectives: To 1) estimate the extent to which N SAIDs are prescribed unnecessarily and NSAID-related side effects are inaccurately diagnosed and inappropriately managed and 2) identify the physician and visit characteristics associated with suboptimal use of NSAIDs. Design: Prospective cohort study. Setting: Montreal, Canada. Participants: 112 physicians representing academically affiliated gene ral practitioners, community-based general practitioners, and resident s in family medicine and internal medicine. Interventions: Blinded, of fice-based assessment of the management of two clinical cases (chronic hip pain due to early osteoarthritis and NSAID-related gastropathy) u sing elderly standardized patients. Measurements: Quality of drug mana gement and potential predictors of suboptimal drug management. Results : Unnecessary prescriptions for NSAIDs or other drugs were written dur ing 41.7% of visits. Gastropathy related to NSAID use was correctly di agnosed in 93.4% of visits and was acceptably managed in 77.4% of visi ts. The risk for an unnecessary NSAID prescription was greater when th e contraindications to NSAID therapy were incompletely assessed (odds ratio, 2.3 [95% CI, 1.0 to 5.21) and when the case was managed by resi dents in internal medicine (odds ratio, 4.1 [CI, 1.2 to 14.7]). The ri sk for suboptimal management of NSAID-related side effects was increas ed by incorrect diagnosis (odds ratio, 16.6 [Cl, 3.6 to 76.5]) and sho rter visits. Conclusions: Unnecessary NSAID prescribing and suboptimal management of NSAID-related side effects were sufficiently common to raise questions about the appropriateness of NSAID use in the general population. If these results reflect current practice, prescribing pat terns may contribute to avoidable gastrointestinal morbidity in elderl y persons.