Rheumatologists' adherence to guidelines for misoprostol use in patients at high risk for NSAID gastropathy

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J Rheumatol 2002 Feb;29(2):339-46

Rheumatologists' adherence to guidelines for misoprostol use in patients

at high risk for nonsteroidal antiinflammatory drug gastropathy.

Cibere J, Sibley JT, Haga M.

Arthritis Research Centre of Canada, Vancouver, British Columbia.

jcibere@...

OBJECTIVE: To determine the extent of evidence based practice among

rheumatologists in the prevention of nonsteroidal antiinflammatory drug

(NSAID) associated peptic ulcer disease and to seek ways to improve the

management of high risk NSAID users.

METHODS: In March 1996 all 7 rheumatologists from Saskatoon participated

in a consensus conference to develop local guidelines for the

prophylaxis of NSAID associated peptic ulcer disease. We performed a

retrospective chart review for September/October 1995 (baseline) and for

June/July 1996 (post-consensus guideline) of all patients from Saskatoon

rheumatologists who were being treated with NSAID for either rheumatoid

arthritis (RA) or undifferentiated inflammatory polyarthritis (IP). A

prospective crossover intervention study was performed from January to

April 1997 in which 2 subgroups of rheumatologists (university or

private practice) had a reminder sheet of gastrointestinal (GI) bleeding

risk assessment placed into the front of each patient's chart prior to

each office visit. The GI bleeding risk for each patient at time of

visit was later determined by chart review. The primary outcome was the

proportion of adherence to guidelines for high risk NSAID users in the

combined intervention group (reminder sheet) compared to the combined

control group (no reminder sheet) in the prospective controlled

crossover study.

RESULTS: A total of 484 patients with RA or IP received NSAID during the

4 study periods. Of these, 82 patients (16.9%) were at high risk of GI

bleed. In 1995, the proportion of high risk patients taking misoprostol

was 29% for university and 33% for private practice rheumatologists. The

establishment of local consensus guidelines in 1996 temporarily

increased adherence to guidelines to 43%, but only for private practice

rheumatologists. During the prospective study, adherence to guidelines

was significantly greater in the intervention (reminder sheets) group

compared to the control (no reminder sheets) group (53% vs 15%; p =

0.014).

CONCLUSION: The simple intervention of reminder sheets for GI bleeding

risk assessment resulted in a significant increase in rheumatologists'

adherence to guidelines, although a substantial number of patients

remained untreated with misoprostol. This study illustrates the

difficulty of incorporating new knowledge and recommendations into

clinical practice. Additional strategies should be investigated to more

effectively incorporate new knowledge in the practice of rheumatology.

PMID: 11838854