The development of practice tools to help reduce the risk of non-steroidal anti-inflammatory drugs in primary care

Problem

Non-steroidal anti-inflammatory drugs (NSAIDs) are widely prescribed in primary care. Internationally, they have been identified as responsible for a disproportionate number of potentially avoidable drug-related hospital admissions. It is therefore important to target NSAIDs in the development of medicine-related risk-reduction strategies. Limited knowledge exists about difficulties general practitioners (GPs) face when prescribing NSAIDs or tools that would help them manage this risk in daily practice. This research aims to explore GPs’ views on prescribing NSAIDs and to develop and trial a tool for use in clinical practice to help minimise risk.

Approach

The study comprises three phases:1. Fifteen, semi-structured, face-to-face, audio-recorded qualitative interviews were conducted with a diverse range of GPs from a variety of practice types. Interviews were transcribed verbatim and analysed using an inductive approach. 2. From these data a short prescribing tool was developed for GPs, together with an information handout for use with patients. Feedback on the tools was obtained from an e-survey of the initial interviewees and from two focus groups each with 12 diverse GP participants. In light of this the tools were refined.3. The tools were then trialed in two general practices. Five participating GPs have recruited 17 long-term NSAID users, aged 65 or over, to attend a free-of-charge appointment to discuss their NSAID use, with the aid of the study tools. GPs and patients were interviewed following the consultation about the tool’s acceptability and usefulness, and any resulting changes in NSAID prescribing. Participating GPs’ annual prescribing data before and after use of the tool will also be reviewed.

Findings

In the initial interviews, the benefits of NSAIDs were viewed as outweighing their risks in young, fit patients and those without co-morbidities. However, many GPs identified uncertainty about levels of risk in individual patients with potentially problematic co-morbidity. Some GPs were willing to consider the use of an NSAID in a higher-risk patient for a short time. The prescribing tool developed provided key messages succinctly for GPs and included alternative non-pharmacological approaches and medicines; gastric, cardiac and renal risks of NSAIDs; risk in children; practice points to adopt if prescribing. An information handout specifically designed to aid potentially challenging conversations with patients and suitable to be retained by the patient was also developed. Assessment of the value of the tools to both patients and GPs, and the impact on an individual GP and their practice’s NSAID prescribing is currently underway.

Consequences

A tool with concise, focussed, relevant educational messages for GPs has potential to shape GP prescribing of NSAIDs and reduce harm from their use. Furthermore, a related patient-friendly tool may facilitate potentially difficult conversations between GPs and their patients about this issue.