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.
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.
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).
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.