Pharmacist Interventions in Geriatric Nursing Facility NSAID Therapy: A One-Year Follow-up Study of Costs and Outcomes

Abstract

To document costs and outcomes occurring with acceptance or rejection of ongoing pharmacists' interventions regarding therapy with a nonsteroidal anti-inflammatory drug (NSAID) versus acetaminophen (APAP) therapy in treating osteoarthritis in a long-term care facility in the sixth year of observation. A nonrandomized observational prospective cohort study with all patients resident for 30 or more days over the 12-month study period receiving NSAID or APAP therapy for osteoarthritis. A skilled nursing facility with more than 100 beds. All patients had a monthly drug regimen review, receiving full-dose NSAIDs (not low-dose aspirin alone) on a continuous basis, and were selected for intervention. A control group of patients receiving APAP on a continuous basis also was selected for comparison of outcomes. Patients receiving NSAIDs had (1) periodic hemoglobin and hematocrit determinations; (2) physical assessment of lower eyelid, nailbed, and stool color; (3) and a recommendation to replace NSAID with APAP or to add gastroprotective pharmacotherapy if the NSAID was continued. Patients not receiving an NSAID for osteoarthritis and continuously taking APAP served as a control group. Cost-analysis calculations were performed for existing regimens versus cost savings that would be experienced with recommended pharmacotherapeutic interventions. Fourteen intervention subjects and sixteen control patients were identified. In the three patients for whom the pharmacist's recommendations were accepted within three months (11 NSAID-use months), there were three substitutions of APAP therapy observed over an additional 26 patient-months. Five of 11 patients in the NSAID group for whom pharmacists' recommendations were rejected developed gastrointestional (GI) bleeding, necessitating six hospitalizations. Two of these patients died over the study period. No group for whom APAP was accepted nor control-group patients experienced suspected GI bleeding. Total costs of the control group analgesic therapy was $756.74, or $47.30 per patient. Cost savings for APAP substitution in the intervention rejection group would exceed $91,000, while cost savings with the addition of hemoglobin and hematocrit determinations would exceed $84,200. Cost savings from addition of gastroprotectives to the NSAID would have been misoprostol, $73,000; omeprazole, $71,400. Refusal to accept pharmacists' intervention recommendations regarding alternatives to NSAID pharmacotherapy in this nursing facility population is associated with sustained and considerable costs, morbidity, and mortality.