SPECIAL

Informatics: Detecting risks in elderly patients taking NSAIDs

DNP
SECTION

Informatics
Detecting risks in elderly
patients taking NSAIDs
Abstract: Nonsteroidal anti-inflammatory drugs are strongly associated with gastrointestinal
bleeding among the elderly population. NPs may find the utilization of healthcare informatics
beneficial when addressing adverse events such as this. The innovative healthcare information
technology products available today assist with increasing the quality, safety, and efficiency of
Illustration by Lisa Dischert images istockphoto/Suni/Volodin/Yakobchuk/Khomulo

healthcare delivery.

By Mary Atkinson Smith, MSN, FNP-BC; Connie Hampton, RN, MSN; Lauren Rodier, MSN, FNP-BC, WHNP;
Ashley Taylor, FNP-BC, PMHNP; and Carlotta Taylor-White, APRN-BC

onsteroidal anti-inflammatory drugs (NSAIDs) thwarting the development of adverse events. The purpose

N have long been associated with gastrointestinal

(GI) bleeding, hospitalization and even death.
There is an even greater risk of this occurrence among the
elderly population. NPs may find the utilization of currently
available healthcare informatics tools, such as national data-
bases, beneficial when collecting and analyzing data related
to the incidence and prevalence of GI bleeding among the
elderly taking NSAIDs. The NP may also find clinical deci-
sion software systems (CDSSs) provide excellent support
when it comes to identifying this at-risk population and
of this article is to discuss how healthcare informatics can
assist the NP with assessment of the prevalence of NSAID-
associated GI bleeding among the elderly and implementa-
tion of prevention strategies to help decrease the incidence
of GI bleeding among this vulnerable population.
Elderly and NSAID use
The elderly population that participates in self-medicating
with over-the-counter NSAID products are at an increased
risk for GI bleeding. Self-medicating in the elderly population

Key words: clinical decision software systems use with electronic prescribing, healthcare databases, health information technology,
nonsteroidal anti-inflammatory drug risks.
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 Informatics: Detecting risks in elderly patients taking NSAIDs
may be responsible for over one-third of the complications
related to NSAID use.1 Upper GI symptoms are twice as likely
to occur when taking NSAIDs.1 Individuals who routinely
take high amounts of over-the-counter NSAIDs are three
times more likely to develop GI bleeding.2 Twenty percent of
patients taking traditional over-the-counter NSAIDs experi-
ence adverse GI events and 107,000 hospitalizations along
with 16,000 deaths each year are a result of GI complications
attributed to NSAID use.3 A cross-sectional retrospective
study performed by Marco, Amariles, Bosca, and Castello
concluded age to be the most prevalent relevant risk fac-
tor (75.6%) for GI bleeding due to NSAID use. Therefore,
the incidence of NSAID-related adverse reactions increases
with age and they are more likely to develop in the elderly
population.4
The American Geriatric Society (AGS) updated their
guidelines in 2009 regarding NSAID use among the el-
derly.5 The AGS now recommends that acetaminophen
instead of NSAIDs be used among the elderly for the
initial and continued treatment of pain, especially mus-
culoskeletal-related pain. Due to NSAIDs having a history
of causing significant GI-related adverse events, pain
control with NSAIDs should be considered very rarely
and with extreme caution, especially among the elderly
population.3
Healthcare databases
Healthcare databases are banks of healthcare-related in-
formation that is stored in an organized fashion so that
it may be retrieved for meaningful use. The data that are
stored in these databases are derived from sources such as
hospital associations, private data organizations, and the
state and federal government. Meaningful use may include
extracting data to allow an organization to benchmark their
services against similar organizations or collecting data
for research purposes. There are many national databases
in existence today. Some databases allow free access of in-
formation, while others require a fee for access. Examples
of currently available databases include the Healthcare
Cost and Utilization Project (HCUP) Nationwide Inpa-
tient Sample from the Agency for Healthcare Research
and Quality and the National Database of Nursing Quality
Indicators (NDNQI).
Benefits of use
There are several advantages to accessing data from health-
care databases. NPs may access diagnosis-specific data to
further investigate clinical areas of concern or inquiry. The
data obtained can reveal the prevalence and incidence of
certain medical conditions in addition to the outcomes of
various treatment modalities. Data related to costs, inci-
52 The Nurse Practitioner Vol. 36, No. 4
Copyright 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
dence, and prevalence may be extracted per region or type
of agency. Obtaining this information from healthcare
databases allows the NP to utilize evidence-based practice,
which will lead to an increase in cost-effective, high-quality
care and encourage positive patient outcomes.6 (See Benefits
of utilizing healthcare databases).
Database utilization
The authors utilized the HCUP Nationwide Inpatient Sam-
ple to evaluate for a trend in ED admissions over a 2-year
period among the elderly with a diagnosis of NSAID-related
GI bleeding.7 A convenience sample was collected using
data from the HCUP Nationwide Inpatient Sample.8 The
data consisted of the following: EDs utilizing the clinical
classifications software from all hospitals, first listed diag-
noses, GI hemorrhage ICD-9 code 153, total number of
ED visits, total number of patients age 65 and older from
the geographical northeast, south, west, Midwest, number
of patients discharged from ED, number of patients who
died in ED, number of patients who were admitted for
inpatient care, and number of patients who died while in
inpatient care.
Based on the data collected from the HCUP Nationwide
Inpatient Sample, the total number of ED patients present-
ing with ICD-9 code 153 decreased in 2007 from 251,489 to
248,399. 8 This is a 1% decrease nationally, indicating a sta-
tistically weak decrease of ED visits. The statistical data from
this retrospective review show a small decrease in subjects
presenting to the ED. They also reveal that geographical ar-
eas of the nation that had an increase in ED visits associated
with NASID-related GI bleeding were the Northeastern,
Western, and Midwestern areas of the nation. In 2007, the
number of ED deaths related to GI bleeding among NSAID
users increased from 504 subjects to 683 subjects, resulting
in a 35% increase overall.8
Clinical decision support systems
CDSSs are interactive computer software programs that
assist healthcare providers with making clinical deci-
sions. CDSSs can also assist with diagnosis determination
and analysis of patient data. CDSSs have been recom-
mended for use with electronic prescribing for inpatient
and ambulatory settings to help decrease the incidence of
inappropriate prescribing and avoidance of adverse drug
events. CDSSs may be used alone or incorporated into
an electronic medical record. Utilization of these CDSSs
is not meant to replace sound clinical judgment, but en-
hance it. Clinical decision-making can be influenced by
multiple factors such as experience, reasoning, research
data, and clinical guidelines by accrediting bodies. Re-
search has indicated that more positive outcomes and
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 Informatics: Detecting risks in elderly patients taking NSAIDs
higher quality of care occurs when healthcare providers
use CDSSs.8
Benefits of use
CDSSs require NPs to utilize their own knowledge when
interacting with the software to ensure a more thorough
analysis of patient data. The CDSS will then produce rec-
ommendations regarding plan of care. The NP is able to
tailor this recommended plan of care by selecting or delet-
ing specific items. Implementing CDSS use when treating
elderly patients who take NSAIDs will assist the NP by
ensuring utilization of recommended prevention strategies
related to NSAID-induced GI bleeding in the elderly, thus
leading to improved health outcomes. Implementation
and utilization of these available CDSSs has been shown
to improve the quality of healthcare, improve patient out-
comes, enhance the patients quality of life, and empower
patients to play a more proactive role in their healthcare
regime.8 The Institute of Medicine endorses the use of
CDSSs to encourage adherence to condition-specific clini-
cal guidelines.9
Clinical study
Berner et al. conducted a randomized controlled trial involv-
ing the use of CDSSs among 68 consenting Internal Medi-
cine resident physicians.9 The study design was randomized
using preintervention and postintervention assessment of
safe prescribing methods. The CDSS was customized to
include a NSAID GI risk assessment with treatment recom-
mendations and the GI SCORE (Stanford Calculator of Risk
and Events) from Stanford University.10 The NSAID GI risk
assessment was used to assess six established risk factors for
GI complications including: age, self-assessed health status,
diagnosis of rheumatoid arthritis, corticosteroid use, history
of GI hemorrhage, and history of hospitalization for ulcer
or symptoms with NSAID use. The presence or absence
of these risk factors serves as a guideline for prescribing
NSAIDs. A GI risk score of 15 and lower indicates safe use
of NSAIDs, and scores of 16 or above indicate moderate risk
with extended use. This study revealed the use of a CDSS
designed for GI risk assessment when prescribing NSAIDs
improved clinical safety by 50%.9
Decreasing prevalence
Medical professionals have long been aware of the potential
for GI bleeding among the elderly taking NSAID medica-
tions. The data collected from the HCUP database reveal that
despite more than a decade of knowledge of the hazards of
NSAIDs for GI bleeding, ED admissions for this condition
continue at a significant rate. NPs should consider utilizing
a CDSS to screen for GI bleeding risk before prescribing
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Copyright 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Benefits of utilizing healthcare databases
Provides organized diagnosis-specific data
Data may be extracted based on costs, incidence, and
prevalence
Data may be obtained by region or type of agency
Allows for investigation of clinical interest or inquiry
Allows for comparing or benchmarking
Provides data of diagnosis-specific tests, procedures,
and interventions
Provides data pertaining to diagnosis-specific patient
outcomes
Encourages evidence-based practice
NSAIDs. CDSSs have been identified as a helpful resource
for NPs when prescribing NSAIDs and may be beneficial
in decreasing the prevalence of NSAID-related GI bleeding
in the elderly. Additionally, NPs should also take advantage
of available online databases to assist them with clinical
decision-making and the improvement of the delivery of
healthcare services.
ACKNOWLEDGMENTS
The authors wrote this manuscript as an assignment in their Informatics
for Advance Nursing Practice course, which is a component of the Doctor of
Nursing Practice (DNP) curriculum at the University of Alabama Capstone
College of Nursing in Tuscaloosa, AL. They would like to thank faculty member
Ruby Morrison, DSN, RN, CNL for her guidance and expertise.
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Mary Atkinson Smith is an NP at Starkville Orthopedic Clinic and sole proprietor of
Golden Triangle Geriatric Consulting, Starkville, Miss. Connie Hampton is a nurse
manager in Medical/Oncology at the Atlanta VA Medical Center, Decatur, GA. Lauren
Rodier is Health Services Chief, County of Honolulu, Hawaii. Ashley Taylor is an NP at
Mountain Home VA Medical Center, Johnson City, Tenn. Carlotta Taylor-White is an
adult NP in the preadmission center at Barnes Jewish Hospital, St. Louis, Mo.
DOI-10.1097/01.NPR.0000394995.79798.9c
The Nurse Practitioner April 2011 53