Abstract
OBJECTIVE: To quantify medical care costs for the diagnosis and treatment of gastrointestinal disorders attributable to use of nonsteroidal anti-inflammatory drugs (NSAIDs) other than aspirin in elderly persons.
DESIGN AND SETTING: Retrospective cohort study of 75,350 Tennessee Medicaid enrollees at least 65 years of age.
MEASUREMENTS: The cohort was classified by baseline NSAID use as nonusers (no use preceding 1988), occasional users (⩾75% of days) or regular users (<75% of days). For the follow-up year (1989), we calculated annual rates of utilization of and Medicare/Medicaid payments for: medical care for NSAID-associated gastrointestinal disorders; hospitalizations/emergency department visits for peptic ulcers, gastritis/duodenitis, and gastrointestinal bleeding; outpatient upper and lower gastrointestinal tract radiologic and endoscopic examinations; and histamine2 (H2)-receptor antagonist, sucralfate, and antacid prescriptions. Rates were adjusted for demographic characteristics and baseline health care utilization.
RESULTS: Among nonusers of NSAIDs, the adjusted mean annual payment for all types of medical care for study gastrointestinal disorders was $134. This increased to $180 among occasional users, an excess of $46 (p<.001); and to $244 among regular users, an excess of $111 (p<.001, comparison with both nonusers and occasional users). Cohort members with any baseline year NSAID use had an adjusted mean annual payment of $191, $57 (p<.001) higher than that for nonusers. In both users and nonusers of NSAIDs, medications and inpatient care accounted for the largest component of costs. Among regular NSAID users, excess payments increased with baseline NSAID dose: $56, $120, and $157 for less than 1, 1 to 2, and more than 2 standard units per day, respectively (p<.01, linear trend).
CONCLUSIONS: Nonsteroidal anti-inflammatory drug (NSAID) use in elderly patients was associated with substantial excess costs and utilization of medical care for gastrointestinal disorders.
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Griffin MR. Piper JM. Daugherty JR. Snowden M. Ray WA. Non-steroidal anti-inflammatory drug use and increased risk for peptic ulcer disease in elderly persons. Ann Intern Med. 1991;114:257–63.
Somerville K, Faulkner G. Langmen M. Non-steroidal anti-inflammatory drugs and bleeding peptic ulcer. Lancet. 1986;1:462–4.
Chrischilles EA, Lemke JH, Wallace RB, Drube GA. Prevalence and characteristics of multiple analgesic drug use in an elderly study group. J Am Geriatr Soc. 1990;38:979–84.
Soil AH, Weinstein WM, Kurata J, McCarthy D. Nonsteroidal anti-inflammatory drugs and peptic ulcer disease. Ann Intern Med. 1991;114:307–19.
Allison MC, Howaston AG, Torrance CJ, Lee FD, Russell RI. Gastrointestinal damage associated with the use of nonsteroidal anti-inflammatory drugs. N Engl J Med. 1992;327:749–54.
Larkai EN. Smith JL, Lidsky MD, Graham DY. Gastroduodenal mucosa and dyspeptic symptoms in arthritis patients during chronic nonsteroidal anti-inflammatory drug use. Am J Gastroenterol. 1987;82:1153–8.
Graham DY, White RH, Moreland LW. et al. Duodenal and gastric ulcer presention with misoprostol in arthritic patients taking NSAIDs. Ann Intern Med. 1993;119:257–62.
Silvoso GR, Ivey KJ, Butt JH, et al. Incidence of gastric lesions in patients with rheumatic diseases on chronic aspirin therapy. Ann Intern Med. 1979;91:517–20.
Graham DY, Agrawal NM, Roth SH. Prevention of NSAID-induced gastric ulcer with misoprostol: multicentre, double-blind, placebo-controlled trial. Lancet. 1988;2:1277–80.
Smalley WE, Ray WA, Daugherty J, Griffin MR. Nonsteroidal anti-inflammatory drugs and the incidence of hospitalizations for peptic ulcer disease in elderly persons. Am J Epidemiol. 1995;141:539–45.
Griffin MR, Ray WA, Schaffner W. Nonsteroidal anti-inflammatory drug use and death from peptic ulcer in elderly persons. Ann Intern Med. 1988;109:359–63.
Drummond MF. Basing prescription drug payment on economic analysis: the case of Australia. Health Aff (Millwood). 1992;11:191–6.
Detsky AS, Naglie IG. A clinician’s guide to cost-effectiveness analysis. Ann Intern Med. 1990;113:147–54.
Walt RP. Misoprostol for the treatment of peptic ulcer and antiinflammatory-drug-induced gastroduodenal ulceration. N Engl J Med. 1992;327:1575–80.
Bradley JD, Brandt KD, Katz BP, Kalasinski LA, Ryan S. Comparison of an antiinflammatory dose of ibuprofen, an analgesic dose of ibuprofen, and acetaminophen in the treatment of patients with osteoarthritis of the knee. N Engl J Med. 1991;325:87–91.
Gotzsche PC. Review of dose-response studies of NSAIDs in rheumatoid arthritis. Dan Med Bull. 1989;36:395–9.
Kovar PA, Allegrante JP, MacKenzie R, Peterson MGE, Gutin B. Charlson ME. Supervised fitness walking in patients with osteoarthritis of the knee. Ann Intern Med. 1992;116:529–34.
Deal CL, Schnitzer TJ, Lipstein E, Seibold JR, Stevens RM, Levy MD. Treatment of arthritis with topical capsaicin: a double-blind trial. Clin Ther. 1991;13:383–95.
Felson DT, Zhang Y, Anthony JM, Naimark A, Anderson JJ. Weight loss reduces the risk for symptomatic knee osteoarthritis in women. Ann Intern Med. 1992;116:535–9.
Ray WA, Griffin MR. Use of Medicaid data for pharmacoepidemiology. Am J Epidemiol. 1989;129:837–49.
U.S. Department of Health and Human Services. The International Classification of Diseases, 9th Revision, Clinical Modification, ICD 9 CM. 2nd ed. Washington, DC: US Government Printing Office; 1980.
Latta VB, Helbing C. Medicare short-stay hospital services by diagnosis related groups. Health Care Financing Rev. 1991;12(4):105–25.
Kirshner CG, Burkett RC, Coy JA, et al. Physicians’ Current Procedural Terminology. 4th ed. Chicago, Ill: American Medical Association; 1993.
Drugs for rheumatoid arthritis. Med Lett Drugs Ther. 1993;33:65–70.
Duan N, Manning WG, Morris CN, Newhouse JP. A comparison of alternative models for the demand for medical care. J Bus Econ Stat. 1983;l:115–26.
Kemper P. The use of formal and informal home care by the disabled elderly. Health Serv Res. 1992;27:421–49.
McCullagh P, Nelder JA. Generalized Linear Models. 2nd ed. New York, NY: Chapman and Hall; 1989;193–208.
Kendall M, Stuart A. The Advanced Theory of Statistics. 4th ed. New York, NY:Macmillan; 1979;2:74.
Duan N. Smearing estimate: a nonparametric retransformation method. J Am Stat Assoc. 1983;78:605–10.
Wilcosky TC, Chambless LE. A comparison of direct adjustment and regression adjustment of epidemiologic measures. J Chron Dis. 1985;38:849–56.
Manning WG, Newhouse JP, Duan N, Keeler EB. Leibowitz A, Marquis MS. Health insurance and the demand for medical care: evidence from a randomized experiment. Am Econ Rev. 1987;77:251–77.
SAS Institute. The GLM procedure. In: SAS/STAT Users Guide, Version 6. Cary, NC: SAS Institute; 1989;890–996.
Roth SH, Bennett RE. Nonsteroidal anti-inflammatory drug gastropathy: recognition and response. Arch Intern Med. 1989;147:2093–100.
Gabriel SE, Jaakkimainen L, Bombardier C. Risk for serious gastrointestinal complications related to use of nonsteroidal anti-inflammatory drugs. A meta-analysis. Ann Intern Med. 1991;115:787–96.
Guess HA. West R. Stand LM. et al. Fatal upper gastrointestinal hemorrhage or perforation among users and non-users of non-steroidal anti-inflammatory drugs in Saskatchewan, Canada, 1983. J Clin Epidemiol. 1988;41:35–45.
Levy M, Miller DR, Kaufman DW, et al. Major upper gastrointestinal tract bleeding: relation to the use of aspirin and other nonnarcotic analgesics. Arch Intern Med. 1988;148:281–5.
Beard K, Walker AM, Perera DR, Jick H. Nonsteroidal anti-inflammatory drugs and hospitalization for gastroesophageal bleeding in the elderly. Arch Intern Med. 1987;147:1621–3.
Langman MJS, Morgan L, Worrall A. Use of anti-inflammatory drugs by patients admitted with small or large bowel perforations and hemorrhage. BMJ. 1985;290:347–9.
Campbell K, Steele RJC. Non-steroidal anti-inflammatory drugs and complicated diverticular disease: a case-control study. Br J Surg. 1991;78:190–1.
Morris AJ, Madhok R, Sturrock RD, Capell HA, MacKenzie JF. Enteroscopic diagnosis of small bowel ulceration in patients receiving nonsteroidal anti-inflammatory drugs. Lancet. 1991;337:520.
Bjarnason I, Prouse P, Smith T, et al. Blood and protein loss via small-intestinal inflammation induced by non-steroidal anti-inflammatory drugs. Lancet. 1987;711–4.
Kleinbaum DG, Kupper LL, Morgenstern H. Epidemiologic Research: Principles and Quantitative Methods. Belmont, Calif: Lifetime Learning Publications; 1983.
Bloom BS. Risk and cost of gastrointestinal side effects associated with nonsteroidal anti-inflammatory drugs. Arch Intern Med. 1989;149:1019–22.
Gabriel SE, Jaakkimainen RL, Bombardier C. The cost-effectiveness of misoprostol for nonsteroidal antinflammatory drug-associated adverse gastrointestinal events. Arthritis Rheum. 1993;36(4):447–59.
Edelson JT, Tosteson ANA, Sax P. Cost-effectiveness of misoprostol for prophylaxis against nonsteroidal anti-inflammatory drug-induced gastrointestinal tract bleeding. JAMA. 1990;264:41–7.
Hillman AL, Bloom BS. Economic effects of prophylactic use of misoprostol to prevent gastric ulcer in patients taking nonsteroidal anti-inflammatory drugs. Arch Intern Med. 1989;149:2061–5.
Knill-Jones R, Drummond M, Kohli H. Davies L. Economic evaluation of gastric ulcer prophylaxis in patients with arthritis receiving non-steroidal anti-inflammatory drugs. Postgrad Med J. 1990;66:639–46.
Carrin GJ, Torfs KE. Economic evaluation of prophylactic treatment with misoprostol in osteoarthritic patients treated with NSAIDs. The case of Belgium. Rev Epidemiol Sante Publique. 1990;38:187–99.
de Pouvourville G. The economic consequences of NSAID-induced gastropathy: the French context. Scand J Rheumatol. 1992;96(suppl):49–53.
Stewart RB, Hale WE, Marks RG. Analgesic drug use in an ambulatory elderly population. Drug Intell Clin Pharmacol. 1982;16:833.
Graves EJ. Detailed diagnoses and procedures. National Hospital Discharge Survey, 1989. National Center for Health Statistics. Vital Health Stat. 1991;13:108.
McCarthy GM. McCarty DJ. Effect of topical capsaicin in the therapy of painful osteoarthritis of the hands. J Rheumatol. 1992;19:604–7.
Tomita DK, Kennedy DL, Baum C. Knapp DE. Anello C. Drug Utilization in the United States: 1988. Tenth Annual Review. Washington, DC: Department of Health and Human Services; 1989.
Tomita DK, Baum C, Kennedy DL, Knapp DE, Perry ZA. Drug Utilization in the United States: 1987. Ninth Annual Review. Washington, DC: Department of Health and Human Services; 1988.
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Supported in part by a grant from the Agency for Health Care Policy Research (HS07768) and a cooperative agreement with the Food and Drug Administration (FD-U-0000073). Dr. Smalley was a Ciba-Geigy Fellow in Pharmacoepidemiology during the preparation of this manuscript.
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Smalley, W.E., Griffin, M.R., Fought, R.L. et al. Excess costs from gastrointestinal disease associated with nonsteroidal anti-inflammatory drugs. J Gen Intern Med 11, 461–469 (1996). https://doi.org/10.1007/BF02599040
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DOI: https://doi.org/10.1007/BF02599040