Encouraging physician appropriate prescribing of non-steroidal anti-inflammatory therapies: protocol of a randomized controlled trial [ISRCTN43532635]

This is an ongoing, randomized controlled trial. All primary care physicians in Manitoba, Canada have been randomly assigned to a control group or an intervention study group. The educational intervention being evaluated consists of an audit and feedback mechanism combined with optional participation in a Continuing Medical Education interactive workshop. The primary outcome of the study is the change, from pre-to post-intervention, in physicians' appropriate prescribing of non-steroidal anti-inflammatory therapies for patients requiring chronic treatment. Three classes of non-steroidal anti-inflammatory therapies have been identified: coxib therapy, traditional NSAID monotherapy, and traditional NSAID therapy combined with gastro-protective agents. Appropriate prescribing is defined based on international clinical practice guidelines and the provincial drug reimbursement policy in Manitoba.Traditional non-steroidal anti-inflammatory drugs (NSAIDs) are a widely prescribed class of therapy used to relieve pain and inflammation. The drugs have been shown to be effective for a variety of common disorders (hence their widespread use), most notably chronic osteoarthritis and rheumatoid arthritis. They are relatively inexpensive due to the available generic versions, but unfortunately have clinically important drawbacks related to their gastrointestinal (GI) toxicity [1]. Each year, about 1% to 1.5% of patients taking traditional NSAIDs experience serious GI side effects such as perforations, ulcers, and bleeding [2-5]. When multiplied by the total number of NSAID users this translates into significant patient morbidity and mortality [1,6] and is associated with considerable health care costs related to hospitalizations or to the prescribing of expensive gastro-protective agents (GPAs) [7-12]. The cause of this GI toxicity is the "non-selective nature" of traditional NSAIDs that block both cyclo-oxygenase-2 (Cox-2), an enzyme involved in the production of inflammation and