Reducing NSAID Prescriptions in Patients Receiving ACE Inhibitors/ARBs and Diuretics: A Quality Improvement Initiative

Abstract

Background: Concurrent prescribing of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) to patients taking an ACE inhibitor or Angiotensin Receptor Blocker (ARB) together with a diuretic (“triple whammy”) increases Acute Kidney Injury (AKI) risk. This Quality Improvement (QI) initiative sought to reduce avoidable NSAID prescribing among high-risk patients in primary care.

Objective: To reduce NSAID prescriptions by 50% among adults concurrently receiving ACEI/ARB and a diuretic over a 3-month period (May–July 2024).

Methods: Using the Institute for Healthcare Improvement Model for Improvement, we implemented prescriber education, pharmacist counseling, and monthly electronic medical record (EMR) audits. The primary outcome was the monthly proportion of high-risk patients receiving an NSAID; 95% Confidence Intervals (CI) were calculated and a chi-square test assessed change across months.

Results: NSAID prescribing decreased from 31.0% (9/29) in May to 21.7% (5/23) in June and 14.3% (3/21) in July. This represented a 54.0% relative reduction. Chi-square test of independence: χ²=1.96, p=0.376. Two-proportion (May vs July) z-test: z=1.37, p=0.171. Balancing measures included qualitative patient feedback on pain control.

Conclusions: A structured QI approach integrating prescriber education, pharmacist counseling, and EMR audit feedback achieved a substantial reduction in NSAID prescribing among patients at elevated AKI risk.