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Bjelkarøy MT, Simonsen TB, Siddiqui TG, Halset S, Cheng S, Grambaite R, Benth JŠ, Gerwing J, Kristoffersen ES, Lundqvist C. Brief Intervention as a Method to Reduce Z-Hypnotic Use by Older Adults: Feasibility Case Series. JMIR Form Res 2024; 8:e51862. [PMID: 38329779 PMCID: PMC10884901 DOI: 10.2196/51862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 01/06/2024] [Accepted: 01/18/2024] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND Z-hypnotics or z-drugs are commonly prescribed for insomnia and sleep difficulties in older adults. These drugs are associated with adverse events and dependence and are not recommended for long-term use. Despite evidence of older adults being more sensitive to a wide array of adverse events and clinical guidelines advocating limiting use, inappropriate use in this population is still prevalent. Previous intervention studies have focused mainly on prescriber information. Simple, individually focused intervention designs are less studied. Brief intervention (BI) is a simple, easily transferable method mainly used to treat patients at risk of alcohol overuse. OBJECTIVE Our objective was to design and test the feasibility and acceptability of a BI intervention adapted to address individual, inappropriate use of z-hypnotics among older adults. This preparatory study aimed to optimize the intervention in advance of a quantitative randomized controlled trial investigating the treatment effect in a larger population. METHODS This feasibility case series was conducted at Akershus University Hospital, Norway, in autumn 2021. We included 5 adults aged ≥65 years with long-term (≥4 weeks) use of z-hypnotics and 2 intervening physicians. Additionally, 2 study investigators contributed with process evaluation notes. The BI consists of information on the risk of inappropriate use and individualized advice on how to reduce use. The focus of the intervention is behavioral and aims, in cooperation with the patient and based on shared decision-making, to change patient behavior regarding sleep medication rather than physician-based detoxification and termination of z-hypnotic prescriptions. Qualitative and descriptive quantitative data were collected from intervening physicians, study investigators, and participants at baseline, immediately after the intervention, and at the 6-week follow-up. RESULTS Data were obtained from 2 physicians, 2 study investigators, and 5 participants (4 women) with a median age of 84 years. The average time spent on the BI consultation was 15 minutes. All 5 participants completed the intervention without problems. The participants and 2 intervening physicians reported the intervention as acceptable and were satisfied with the delivery of the intervention. After the intervention, 2 participants stopped their use of z-hypnotics completely and participated in the follow-up interview. Study investigators identified logistical challenges regarding location and time requirements. Identified aspects that may improve the intervention and reduce dropouts included revising the intervention content, focusing on rebound insomnia, adding an information leaflet, and supporting the patient in the period between the intervention and follow-up. The notion that the intervention should best be located and conducted by the patient's own general practitioner was supported by the participants. CONCLUSIONS We identified important aspects to improve the designed intervention and found that the BI is feasible and acceptable for incorporation into a larger randomized trial investigating the treatment effect of BI for reducing z-hypnotic use by older adults. TRIAL REGISTRATION ClinicalTrials.gov NCT03162081; http://tinyurl.com/rmzx6brn.
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Affiliation(s)
- Maria Torheim Bjelkarøy
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Campus Ahus, Lørenskog, Norway
- Health Services Research Unit Helsetjenesteforskning, Akershus University Hosptial, Lørenskog, Norway
| | - Tone Breines Simonsen
- Health Services Research Unit Helsetjenesteforskning, Akershus University Hosptial, Lørenskog, Norway
| | - Tahreem Ghazal Siddiqui
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Campus Ahus, Lørenskog, Norway
- Health Services Research Unit Helsetjenesteforskning, Akershus University Hosptial, Lørenskog, Norway
| | - Sigrid Halset
- Department of Geriatrics, Akershus University Hospital, Lørenskog, Norway
| | - Socheat Cheng
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Campus Ahus, Lørenskog, Norway
- Health Services Research Unit Helsetjenesteforskning, Akershus University Hosptial, Lørenskog, Norway
| | - Ramune Grambaite
- Health Services Research Unit Helsetjenesteforskning, Akershus University Hosptial, Lørenskog, Norway
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Campus Ahus, Lørenskog, Norway
- Health Services Research Unit Helsetjenesteforskning, Akershus University Hosptial, Lørenskog, Norway
| | - Jennifer Gerwing
- Health Services Research Unit Helsetjenesteforskning, Akershus University Hosptial, Lørenskog, Norway
| | - Espen Saxhaug Kristoffersen
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Christofer Lundqvist
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Campus Ahus, Lørenskog, Norway
- Health Services Research Unit Helsetjenesteforskning, Akershus University Hosptial, Lørenskog, Norway
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
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Takamine L, Krein SL, Ratliff E, Strominger J, Virk A, Maust DT. Examining Adult Patients' Success with Discontinuing Long-term Benzodiazepine Use: a Qualitative Study. J Gen Intern Med 2024; 39:247-254. [PMID: 37653209 PMCID: PMC10853089 DOI: 10.1007/s11606-023-08385-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/18/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Little is known about patients' experiences with benzodiazepine (BZD) discontinuation, which is thought to be challenging given the physiological and psychological dependence and accompanying potential for significant withdrawal symptoms. The marked decline in BZD prescribing over the past decade in the US Department of Veterans Affairs healthcare system presents an important opportunity to examine the experience of BZD discontinuation among long-term users. OBJECTIVE Examine the experience of BZD discontinuation among individuals prescribed long-term BZD treatment to identify factors that contributed to successful discontinuation. DESIGN Descriptive qualitative analysis of semi-structured interviews conducted between April and December of 2020. PARTICIPANTS A total of 21 Veterans who had been prescribed long-term BZD pharmacotherapy (i.e., > 120 days of exposure in a 12-month period) and had their BZD discontinued. APPROACH We conducted semi-structured interviews with Veteran participants to learn about their BZD use and the process of discontinuation, with interviews recorded and transcribed verbatim. Data were deductively and inductively coded and coded text entered into a matrix to identify factors that contributed to successful BZD discontinuation. KEY RESULTS The mean age of interview participants was 63.0 years (standard deviation 3.9); 94.2% were male and 76.2% were white. Of 21 participants, only 1 had resumed BZD treatment (prescribed by a non-VA clinician). Three main factors influenced success with discontinuation: (1) participants' attitudes toward BZDs (e.g., risks of long-term use, perceived lack of efficacy, potential for dependence); (2) limited withdrawal symptoms; and (3) effective alternatives, either from their clinician (e.g., medication, psychotherapy) or identified by participants. CONCLUSIONS BZD discontinuation after long-term use is relatively well tolerated, and participants appreciated reducing their medication exposure, particularly to one associated with physical dependence. These findings may help reduce both patient and clinician anxiety related to BZD discontinuation.
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Affiliation(s)
- Linda Takamine
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI, USA.
| | - Sarah L Krein
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Erika Ratliff
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Julie Strominger
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI, USA
| | - Amarra Virk
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, FL, USA
| | - Donovan T Maust
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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Maust DT, Petzold K, Strominger J, Kim HM, Bohnert ASB. Benzodiazepine Discontinuation and Mortality Among Patients Receiving Long-Term Benzodiazepine Therapy. JAMA Netw Open 2023; 6:e2348557. [PMID: 38117495 PMCID: PMC10733804 DOI: 10.1001/jamanetworkopen.2023.48557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/07/2023] [Indexed: 12/21/2023] Open
Abstract
Importance There is interest in reducing long-term benzodiazepine prescribing given harms associated with use, but the cumulative risks or benefits of discontinuation are unknown. Objective To identify the association of benzodiazepine discontinuation with mortality and other adverse events among patients prescribed stable long-term benzodiazepine therapy, stratified by baseline opioid exposure. Design, Setting, and Participants This comparative effectiveness study with a trial emulation approach included data from a US commercial insurance database between January 1, 2013, and December 31, 2017. Eligible participants were adults with stable long-term benzodiazepine prescription treatment. Data were analyzed between December 2022 and November 2023. Exposure Benzodiazepine discontinuation, defined as no benzodiazepine prescription coverage for 31 consecutive days identified during a 6-month grace period after baseline. Main Outcome and Measures Mortality during 12 months of follow-up; secondary outcomes included nonfatal overdose, suicide attempt or self-inflicted injury, suicidal ideation, and emergency department use, identified in medical claims. Inverse probability weighting was used to adjust for baseline confounders that potentially affected treatment assignment and censoring due to death or disenrollment. Primary analysis used an intention-to-treat approach; a secondary per-protocol analysis estimated associations after accounting for nonadherence. Analyses were stratified by opioid use. Results The study included 213 011 (136 609 female [64.1%]; mean [SD] age, 62.2 [14.9] years; 2953 Asian [1.4%], 18 926 Black [8.9%], 22 734 Hispanic [10.7%], and 168 398 White [60.2%]) and 140 565 (91 811 female [65.3%]; mean [SD] age, 61.1 [13.2] years; 1319 Asian [0.9%], 15 945 Black [11.3%], 11 989 Hispanic [8.5%], and 111 312 White [79.2%]) patients with stable long-term benzodiazepine use without and with opioid exposure, respectively. Among the nonopioid exposed, the adjusted cumulative incidence of death after 1 year was 5.5% (95% CI, 5.4%-5.8%) for discontinuers, an absolute risk difference of 2.1 percentage points (95% CI, 1.9-2.3 percentage points) higher than for nondiscontinuers. The mortality risk was 1.6 (95% CI, 1.6-1.7) times that of nondiscontinuers. Among those with opioid exposure, the adjusted cumulative incidence of death was 6.3% (95% CI, 6.0%-6.6%) for discontinuers, an absolute risk difference of 2.4 percentage points (95% CI, 2.2-2.7 percentage points) higher than for nondiscontinuers and a mortality risk 1.6 (95% CI, 1.5-1.7) times that of nondiscontinuers. Cumulative incidence of secondary outcomes was also higher among discontinuers. Conclusions and Relevance This study identifies small absolute increases in risk of harms among patients with stable long-term prescription benzodiazepine treatment who appear to discontinue relative to continuing treatment, including those with and without recent prescription opioid exposure. Policy broadly promoting benzodiazepine discontinuation may have unintended risks.
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Affiliation(s)
- Donovan T. Maust
- Department of Psychiatry, University of Michigan, Ann Arbor
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Kierstdea Petzold
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Julie Strominger
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - H. Myra Kim
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Center for Statistical Consultation and Research, University of Michigan, Ann Arbor
| | - Amy S. B. Bohnert
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Anesthesiology, University of Michigan, Ann Arbor
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Chahal K, Glass M, Falk J, Singer A, Leong C. Patient values and preferences regarding communicating risk versus benefit of benzodiazepine initiation: A cross-sectional survey study. Health Sci Rep 2023; 6:e1597. [PMID: 38045626 PMCID: PMC10690834 DOI: 10.1002/hsr2.1597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/22/2023] [Accepted: 09/18/2023] [Indexed: 12/05/2023] Open
Abstract
Background and Aims Communicating information about the risks and benefits of benzodiazepines so that it is meaningful to the patient has not been previously described. This study aims to determine patient preferences regarding information received before initiating a benzodiazepine. Methods An online survey was distributed through social media and advertisements to Canadians ≥18 years old over a 6-month period (May-Oct 2022) to collect participant's rating of importance of statements and factors about the risk and benefits of benzodiazepines before initiating treatment using a 10-point Likert-type scale. Treatment preferences based on efficacy and risk information were also elicited. The survey was developed and pilot-tested in collaboration with an advisory committee of individuals with lived and living experience with benzodiazepine use. Results Thirty-seven participants responded to the survey (mean age 30 years old, 81.1% identified as female). The majority of respondents had a history of anxiety (83.8%) or insomnia (32.4%), and 10 (27.0%) respondents had used a benzodiazepine. Patient counseling related to withdrawal symptoms of benzodiazepines, risk of harm in combination with other sedating agents, risk of physical and psychological dependence, and risk of effects on cognition were rated high in the importance of receiving this information before starting a benzodiazepine relative to efficacy endpoints, such as improvement in sleep parameters. When provided with information about the chance of efficacy and risk of harm, 100% would have selected cognitive behavioral therapy as the best treatment option. The most frequently reported source of medication information where patients have sought information was from the internet (25.0%), followed by doctors (21.9%) and pharmacists (18.8%). Conclusions This study identified patient important factors and statements viewed as important to communicate before initiating a benzodiazepine. The findings of this survey study will help inform decision-making when considering treatment options for managing anxiety or insomnia.
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Affiliation(s)
- Karn Chahal
- College of Pharmacy, Rady Faculty of Health Sciences University of Manitoba Winnipeg Manitoba Canada
| | - Matthew Glass
- College of Pharmacy, Rady Faculty of Health Sciences University of Manitoba Winnipeg Manitoba Canada
| | - Jamie Falk
- College of Pharmacy, Rady Faculty of Health Sciences University of Manitoba Winnipeg Manitoba Canada
| | - Alexander Singer
- Department of Family Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences University of Manitoba Winnipeg Manitoba Canada
| | - Christine Leong
- College of Pharmacy, Rady Faculty of Health Sciences University of Manitoba Winnipeg Manitoba Canada
- Department of Psychiatry, Max Rady College of Medicine, Rady Faculty of Health Sciences University of Manitoba Winnipeg Manitoba Canada
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Kosto A, Lev D, Reiss N, Meged-Book T, Press Y. Discontinuation of benzodiazepines and Z-drugs in hospitalised population at the age of 60 and above. An open-label randomized controlled trial. Int J Geriatr Psychiatry 2023; 38:e6012. [PMID: 37807766 DOI: 10.1002/gps.6012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/25/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Treating insomnia with hypnotic drugs in elderly patients has many adverse effects. This study aims to assess the effect of two discontinuation methods of hypnotic drugs during acute hospitalization. METHODS We conducted an open-label randomized controlled trial that included participants aged 60 and above taking benzodiazepines or Z-Drugs for at least 3 months as a treatment for insomnia and were admitted to the hospital. In the prospective arm, patients were randomly assigned into two intervention groups. In the Minimal Intervention (MI) group, patients received an explanation of the dangers of long-term treatment and a recommendation to stop the treatment. In the Tapering Down Intervention (TDI) group, in addition to the explanation, patients received a tapering down table. In the retrospective arm (control group), we examined the use of hypnotic drugs among hospitalized patients 3 months after hospitalization, similar to the patients in the prospective arm. RESULTS 46 patients were enrolled in the MI group, 55 patients in the TDI group, and 114 patients in the control group. The mean age in the three groups was 75.0 ± 8.2, 75.9 ± 9.0, and 75.0 ± 7.9 years respectively (p = 0.85). After 3 months, seven (15.2%) of the patients in the MI group, 15 (27.3%) in the TD group, and 2 (1.8%) in the control group (p = 0.00003) were weaned from the hypnotic drugs treatment, without a significant difference between the intervention groups (p = 0.221). CONCLUSIONS A short intervention during hospitalization results in a significant decrease in hypnotic drug use.
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Affiliation(s)
- Amit Kosto
- Department of Internal Medicine, Soroka Medical Center, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Danielle Lev
- Department of Internal Medicine, Soroka Medical Center, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Nadav Reiss
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Psychiatry, Soroka Medical Center, Beer-Sheva, Israel
| | - Tehilah Meged-Book
- Department of Internal Medicine, Soroka Medical Center, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Yan Press
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel
- Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer- Sheva, Israel
- Unit for Community Geriatrics, Division of Health in the Community, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Center for Multidisciplinary Research in Aging, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Nizet P, Evin A, Brociero E, Vigneau CV, Huon JF. Outcomes in deprescribing implementation trials and compliance with expert recommendations: a systematic review. BMC Geriatr 2023; 23:428. [PMID: 37438697 DOI: 10.1186/s12877-023-04155-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 07/05/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Deprescribing, defined as discontinuing or reducing the dose of medications that are no longer needed or for which the risks outweigh the benefits is a way to reduce polypharmacy. In 2022, the US Deprescribing Research Network (USDeN) published recommendations concerning the measurement of outcomes for deprescribing intervention studies. The objectives of this systematic review were to identify the outcome categories used in deprescribing intervention trials and to relate them to the previously published recommendations. METHODS We searched MEDLINE, Embase, PsychInfo, and the Cochrane library from January 2012 through January 2022. Studies were included if they were randomized controlled trials evaluating a deprescribing intervention. After data extraction, outcomes were categorized by type: medication outcomes, clinical outcomes, system outcomes, implementation outcomes, and other outcomes based on the previously published recommendations. RESULTS Thirty-six studies were included. The majority of studies focused on older adults in nursing homes and targeted inappropriate medications or polypharmacy. In 20 studies, the intervention was a medication review; in seven studies, the intervention was educational or informative; and three studies based their intervention on motivational interviewing or patient empowerment. Thirty-one studies presented a medication outcome (primary outcome in 26 studies), 25 a clinical outcome, 18 a system outcome, and seven an implementation outcome. Only three studies presented all four types of outcomes, and 10 studies presented three types of outcomes. CONCLUSIONS This review provides an update on the implementation of gold standard deprescribing studies in clinical practice. Implementation outcomes need to be developed and specified to facilitate the implementation of these practices on a larger scale and clinical outcome need to be prioritized. Finally, this review provides new elements for future real-life deprescribing studies.
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Affiliation(s)
- Pierre Nizet
- Nantes Université, CHU Nantes, 44000, Pharmacie, France.
- U1246 SPHERE "methodS in Patient-Centered Outcomes and HEalth ResEarch", Université de Nantes, Université de Tours, INSERM, Nantes, France.
| | - Adrien Evin
- Nantes Université, CHU Nantes, Service de Soins Palliatifs Et de Support, 44000, Nantes, France
| | - Emma Brociero
- Nantes Université, CHU Nantes, 44000, Pharmacie, France
| | - Caroline Victorri Vigneau
- U1246 SPHERE "methodS in Patient-Centered Outcomes and HEalth ResEarch", Université de Nantes, Université de Tours, INSERM, Nantes, France
- Nantes Université, CHU Nantes, Service de Pharmacologie Clinique, 44000, Nantes, France
| | - Jean-François Huon
- Nantes Université, CHU Nantes, 44000, Pharmacie, France
- U1246 SPHERE "methodS in Patient-Centered Outcomes and HEalth ResEarch", Université de Nantes, Université de Tours, INSERM, Nantes, France
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Van der Linden L, Hias J, Liesenborghs A, Walgraeve K, Van Brantegem P, Hellemans L, Milisen K, Tournoy J. The impact of a pharmacist intervention on post-discharge hypnotic drug discontinuation in geriatric inpatients: a before-after study. BMC Geriatr 2023; 23:407. [PMID: 37400758 DOI: 10.1186/s12877-023-04139-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 06/27/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Chronic use of hypnotic agents is prevalent in older adults, who as a result are at increased risk for certain adverse events, such as day-time drowsiness and falls. Multiple strategies to discontinue hypnotics have been tested in geriatric patients, but evidence remains scarce. Hence, we aimed to investigate a multicomponent intervention to reduce hypnotic drug use in geriatric inpatients. METHODS A before-after study was performed on the acute geriatric wards of a teaching hospital. The before group (= control group) received usual care, while intervention patients (= intervention group) were exposed to a pharmacist-led deprescribing intervention, comprising education of health care personnel, access to standardized discontinuation regimens, patient education and support of transitional care. The primary outcome was hypnotic drug discontinuation at one month after discharge. Secondary outcomes among others were sleep quality and hypnotic use at one and two weeks after enrolment and at discharge. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) upon inclusion, two weeks after enrolment and one month after discharge. Determinants for the primary outcome were identified using regression analysis. RESULTS A total of 173 patients were enrolled, with 70.5% of patients taking benzodiazepines. Average age was 85 years (interquartile range 81-88.5) and 28.3% were male. A higher discontinuation rate at one month after discharge was observed in favour of the intervention (37.7% vs. 21.9%, p = 0.02281). No difference in sleep quality was found between both groups (p = 0.719). The average sleep quality was 8.74 (95% confidence interval (CI): 7.98-9.49) and 8.57 (95% CI: 7.75-9.39) in the control and intervention groups respectively. Determinants for discontinuation at one month were: the intervention (odds ratio (OR) 2.36, 95% CI: 1.14-4.99), fall on admission (OR 2.05; 95% CI: 0.95-4.43), use of a z-drug (OR 0.54, 95% CI: 0.23-1.22), PSQI score on admission (OR 1.08, 95% CI: 0.97-1.19) and discontinuation prior to discharge (OR 4.71, 95% CI: 2.26-10.17). CONCLUSIONS A pharmacist-led intervention in geriatric inpatients was associated with a reduction of hypnotic drug use one month after discharge, without any loss in sleep quality. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05521971 (retrospectively registered on 29th of August 2022).
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Affiliation(s)
- Lorenz Van der Linden
- Hospital Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
| | - Julie Hias
- Hospital Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Astrid Liesenborghs
- Hospital Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Karolien Walgraeve
- Hospital Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Pieter Van Brantegem
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Laura Hellemans
- Hospital Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Research Foundation - Flanders (FWO), Brussels, Belgium
| | - Koen Milisen
- Department of Public Health and Primary Care, Academic Center for Nursing and Midwifery, KU Leuven, Leuven, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Jos Tournoy
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Public Health and Primary Care, Gerontology and Geriatrics, KU Leuven, Leuven, Belgium
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Wang Y, Wilson DL, Fernandes D, Adkins LE, Bantad A, Copacia C, Dharma N, Huang PL, Joseph A, Park TW, Budd J, Meenrajan S, Orlando FA, Pennington J, Schmidt S, Shorr R, Uphold CR, Lo-Ciganic WH. Deprescribing Strategies for Opioids and Benzodiazepines with Emphasis on Concurrent Use: A Scoping Review. J Clin Med 2023; 12:jcm12051788. [PMID: 36902574 PMCID: PMC10002935 DOI: 10.3390/jcm12051788] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/15/2023] [Accepted: 02/19/2023] [Indexed: 02/25/2023] Open
Abstract
While the Food and Drug Administration's black-box warnings caution against concurrent opioid and benzodiazepine (OPI-BZD) use, there is little guidance on how to deprescribe these medications. This scoping review analyzes the available opioid and/or benzodiazepine deprescribing strategies from the PubMed, EMBASE, Web of Science, Scopus, and Cochrane Library databases (01/1995-08/2020) and the gray literature. We identified 39 original research studies (opioids: n = 5, benzodiazepines: n = 31, concurrent use: n = 3) and 26 guidelines (opioids: n = 16, benzodiazepines: n = 11, concurrent use: n = 0). Among the three studies deprescribing concurrent use (success rates of 21-100%), two evaluated a 3-week rehabilitation program, and one assessed a 24-week primary care intervention for veterans. Initial opioid dose deprescribing rates ranged from (1) 10-20%/weekday followed by 2.5-10%/weekday over three weeks to (2) 10-25%/1-4 weeks. Initial benzodiazepine dose deprescribing rates ranged from (1) patient-specific reductions over three weeks to (2) 50% dose reduction for 2-4 weeks, followed by 2-8 weeks of dose maintenance and then a 25% reduction biweekly. Among the 26 guidelines identified, 22 highlighted the risks of co-prescribing OPI-BZD, and 4 provided conflicting recommendations on the OPI-BZD deprescribing sequence. Thirty-five states' websites provided resources for opioid deprescription and three states' websites had benzodiazepine deprescribing recommendations. Further studies are needed to better guide OPI-BZD deprescription.
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Affiliation(s)
- Yanning Wang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
- Department of Health Outcome and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Debbie L. Wilson
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Deanna Fernandes
- North Florida/South Georgia Veterans Health System Geriatric Research Education and Clinical Center, Gainesville, FL 32601, USA
| | - Lauren E. Adkins
- Health Science Center Libraries, University of Florida, Gainesville, FL 32610, USA
| | - Ashley Bantad
- College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Clint Copacia
- College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Nilay Dharma
- College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Pei-Lin Huang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Amanda Joseph
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Tae Woo Park
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Jeffrey Budd
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL 32611, USA
| | - Senthil Meenrajan
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL 32611, USA
| | - Frank A. Orlando
- Department of Community Heath and Family Medicine, College of Medicine, University of Florida, Gainesville, FL 32608, USA
| | - John Pennington
- Department of Community Heath and Family Medicine, College of Medicine, University of Florida, Gainesville, FL 32608, USA
| | - Siegfried Schmidt
- Department of Community Heath and Family Medicine, College of Medicine, University of Florida, Gainesville, FL 32608, USA
| | - Ronald Shorr
- North Florida/South Georgia Veterans Health System Geriatric Research Education and Clinical Center, Gainesville, FL 32601, USA
- Department of Epidemiology, College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Constance R. Uphold
- North Florida/South Georgia Veterans Health System Geriatric Research Education and Clinical Center, Gainesville, FL 32601, USA
- Department of Physiology and Aging, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
- Center for Drug Evaluation and Safety (CoDES), College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
- Correspondence:
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9
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Soni A, Thiyagarajan A, Reeve J. Feasibility and effectiveness of deprescribing benzodiazepines and Z-drugs: systematic review and meta-analysis. Addiction 2023; 118:7-16. [PMID: 35815384 DOI: 10.1111/add.15997] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 06/26/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS A total of 2.4 million adults in England were dispensed a benzodiazepine or Z-drug (BZRA) in 2017/18, and more than 250 000 patients in the UK take BZRAs beyond the recommended duration. Deprescribing is a clinician-guided process of withdrawing inappropriate drugs. This review aimed to evaluate the evidence base supporting the feasibility and clinical effectiveness of all forms of deprescribing initiatives used to discontinue long-term (≥ 4 weeks) BZRAs. METHOD Systematic review of randomized controlled trials evaluating BZRAs deprescribing among adults in community, primary or outpatient settings. MEDLINE, Embase and PsycINFO were searched from inception to February 2021. Primary outcomes were successful discontinuation in the short (< 4 weeks) or long term (≥ 4 weeks) and the occurrence of withdrawal symptoms, behavioural or psychological symptoms. Studies were categorized as pharmacological or non-pharmacological supported interventions. Study quality was assessed using the Cochrane risk-of-bias tool. Where appropriate, risk ratios (RRs), mean differences and 95% confidence intervals (CIs) were calculated, and Mantel-Haenszel methods using the random-effect meta-analysis was undertaken to calculate summary effect estimates. RESULTS Ten studies were included (n = 1431 participants). Heterogeneity in study design and effect was observed. Benzodiazepines were successfully deprescribed when gradually tapered with non-pharmacological support compared with gradual tapering alone in the short term (n = 124; RR = 2.02; 95% CI = 1.41, 2.89) and long term (n = 123; RR = 2.45; 95% CI = 1.56, 3.85). Benzodiazepine deprescribing was more successful when supported by non-pharmacological methods versus routine care (n = 189; RR = 3.26; 95% CI = 2.36, 4.51). Quality of evidence reporting effectiveness was very low to low. CONCLUSIONS It may be feasible to deprescribe benzodiazepines depending on the process and support mechanisms employed.
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Affiliation(s)
- Anisha Soni
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Joanne Reeve
- Academy of Primary Care, Hull York Medical School, Hull, UK
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10
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Barry A, Lewin S, Cadogan CA. Applying the intervention Complexity Assessment Tool to brief interventions targeting long-term benzodiazepine receptor agonist use in primary care: Lessons learned. BMC PRIMARY CARE 2022; 23:175. [PMID: 35842593 PMCID: PMC9288038 DOI: 10.1186/s12875-022-01775-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 06/17/2022] [Indexed: 11/28/2022]
Abstract
Background Benzodiazepine receptor agonists (BZRAs) are often prescribed for long-term use. However, guidelines recommend limiting prescriptions to short-term use (< 4 weeks) to reduce the risk of adverse effects and dependence. A recent systematic review reported that brief interventions targeting long-term BZRA use in primary care (e.g., short consultations, written letters to patients) were effective in helping patients to discontinue BZRA medication. However, the complexity of these interventions has not been examined in detail. This study aimed to apply the intervention Complexity Assessment Tool for Systematic Reviews (iCAT_SR) to brief interventions targeting long-term BZRA use. Methods Two reviewers independently assessed the interventions using the six core iCAT_SR dimensions: organisational level/ category targeted, behaviour targeted, number of intervention components, degree of tailoring, skill level required by those delivering and receiving the intervention. The four optional iCAT_SR dimensions were applied where possible. A scoring system was using to calculate a complexity score for each intervention. Pearson’s correlations were used to assess the relationship between intervention complexity and effect size, as well as the relationship between intervention complexity and number of component behaviour change techniques (BCTs). Inter-rater reliability was calculated using Cohen’s Kappa coefficient. Results Four of the six core iCAT_SR dimensions were applied to the interventions with high inter-rater reliability (Cohen’s Kappa = 0.916). Application of the four optional dimensions was prevented by a lack of detail in study reports. Intervention complexity scores ranged from 8 to 11 (median: 11). There was no relationship detected between intervention complexity and either intervention effect size or number of component BCTs. Conclusions This study adds to the literature on worked examples of the practical application of the iCAT_SR. The findings highlight how more detailed reporting of interventions is needed in order to optimise the application of iCAT_SR and its potential to differentiate between interventions across the full range of complexity dimensions. Further work is needed to establish the validity of applying a scoring system to iCAT_SR assessments. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-022-01775-y.
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11
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Gozda K, Leung J, Baum L, Singer A, Konrad G, McMillan DE, Falk J, Kosowan L, Leong C. Insights into patient characteristics and documentation of the use of sedative-hypnotic/anxiolytics in primary care: a retrospective chart review study. BMC PRIMARY CARE 2022; 23:111. [PMID: 35538427 PMCID: PMC9087974 DOI: 10.1186/s12875-022-01724-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 04/25/2022] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Despite the known safety risks of long-term use of sedative-hypnotic/anxiolytic medications, there has been limited guidance for the safe and effective use of their chronic use in a primary care clinic setting. Understanding the characteristics of patients who receive sedative-hypnotic/anxiolytic medication and the clinical documentation process in primary care is the first step towards understanding the nature of the problem and will help inform future strategies for clinical research and practice.
Objectives
Characterize patients who received a sedative-hypnotic/anxiolytic prescription in primary care, and (2) gain an understanding of the clinical documentation of sedative-hypnotic/anxiolytic indication and monitoring in electronic medical records (EMR).
Methods
A random selection of patients who received a prescription for a benzodiazepine or Z-drug hypnotic between January 2014 and August 2016 from four primary care clinics in Winnipeg were included. Data was collected retrospectively using the EMR (Accuro®). Patient variables recorded included sex, age, comorbidities, medications, smoking status, and alcohol status. Treatment variables included drug type, indication, pattern of use, dose, adverse events, psychosocial intervention, tapering attempts, social support, life stressor, and monitoring parameters for sedative-hypnotic use. Demographic and clinical characteristics were described using descriptive statistics.
Results
Records from a sample of 200 primary care patients prescribed sedative-hypnotic/anxiolytics were analyzed (mean age 55.8 years old, 61.5% ≥ 65 years old, 61.0% female). Long-term chronic use (≥ 1 year) of a sedative-hypnotic/anxiolytic agent was observed in 29.5% of the sample. Zopiclone (30.7%) and lorazepam (28.7%) were the most common agents prescribed. Only 9.5% of patients had documentation of a past tapering attempt of their sedative-hypnotic/anxiolytic. The most common indications for sedative-hypnotic/anxiolytic use recorded were anxiety (33.0%) and sleep (18.0%), but indication was undetermined for 57.0% of patients. Depression (33.5%) and falls (18.5%) were reported by patients after the initiation of these agents.
Conclusions
A higher proportion of females and users 65 years and older received a prescription for a sedative-hypnotic/anxiolytic, consistent with previous studies on sedative-hypnotic use. We found inconsistencies in the documentation surrounding sedative-hypnotic/anxiolytic use. The indication for their use was unclear in a large number of patients. These findings will help us understand the state of the problem in primary care and inform future strategies for clinical research.
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Coteur K, Henrard G, Schoenmakers B, Laenen A, Van den Broeck K, De Sutter A, Anthierens S, Devroey D, Kacenelenbogen N, Offermans AM, Van Nuland M. Blended care to discontinue BZRA use in patients with chronic insomnia disorder: a pragmatic cluster randomized controlled trial in primary care. Sleep 2022; 46:6840128. [PMID: 36413221 PMCID: PMC10091092 DOI: 10.1093/sleep/zsac278] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 11/14/2022] [Indexed: 11/24/2022] Open
Abstract
STUDY OBJECTIVES International guidelines recommend using benzodiazepine receptor agonists (BZRA) for maximally four weeks. Nevertheless, long-term use for chronic insomnia disorder remains a common practice. This study aimed to test the effectiveness of blended care for discontinuing long-term BZRA use in general practice. METHODS A pragmatic cluster randomized controlled superiority trial compared blended care to usual care through urine toxicology screening. In the intervention, care by the general practitioner (GP) was complemented by an interactive e-learning program, based on cognitive behavioral therapy for insomnia. Adults using BZRA daily for minimally six months were eligible. Participants were clustered at the level of the GP surgery for allocation (1:1). Effectiveness was measured as the proportion of patients who had discontinued at one-year follow-up. Data analysis followed intention-to-treat principles. RESULTS In total, 916 patients in 86 clusters, represented by 99 GPs, were randomized. Primary outcome data was obtained from 727 patients (79%). At one-year follow-up, 82 patients (18%) in blended care, compared to 91 patients (20%) in usual care, had discontinued. There was no statistically significant effect for the intervention (OR: 0·924; 95% CI: 0·60, 1·43). No adverse events were reported to the research team. CONCLUSIONS The findings did not support the superiority of blended care over usual care. Both strategies showed clinical effectiveness, with an average of 19% of patients having discontinued at one-year follow-up. Further research is important to study the effect of structurally implementing digital interventions in general practice.
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Affiliation(s)
- Kristien Coteur
- Department of Public Health and Primary Care, Academic Centre for General Practice, KU Leuven, Leuven, Belgium
| | - Gilles Henrard
- Department of General Practice, Research Unit Primary Care & Health, Liège Université, Liège, Belgium
| | - Birgitte Schoenmakers
- Department of Public Health and Primary Care, Academic Centre for General Practice, KU Leuven, Leuven, Belgium
| | - Annouschka Laenen
- Leuven Biostatistics and Statistical Bioinformatics Centre (L-Biostat), KU Leuven, Leuven, Belgium
| | - Kris Van den Broeck
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - An De Sutter
- Department of Public Health and Primary Care, Centre for Family Medicine, Ghent University, Ghent, Belgium
| | - Sibyl Anthierens
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Dirk Devroey
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Anne-Marie Offermans
- Department of General Practice, Université libre de Bruxelles, Brussels, Belgium
| | - Marc Van Nuland
- Department of Public Health and Primary Care, Academic Centre for General Practice, KU Leuven, Leuven, Belgium
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Coteur K, Mamouris P, Vaes B, Van Nuland M, Matheï C, Schoenmakers B. Evolution of benzodiazepine receptor agonist prescriptions in general practice: A registry-based study. Front Public Health 2022; 10:1014734. [PMID: 36211642 PMCID: PMC9546292 DOI: 10.3389/fpubh.2022.1014734] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/05/2022] [Indexed: 01/27/2023] Open
Abstract
Background Contrary to most European guidelines, benzodiazepine receptor agonists (BZRA) are often used continuously at a low dosage, being the most common form of long-term use. In Belgium, BZRA use is monitored by analyzing self-report data about medication use in the last 24 h. This method provides insufficient insight into the terms of use of these psychoactive drugs. Aim To describe trends in BZRA prescribing in Flanders, Belgium, between 2000 and 2019. Design and setting Population-based trend analysis and a case-control study for the year 2019 were done with data from a morbidity registry in general practice. Methods Repeated cross-sectional and joinpoint regression analyses revealed trends in sex- and age-standardized prescription rates among adult patients (18+). Results Overall, BZRA prescriptions increased. The highest overall increase was found among male patients 18-44 years old, with an average annual percentage change of 2.5 (95% CI: 0.9, 4.3). Among 65+ female patients, a decrease was found since 2006, with an annual percentage change of -0.7 (95% CI: -1.3, -0.1). In 2019, 12% of registered patients received minimally one prescription, long-term use was observed in 5%, back pain was the most common morbidity significantly associated with a rise in BZRA prescriptions, and zolpidem was the most prescribed BZRA (22%). Conclusion Despite some statistically significant decreasing trends, an overall increase in BZRA prescriptions was observed throughout the 19-year study period, especially among long-term users of 18-44 years and 65-plus. Zolpidem became the most prescribed BZRA and warrants more attention.
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14
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Cucciare MA, Abraham TH, Kemp L, White P, Marchant K, Hagedorn HJ, Humphreys K. Adapting the Eliminating Medications Through Patient Ownership of End Results Protocol to Promote Benzodiazepine Cessation Among US Military Veterans: Focus Group Study With US Military Veterans and National Veterans Health Administration Leaders. J Med Internet Res 2022; 24:e35514. [PMID: 36121697 PMCID: PMC9531005 DOI: 10.2196/35514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 07/21/2022] [Accepted: 08/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background Long-term dependence on prescribed benzodiazepines is a public health problem. Eliminating Medications Through Patient Ownership of End Results (EMPOWER) is a promising self-management intervention, delivered directly to patients as a printed booklet, that is effective in promoting benzodiazepine reduction and cessation in older adults. EMPOWER has high potential to benefit large health care systems such as the US Veterans Health Administration (VHA), which cares for many veterans who use benzodiazepines for extended periods. Objective We aimed to adapt the original EMPOWER booklet materials for electronic delivery and for use among US military veterans receiving VHA care who were long-term benzodiazepine users. Methods We used elements of Analysis, Design, Development, Implementation, and Evaluation, a framework commonly used in the field of instructional design, to guide a qualitative approach to iteratively adapting EMPOWER Electronic Delivery (EMPOWER-ED). We conducted 3 waves of focus groups with the same 2 groups of VHA stakeholders. Stakeholders were VHA-enrolled veterans (n=16) with medical chart evidence of long-term benzodiazepine use and national VHA leaders (n=7) with expertise in setting VHA policy for prescription benzodiazepine use and developing electronically delivered educational tools for veterans. Qualitative data collected from each wave of focus groups were analyzed using template analysis. Results Themes that emerged from the initial focus groups included veterans’ anxiety about self-tapering from benzodiazepines and prior negative experiences attempting to self-taper without support. Participants also provided feedback on the protocol’s look and feel, educational content, the tapering protocol, and website functionality; for example, feedback from policy leaders included listing, on the cover page, the most commonly prescribed benzodiazepines to ensure that veterans were aware of medications that qualify for self-taper using the EMPOWER-ED protocol. Both groups of stakeholders identified the importance of having access to supportive resources to help veterans manage sleep and anxiety in the absence of taking benzodiazepines. Both groups also emphasized the importance of ensuring that the self-taper could be personalized and that the taper instructions were clear. The policy leaders emphasized the importance of encouraging veterans to notify their provider of their decision to self-taper to help facilitate provider assistance, if needed, with the taper process and to help prevent medication stockpiling. Conclusions EMPOWER-ED is the first direct-to-patient electronically delivered protocol designed to help US military veterans self-taper from long-term benzodiazepine use. We used the Analysis, Design, Development, Implementation, and Evaluation framework to guide the successful adaption of the original EMPOWER booklet for use with this population and for electronic delivery. The next step in this line of research is to evaluate EMPOWER-ED in a randomized controlled trial.
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Affiliation(s)
- Michael A Cucciare
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Affairs Healthcare System, North Little Rock, AR, United States.,Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States.,Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Traci H Abraham
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Affairs Healthcare System, North Little Rock, AR, United States.,Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States.,Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Lakiesha Kemp
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Affairs Healthcare System, North Little Rock, AR, United States
| | - Penny White
- Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - Kathy Marchant
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Affairs Healthcare System, North Little Rock, AR, United States
| | - Hildi J Hagedorn
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, United States.,Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Keith Humphreys
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, United States.,Department of Psychiatry, Stanford University, Menlo Park, CA, United States
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15
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Vicens C, Leiva A, Bejarano F, Sempere-Verdú E, Rodríguez-Rincón RM, Fiol F, Mengual M, Ajenjo-Navarro A, Do Pazo F, Mateu C, Folch S, Alegret S, Coll JM, Martín-Rabadán M, Socias I. Evaluation of a multicomponent intervention consisting of education and feedback to reduce benzodiazepine prescriptions by general practitioners: The BENZORED hybrid type 1 cluster randomized controlled trial. PLoS Med 2022; 19:e1003983. [PMID: 35522626 PMCID: PMC9075619 DOI: 10.1371/journal.pmed.1003983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 04/07/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Current benzodiazepine (BZD) prescription guidelines recommend short-term use to minimize the risk of dependence, cognitive impairment, and falls and fractures. However, many clinicians overprescribe BZDs and chronic use by patients is common. There is limited evidence on the effectiveness of interventions delivered by general practitioners (GPs) on reducing prescriptions and long-term use of BZDs. We aimed to evaluate the effectiveness of a multicomponent intervention for GPs that seeks to reduce BZD prescriptions and the prevalence of long-term users. METHODS AND FINDINGS We conducted a multicenter two-arm, cluster randomized controlled trial in 3 health districts in Spain (primary health centers [PHCs] in Balearic Islands, Catalonia, and Valencian Community) from September 2016 to May 2018. The 81 PHCs were randomly allocated to the intervention group (n = 41; 372 GPs) or the control group (n = 40; 377 GPs). GPs were not blinded to the allocation; however, pharmacists, researchers, and trial statisticians were blinded to the allocation arm. The intervention consisted of a workshop about the appropriate prescribing of BZDs and tapering-off long-term BZD use using a tailored stepped dose reduction with monthly BZD prescription feedback and access to a support web page. The primary outcome, based on 700 GPs (351 in the control group and 349 in the intervention group), compared changes in BZD prescriptions in defined daily doses (DDDs) per 1,000 inhabitants per day after 12 months. The 2 secondary outcomes were the proportion of long-term users (≥6 months) and the proportion of long-term users over age 65 years. Intention-to-treat (ITT) analysis was used to assess all clinical outcomes. Forty-nine GPs (21 intervention group and 28 control group) were lost to follow-up. However, all GPs were included in the ITT analysis. After 12 months, there were a statistically significant decline in total BZD prescription in the intervention group compared to the control group (mean difference: -3.24 DDDs per 1,000 inhabitants per day, 95% confidence interval (CI): -4.96, -1.53, p < 0.001). The intervention group also had a smaller number of long-term users. The adjusted absolute difference overall was -0.36 (95% CI: -0.55, -0.16, p > 0.001), and the adjusted absolute difference in long-term users over age 65 years was -0.87 (95% CI: -1.44, -0.30, p = 0.003). A key limitation of this clustered design clinical trial is the imbalance of some baseline characteristics. The control groups have a higher rate of baseline BZD prescription, and more GPs in the intervention group were women, GPs with a doctorate degree, and trainers of GP residents. CONCLUSIONS A multicomponent intervention that targeted GPs and included educational meeting, feedback about BZD prescriptions, and a support web page led to a statistically significant reduction of BZD prescriptions and fewer long-term users. Although the effect size was small, the high prevalence of BZD use in the general population suggests that large-scale implementation of this intervention could have positive effects on the health of many patients. TRIAL REGISTRATION ISRCTN ISRCTN28272199.
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Affiliation(s)
- Caterina Vicens
- Balearic Health Service IbSalut Son Serra-La Vileta Healthcare Centre, Palma, Illes Balears, Spain
- Research Network on Chronicity, Primary Care, and Health Promotion (RICAPPS)-Balearic Islands Health Research Institute (IdISBa), Mallorca, Spain
| | - Alfonso Leiva
- Research Network on Chronicity, Primary Care, and Health Promotion (RICAPPS)-Balearic Islands Health Research Institute (IdISBa), Mallorca, Spain
- Balearic Health Service IbSalut, Reseach Unit Primary care Mallorca, Palma, Illes Balears, Spain
- * E-mail:
| | - Ferran Bejarano
- Catalan Institute of Health Cat-salut, DAP Camp de Tarragona, Tarragona, Catalunya, Spain
| | - Ermengol Sempere-Verdú
- Conselleria de Sanitat Universal i Salut Pública, Paterna Healthcare Centre, Valencia, Comunitat Valenciana, Spain
| | - Raquel María Rodríguez-Rincón
- Balearic Health Service IbSalut Hospital Universitari Son Espases, Pharmacy Department,Palma de Mallorca, Illes Balears, Spain
| | - Francisca Fiol
- Balearic Health Service IbSalut Son Serra-La Vileta Healthcare Centre, Palma, Illes Balears, Spain
| | - Marta Mengual
- Catalan Institute of Health Cat-salut, DAP Camp de Tarragona, Tarragona, Catalunya, Spain
| | - Asunción Ajenjo-Navarro
- Conselleria de Sanitat Universal i Salut Pública, Paterna Healthcare Centre, Valencia, Comunitat Valenciana, Spain
| | - Fernando Do Pazo
- Balearic Health Service IbSalut Hospital Universitari Son Espases, Pharmacy Department,Palma de Mallorca, Illes Balears, Spain
| | - Catalina Mateu
- Balearic Health Service IbSalut Son Serra-La Vileta Healthcare Centre, Palma, Illes Balears, Spain
| | - Silvia Folch
- Catalan Institute of Health Cat-salut, DAP Camp de Tarragona, Tarragona, Catalunya, Spain
| | - Santiago Alegret
- Balearic Health Service IbSalut Son Serra-La Vileta Healthcare Centre, Palma, Illes Balears, Spain
| | - Jose Maria Coll
- Balearic Health Service IbSalut, Menorca Primary Care Management, Maó, Illes Baleares, Spain
| | - María Martín-Rabadán
- Balearic Health Service IbSalut, Can Misses Healthcare Centre Ibiza, Illes Baleares, Spain
| | - Isabel Socias
- Research Network on Chronicity, Primary Care, and Health Promotion (RICAPPS)-Balearic Islands Health Research Institute (IdISBa), Mallorca, Spain
- Balearic Health Service IbSalut, Manacor Healthcare Centre, Manacor, Illes Baleares, Spain
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Toth JM, Jadhav S, Holmes HM, Sharma M. Prescribing trends of proton pump inhibitors, antipsychotics and benzodiazepines of medicare part d providers. BMC Geriatr 2022; 22:306. [PMID: 35395728 PMCID: PMC8993456 DOI: 10.1186/s12877-022-02971-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/22/2022] [Indexed: 11/21/2022] Open
Abstract
Background Proton pump inhibitors, benzodiazepines, and antipsychotics are considered potentially inappropriate medications in older adults according to the American Geriatric Society Beers Criteria, and deprescribing algorithms have been developed to guide use of these drug classes. The objective of this study was to describe the number of beneficiaries prescribed these medications, provider specialty and regional trends in prescribing, and the aggregate costs for these claims in Medicare Part D. Methods This was a retrospective cross-sectional study using publicly available Medicare Provider Utilization and Payment Data: Part D Prescriber data for years 2013–2019. Descriptive statistics and the Cochrane-Armitage test were used to summarize the trends. Results Overall, 30.1%, 25.6%, 4.6% of Medicare Part D beneficiaries had a proton pump inhibitor, benzodiazepine, and antipsychotic claim in 2013, respectively. These rates decreased to 27.5%, 17.5%, 4.1% in 2019 (p-value < 0.0001). However, the number of standardized 30-day claims increased from 63 million in 2013 to 84 million in 2019 for proton pump inhibitors, remained steady for benzodiazepines and slightly increased (10 million to 13 million) for antipsychotics. Total aggregate costs decreased by almost $1.5 billion for proton pump inhibitor, $100 million for benzodiazepine, and $700 million for antipsychotic from 2013 to 2019 (p-value < 0.0001). Almost 93% of gastroenterologists prescribed a proton pump inhibitor, and 60% of psychiatrists prescribed benzodiazepines and antipsychotics all seven years. The Other region had the highest percentage of providers prescribing all three classes and the highest number of standardized 30-day benzodiazepine claims. Conclusions The overall rate of use of proton pump inhibitors, benzodiazepines, and antipsychotics decreased from 2013–2019 among Medicare Part D beneficiaries. Despite the increase in raw number of standardized 30-day claims, the costs decreased which is likely due to generics made available. These prescribing trends may aid in identifying and targeting potential deprescribing interventions.
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Affiliation(s)
- Jennifer M Toth
- Department of Pharmacy Administration, The University of Mississippi, University, MS, 38677, USA.
| | - Saumil Jadhav
- Department of Pharmacy Administration, The University of Mississippi, University, MS, 38677, USA
| | - Holly M Holmes
- Division of Geriatric and Palliative Medicine, McGovern Medical School, The University of Texas Health Science Center, Houston, TX, USA
| | - Manvi Sharma
- Department of Pharmacy Administration, The University of Mississippi, University, MS, 38677, USA
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Fernandes M, Neves I, Oliveira J, Santos O, Aguiar P, Atalaia P, Matos F, Freitas MC, Alvim A, Maria V. Discontinuation of chronic benzodiazepine use in primary care: a nonrandomized intervention. Fam Pract 2022; 39:241-248. [PMID: 35196378 DOI: 10.1093/fampra/cmab143] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Chronic benzodiazepine use is a challenge in primary care practice. Protocols to support safe discontinuation are still needed, especially in countries with high utilization rates. OBJECTIVES To evaluate the feasibility, effectiveness, and safety of a benzodiazepine discontinuation protocol in primary care setting. METHODS Nonrandomized, single-arm interventional study, at primary care units. Family physicians (FPs) recruited patients (18-85 years-old) with benzodiazepine dependence and chronic daily use ≥3 months. Patients with daily dosages ≥30 mg diazepam-equivalent, taking zolpidem, with a history of other substance abuse or major psychiatric disease were excluded. After the switch to diazepam, the dosage was gradually tapered according to a standardized protocol. Primary endpoint was the percentage of patients who stopped benzodiazepine at the intervention last visit. Dosage reduction, withdrawal symptoms, patients' and FPs' satisfaction with the protocol were evaluated. RESULTS From 66 enrolled patients (74% female; 66.7% aged >64 years; median time of benzodiazepine use was 120 months), 2 withdrew due to medical reasons and 3 presented protocol deviations. Overall, 59.4% of participants successfully stopped benzodiazepine (60.7% when excluding protocol deviations). Men had higher probability of success (relative risk = 0.51, P = 0.001). A total of 31 patients reported at least 1 withdrawal symptom, most frequently insomnia and anxiety. Most of participating FP considered the clinical protocol useful and feasible in daily practice. Among patients completing the protocol, 77% were satisfied. For the patients who reduced dosage, 85% kept without benzodiazepines after 12 months. CONCLUSION The discontinuation protocol with standardized dosage reduction was feasible at primary care and showed long-term effectiveness.
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Affiliation(s)
- Milene Fernandes
- Instituto de Medicina Preventiva e Saúde Pública, Faculdade de Medicina-Universidade de Lisboa, Av. Prof. Egas Moniz, Lisboa 1649-028, Portugal
| | - Inês Neves
- Instituto de Medicina Preventiva e Saúde Pública, Faculdade de Medicina-Universidade de Lisboa, Av. Prof. Egas Moniz, Lisboa 1649-028, Portugal
| | - Joana Oliveira
- Instituto de Medicina Preventiva e Saúde Pública, Faculdade de Medicina-Universidade de Lisboa, Av. Prof. Egas Moniz, Lisboa 1649-028, Portugal.,ACES Almada Seixal, Administração Regional de Saúde de Lisboa e Vale do Tejo, Largo Professor Arnaldo Sampaio, Lisboa 1549-010, Portugal
| | - Osvaldo Santos
- Instituto de Medicina Preventiva e Saúde Pública, Faculdade de Medicina-Universidade de Lisboa, Av. Prof. Egas Moniz, Lisboa 1649-028, Portugal.,Instituto de Saúde Ambiental, Faculdade de Medicina-Universidade de Lisboa, Av. Prof. Egas Moniz, Lisboa 1649-028, Portugal
| | - Pedro Aguiar
- Public Health Research Center, Escola Nacional de Saúde Pública-Universidade Nova de Lisboa, Av. Padre Cruz, Lisboa 1600-560, Portugal
| | - Paula Atalaia
- ACES Almada Seixal, Administração Regional de Saúde de Lisboa e Vale do Tejo, Largo Professor Arnaldo Sampaio, Lisboa 1549-010, Portugal
| | - Fátima Matos
- ACES Almada Seixal, Administração Regional de Saúde de Lisboa e Vale do Tejo, Largo Professor Arnaldo Sampaio, Lisboa 1549-010, Portugal
| | - Maria Carina Freitas
- ACES Almada Seixal, Administração Regional de Saúde de Lisboa e Vale do Tejo, Largo Professor Arnaldo Sampaio, Lisboa 1549-010, Portugal
| | - António Alvim
- ACES Almada Seixal, Administração Regional de Saúde de Lisboa e Vale do Tejo, Largo Professor Arnaldo Sampaio, Lisboa 1549-010, Portugal
| | - Vasco Maria
- Instituto de Medicina Preventiva e Saúde Pública, Faculdade de Medicina-Universidade de Lisboa, Av. Prof. Egas Moniz, Lisboa 1649-028, Portugal.,ACES Almada Seixal, Administração Regional de Saúde de Lisboa e Vale do Tejo, Largo Professor Arnaldo Sampaio, Lisboa 1549-010, Portugal
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Part I: Interactive case: Rational deprescribing of benzodiazepine receptor agonists for insomnia. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2022. [DOI: 10.1002/jac5.1612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Bai I, Isenor JE, Reeve E, Whelan AM, Martin-Misener R, Burgess S, Kennie-Kaulbach N. Using the behavior change wheel to link published deprescribing strategies to identified local primary healthcare needs. Res Social Adm Pharm 2021; 18:3350-3357. [PMID: 34895842 DOI: 10.1016/j.sapharm.2021.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/30/2021] [Accepted: 12/02/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Polypharmacy is a major global problem. Evidence in primary care shows deprescribing can be beneficial. Behaviour change theories such as the Theoretical Domains Framework (TDF) and the Behaviour Change Wheel (BCW) can help develop successful implementation of deprescribing initiatives. OBJECTIVES To link locally identified deprescribing influencers with components of successfully trialed deprescribing strategies, with the aim of informing the development of local deprescribing initiatives. METHODS Two background studies were completed. A qualitative study of interviews and focus groups identified influencers of deprescribing from local primary care physicians, nurse practitioners, and pharmacists. Transcripts were coded using the TDF and mapped to the Intervention Functions of the BCW. A scoping review identified studies that investigated primary care deprescribing strategies, which were mapped to the BCW Intervention Functions and the Behaviour Change Techniques (BCTs). For this analysis, six main TDF domains from the qualitative study were linked to the BCTs identified in the scoping review through the Intervention Functions of the BCW. RESULTS Within the BCW component Capability, one TDF domain identified in the qualitative study, Memory, Attention and Decision Process, was linked to strategies like academic detailing from the scoping review. For the Opportunity component, two TDF domains, Social Influences and Environmental Context and Resources, were linked to strategies such as pharmacist medication reviews, providing patient information leaflets, and evidence-based deprescribing tools. For the Motivation component, three TDF domains, Social/Professional Role and Identity, Intentions, and Beliefs about Consequences, were linked to strategies such as sending deprescribing information to prescribers, using tools to identify eligible patients, and having patients report adverse events of medications. CONCLUSIONS This analysis identified deprescribing strategies that can be used to address influencers related to behaviour change from the perspective of primary care providers, and to assist with future deprescribing initiative development and implementation in the local context.
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Affiliation(s)
- Isaac Bai
- Faculty of Medicine, Dalhousie University, 5849 University Ave, Halifax, NS, Canada
| | - Jennifer E Isenor
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada.
| | - Emily Reeve
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada; Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia; Geriatric Medicine Research, Faculty of Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada
| | - Anne Marie Whelan
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada
| | - Ruth Martin-Misener
- School of Nursing, Dalhousie University, 5869 University Avenue, Halifax, NS, Canada
| | - Sarah Burgess
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada; Pharmacy Department, Nova Scotia Health Authority, Halifax, NS, Canada
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20
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Geriatric Depression and Inappropriate Medication: Benefits of Interprofessional Team Cooperation in Nursing Homes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182312438. [PMID: 34886164 PMCID: PMC8657238 DOI: 10.3390/ijerph182312438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 11/18/2021] [Accepted: 11/20/2021] [Indexed: 11/26/2022]
Abstract
An investigation of inappropriate medication use in treatment of depressivity in institutionalized older adults, based on a nurse-led evaluation of functional status and depressive symptoms in nursing home residents. Methods: A cross-sectional multicenter study was performed using records from 1087 residents cared for in fifteen nursing homes (NHs) in the Czech Republic. Inclusion criteria were being a permanent resident of one of the facilities, being 60 years of age or older, having a Geriatric Depression Scale score of 6 or more, and having a Mini Mental State examination score 10 or more. The final sample for analysis included 317 depressed NH residents. Results: 52 percent of NH residents with depressivity had no antidepressant treatment. Benzodiazepines were the only medication in 16 percent of depressed residents, and were added to antidepressant treatment in 18 percent of residents. Benzodiazepine users had significantly higher GDS scores compared to non-users (p = 0.007). Conclusion: More than half of depressed NH residents remained without antidepressant treatment. Residents inappropriately treated with benzodiazepines were more depressed than residents treated with antidepressants only, or even not treated at all. Cooperation of the interprofessional team in the screening of depressive symptoms has the potential to improve the quality of care.
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21
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Young EH, Pan S, Yap AG, Reveles KR, Bhakta K. Polypharmacy prevalence in older adults seen in United States physician offices from 2009 to 2016. PLoS One 2021; 16:e0255642. [PMID: 34343225 PMCID: PMC8330900 DOI: 10.1371/journal.pone.0255642] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/20/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND/OBJECTIVES With an aging population suffering from increased prevalence of chronic conditions in the United States (U.S.), a large portion of these patients are on multiple medications. High-risk medications can increase the risk for drug-drug interactions and medication nonadherence. This study aims to describe the prevalence of polypharmacy and high-risk medication prescribing in U.S. physician offices. METHODS This was a cross-sectional study of the Centers for Disease Control and Prevention's National Ambulatory Medical Care Survey from 2009 to 2016. All patients over 65 years old were included. Polypharmacy was categorized as no polypharmacy (< 2 medications), minor polypharmacy (2-3 medications), moderate polypharmacy (4-5 medications), and major polypharmacy (>5 medications). Medications were further categorized into high-risk medication categories (anticholinergics, cardiovascular agents, central nervous system (CNS) medications, pain medications, and other). Comparisons between the degrees of polypharmacy were performed utilizing chi-square or Wilcoxon rank-sum tests with JMP Pro 14® (SAS Institute, Cary, NC). RESULTS Over 2 billion patient visits were included. Overall, Polypharmacy was common (65.1%): minor polypharmacy (16.2%), moderate polypharmacy (12.1%), and major polypharmacy (36.8%). Patients with major polypharmacy were older compared to those with moderate or minor polypharmacy (75 vs. 73 years, respectively) and were most frequently prescribed pain medications (477.3 per 1,000 total visits). NSAIDs were the most frequently prescribed, with 232.4 per 1,000 total visits resulting in one high-risk NSAID prescription, while 21.9 per 1,000 total visits resulted in two or more high-risk NSAIDs. CONCLUSION Most patients over 65 years experienced some degree of polypharmacy, with many experiencing major polypharmacy. This indicates an increased need for expanded pharmacist roles through medication therapy management and safety monitoring in this patient population.
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Affiliation(s)
- Eric H. Young
- College of Pharmacy, The University of Texas at Austin, Austin, Texas, United States of America
- Pharmacotherapy Education & Research Center, UT Health San Antonio, San Antonio, Texas, United States of America
| | - Samantha Pan
- College of Pharmacy, The University of Texas at Austin, Austin, Texas, United States of America
- Pharmacotherapy Education & Research Center, UT Health San Antonio, San Antonio, Texas, United States of America
| | - Alex G. Yap
- College of Pharmacy, The University of Texas at Austin, Austin, Texas, United States of America
- Pharmacotherapy Education & Research Center, UT Health San Antonio, San Antonio, Texas, United States of America
| | - Kelly R. Reveles
- College of Pharmacy, The University of Texas at Austin, Austin, Texas, United States of America
- Pharmacotherapy Education & Research Center, UT Health San Antonio, San Antonio, Texas, United States of America
| | - Kajal Bhakta
- College of Pharmacy, The University of Texas at Austin, Austin, Texas, United States of America
- Pharmacotherapy Education & Research Center, UT Health San Antonio, San Antonio, Texas, United States of America
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22
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Socias I, Leiva A, Pombo-Ramos H, Bejarano F, Sempere-Verdú E, Rodríguez-Rincón RM, Fiol F, Mengual M, Ajenjo-Navarro A, Do Pazo F, Mateu C, Folch S, Alegret S, Coll JM, Martín-Rabadán M, Vicens C. Evaluating the Implementation of a Multicomponent Intervention Consisting of Education and Feedback on Reducing Benzodiazepine Prescriptions by General Practitioners: BENZORED Hybrid Type I Cluster Randomized Controlled Trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:7964. [PMID: 34360267 PMCID: PMC8345522 DOI: 10.3390/ijerph18157964] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/15/2021] [Accepted: 07/21/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND General practitioners (GPs) in developed countries widely prescribe benzodiazepines (BZDs) for their anxiolytic, hypnotic, and muscle-relaxant effects. Treatment duration, however, is rarely limited, and this results in a significant number of chronic users. Long-term BZD use is associated with cognitive impairment, falls with hip fractures, traffic accidents, and increased mortality. The BENZORED IV trial was a hybrid type-1 trial conducted to evaluate the effectiveness and implementation of an intervention to reduce BZD prescription in primary care. The purpose of this qualitative study was to analyze the facilitators and barriers regarding the implementation of the intervention in primary care settings. METHODS A qualitative interview study with 40 GPs from three Spanish health districts. Focus group meetings with GPs from the intervention arm of the BENZORED IV trial were held at primary healthcare centers in the three districts. For sampling purposes, the GPs were classified as high or low implementers according to the success of the intervention measured at 12 months. The Consolidated Framework for Implementation Research (CFIR) was used to conduct the meetings and to code, rate, and analyze the data. RESULTS Three of the 41 CFIR constructs strongly distinguished between high and low implementers: the complexity of the intervention, the individual Stage of Change, and the key stakeholder's engagement. Seven constructs weakly discriminated between the two groups: adaptability in the intervention, external policy and incentives, implementation climate, relative priority, self-efficacy, compatibility, and engaging a formally appointed implementation leader. Fourteen constructs did not discriminate between the two groups, six had insufficient data for evaluation, and eleven had no data for evaluation. CONCLUSIONS We identified constructs that could explain differences in the efficacy in implementation of the intervention. This information is relevant for the design of successful strategies for implementation of the intervention.
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Affiliation(s)
- Isabel Socias
- Healthcare Centre Manacor, Balearic Health Service IbSalut, 07500 Manacor, Spain;
- Balearic Islands Health Research Institute (IdISBa), 07120 Palma, Spain
| | - Alfonso Leiva
- Balearic Islands Health Research Institute (IdISBa), 07120 Palma, Spain
- Reseach Unit Mallorca, Balearic Health Service IbSalut, 07003 Palma, Spain
| | - Haizea Pombo-Ramos
- Primary Care Research Unit of Biscaia, Basque HealthCare Service Osakidetza, BioCruces Health Research Institute, 48903 Bizkaia, Spain;
| | - Ferran Bejarano
- Catalunya Health Services-CatSalut, DAP Camp de Tarragona, 43002 Tarragona, Spain; (F.B.); (M.M.); (S.F.)
| | - Ermengol Sempere-Verdú
- Paterna Healthcare Centre, Conselleria de Sanitat Universal i Salut Pública, 46980 Valencia, Spain; (E.S.-V.); (A.A.-N.)
| | - Raquel María Rodríguez-Rincón
- Pharmacy Department, Hospital Universitari Son Espases, Balearic Health Service IbSalut, 07120 Palma, Spain; (R.M.R.-R.); (F.D.P.)
| | - Francisca Fiol
- Balearic Islands Health Research Institute (IdISBa), 07120 Palma, Spain
- Son Serra-La Vileta Healthcare Centre, Balearic Health Service IbSalut, 07013 Palma, Spain; (F.F.); (C.M.); (S.A.); (C.V.)
| | - Marta Mengual
- Catalunya Health Services-CatSalut, DAP Camp de Tarragona, 43002 Tarragona, Spain; (F.B.); (M.M.); (S.F.)
| | - Asunción Ajenjo-Navarro
- Paterna Healthcare Centre, Conselleria de Sanitat Universal i Salut Pública, 46980 Valencia, Spain; (E.S.-V.); (A.A.-N.)
| | - Fernando Do Pazo
- Pharmacy Department, Hospital Universitari Son Espases, Balearic Health Service IbSalut, 07120 Palma, Spain; (R.M.R.-R.); (F.D.P.)
| | - Catalina Mateu
- Son Serra-La Vileta Healthcare Centre, Balearic Health Service IbSalut, 07013 Palma, Spain; (F.F.); (C.M.); (S.A.); (C.V.)
| | - Silvia Folch
- Catalunya Health Services-CatSalut, DAP Camp de Tarragona, 43002 Tarragona, Spain; (F.B.); (M.M.); (S.F.)
| | - Santiago Alegret
- Son Serra-La Vileta Healthcare Centre, Balearic Health Service IbSalut, 07013 Palma, Spain; (F.F.); (C.M.); (S.A.); (C.V.)
| | - Jose Maria Coll
- Menorca Primary Care Management, Balearic Health Service IbSalut, 07701 Maó, Spain;
| | - María Martín-Rabadán
- Can Misses Healthcare Centre Ibiza, Balearic Health Service IbSalut, 07800 Ibiza, Spain;
| | - Caterina Vicens
- Balearic Islands Health Research Institute (IdISBa), 07120 Palma, Spain
- Son Serra-La Vileta Healthcare Centre, Balearic Health Service IbSalut, 07013 Palma, Spain; (F.F.); (C.M.); (S.A.); (C.V.)
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Burry L, Turner J, Morgenthaler T, Tannenbaum C, Cho HJ, Gathecha E, Kisuule F, Vijenthira A, Soong C. Addressing Barriers to Reducing Prescribing and Implementing Deprescribing of Sedative-Hypnotics in Primary Care. Ann Pharmacother 2021; 56:463-474. [PMID: 34301151 PMCID: PMC8899816 DOI: 10.1177/10600280211033022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To describe interventions that target patient, provider, and system barriers
to sedative-hypnotic (SH) deprescribing in the community and suggest
strategies for healthcare teams. Data Sources: Ovid MEDLINE ALL and EMBASE Classic + EMBASE (March 10, 2021). Study Selection and Data Extraction: English-language studies in primary care settings. Data Synthesis: 20 studies were themed as patient-related and prescriber inertia, physician
skills and awareness, and health system constraints. Patient education
strategies reduced SH dose for 10% to 62% of participants, leading to
discontinuation in 13% to 80% of participants. Policy interventions reduced
targeted medication use by 10% to 50%. Relevance to Patient Care and Clinical Practice: Patient engagement and empowerment successfully convince patients to
deprescribe chronic SHs. Quality improvement strategies should also consider
interventions directed at prescribers, including education and training,
drug utilization reviews, or computer alerts indicating a potentially
inappropriate prescription by medication, age, dose, or disease. Educational
interventions were effective when they facilitated patient engagement and
provided information on the harms and limited evidence supporting chronic
use as well as the effectiveness of alternatives. Decision support tools
were less effective than prescriber education with patient engagement,
although they can be readily incorporated in the workflow through
prescribing software. Conclusions: Several strategies with demonstrated efficacy in reducing SH use in community
practice were identified. Education regarding SH risks, how to taper, and
potential alternatives are essential details to provide to clinicians,
patients, and families. The strategies presented can guide community
healthcare teams toward reducing the community burden of SH use.
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Affiliation(s)
- Lisa Burry
- Sinai Health System, Toronto, Ontario, Canada.,University of Toronto, Ontario, Canada
| | - Justin Turner
- Université de Montréal, Montréal, Québec, Canada.,Institut universitaire de gériatrie de Montréal, Québec, Canada
| | | | | | - Hyung J Cho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Lown Institute, Brookline, Massachusetts, MA, USA
| | | | - Flora Kisuule
- Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | | | - Christine Soong
- Sinai Health System, Toronto, Ontario, Canada.,University of Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, Toronto, Ontario, Canada
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Does education of primary care professionals promote patient self-management and improve outcomes in chronic disease? An updated systematic review. BJGP Open 2021; 5:BJGPO.2020.0186. [PMID: 33712503 PMCID: PMC8278509 DOI: 10.3399/bjgpo.2020.0186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/15/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Primary care has a vital role in supporting patient autonomy to enable people with long-term conditions to manage their own health and wellness. Evidence is needed on whether education and training of health professionals helps support patient self-management and improves outcomes. The authors' first systematic review included only two articles showing patient outcomes following health professional training for promoting patient self-management. AIM To present an updated review undertaken from September 2013 to August 2018. DESIGN & SETTING A systematic review was undertaken using the PRISMA guidelines, following the methodology of the first review and is outlined in the PROSPERO registered protocol. METHOD Six databases were searched - Cochrane Library, PubMed, ERIC, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycINFO - in addition to web searches, hand searches, and bibliographies for articles published from 1 September 2013 to 31 August 2018. RESULTS The updated systematic review showed more evidence is now available with 18 articles in the 5-year period from the 4284 abstracts located. Twelve of these articles showed a difference between intervention and control groups. Of the 18 articles identified, 11 were assessed as having a low risk of bias and five overall were rated of weak quality. The educational interventions with health professionals spanned a range of techniques and modalities, and many incorporated multiple interventions including patient components. There may be a lack of adoption owing to several challenges, including that complex interventions may not be delivered as planned and are difficult to assess, and owing to patient engagement and the need for ongoing follow-up. CONCLUSION More high-quality research is needed on what methods work best, for which patients, and for what clinical conditions in the primary care setting. The practical implications of training healthcare professionals require specific attention.
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Ie K, Aoshima S, Yabuki T, Albert SM. A narrative review of evidence to guide deprescribing among older adults. J Gen Fam Med 2021; 22:182-196. [PMID: 34221792 PMCID: PMC8245739 DOI: 10.1002/jgf2.464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/24/2021] [Accepted: 05/09/2021] [Indexed: 11/30/2022] Open
Abstract
Potentially inappropriate prescription and polypharmacy are well‐known risk factors for morbidity and mortality among older adults. However, recent systematic reviews have failed to demonstrate the overall survival benefits of deprescribing. Thus, it is necessary to synthesize the current evidence to provide a practical direction for future research and clinical practice. This review summarizes the existing body of evidence regarding deprescribing to identify useful intervention elements. There is evidence that even simple interventions, such as direct deprescribing targeted at risky medications and explicit criteria‐based approaches, effectively reduce inappropriate prescribing. On the other hand, if the goal is to improve clinical outcomes such as hospitalization and emergency department visits, patient‐centered multimodal interventions such as a combination of medication review, multidisciplinary collaboration, and patient education are likely to be more effective. We also consider the opportunities and challenges for deprescribing within the Japanese healthcare system.
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Affiliation(s)
- Kenya Ie
- Division of General Internal Medicine Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan.,Division of General Internal Medicine Department of Internal Medicine Kawasaki Municipal Tama Hospital Kawasaki Japan.,Department of Behavioral and Community Health Sciences University of Pittsburgh Graduate School of Public Health Pittsburgh PA USA
| | | | - Taku Yabuki
- Department of Internal Medicine Tochigi Medical Center Tochigi Japan
| | - Steven M Albert
- Department of Behavioral and Community Health Sciences University of Pittsburgh Graduate School of Public Health Pittsburgh PA USA
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Torrens I, Esteva M, Vicens C, Pizá-Portell MR, Vidal-Thomàs MC, Vidal-Ribas C, Lorente-Montalvo P, Torres-Solera E. Assessing the feasibility and acceptability of a cluster-randomized study of cognitive behavioral therapy for chronic insomnia in a primary care setting. BMC FAMILY PRACTICE 2021; 22:77. [PMID: 33863276 PMCID: PMC8052716 DOI: 10.1186/s12875-021-01429-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 04/02/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Cognitive behavioral therapy for chronic insomnia (CBT-i) is the treatment of choice for this condition but is underutilized in patients who attend primary care. The purpose of the present feasibility-pilot study was to assess the feasibility and acceptability of a cluster-randomized study of CBT-i in a primary care setting. METHODS This study, performed at two primary health care centers in Majorca, Spain, was a mixed methods feasibility-pilot study of a parallel cluster-randomized design comparing CBT-i and usual care (UC). Patients were included if they were 18 to 65 years-old; had diagnoses of chronic insomnia according to the Insomnia Severity Index (ISI ≥ 8); had insomnia for more than 3 months. Twenty-five GPs and nurses and 32 patients were randomly allocated to two groups. The main outcome of the intervention was improvement of dimensions of sleep quality, measured using the Spanish version of the Pittsburgh Sleep Quality Index, at baseline and at 3 months after the intervention. Other primary outcomes of the study were the feasibility and applicability of the intervention, collected through nominal groups. A thematic analysis was performed to classify primary care provider (PCP) proposals. Additionally, we assessed the recruitment process, compliance with the intervention sessions, and patient retention. RESULTS We adapted the CBT-i approach of Morin to a primary care context. After intervention training, PCPs expressed the need for more extensive training in the different aspects of the therapy and the discussion of more cases. PCPs considered the intervention as adequate but wanted fewer but longer sessions as well as to discard the cognitive restructuring component. PCPs considered it crucial to prepare each session in advance and to establish a specific agenda for the CBT-i. Regular reminders given to PCPs and patients were suggested to improve study participation. Compared to the UC group, higher proportions of patients in the intervention group had short sleep latency, slept for longer than 5 h, and had fewer sleep disruptions. CONCLUSIONS This feasibility-pilot study identified several key issues that must be addressed before performing a CBT-i intervention in future clinical trial in a primary care setting. TRIAL REGISTRATION NCT04565223 . (Clinical trials.gov) Registered 1 September 2020-Retrospectively registered.
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Affiliation(s)
- Isabel Torrens
- Santa Ponsa Health Center, Majorca Department of Primary Care, Baleares Health Service [IbSalut], Riu Síl, 25, 07180, Santa Ponça, Majorca, Spain
- Balearic Islands Health Research Institute (IdISBa), Edificio S, University Hospital Son Espases, Carretera de Valldemossa, 79, 07120, Palma, Majorca, Spain
| | - Magdalena Esteva
- Balearic Islands Health Research Institute (IdISBa), Edificio S, University Hospital Son Espases, Carretera de Valldemossa, 79, 07120, Palma, Majorca, Spain.
- Primary Care Research Unit, Majorca Department of Primary Care, Baleares Health Service [IbSalut], Escola Graduada 3, 07001, Palma, Spain.
- Preventive Activities and Health Promotion Research Network (REDIAPP), Barcelona, Spain.
| | - Caterina Vicens
- Balearic Islands Health Research Institute (IdISBa), Edificio S, University Hospital Son Espases, Carretera de Valldemossa, 79, 07120, Palma, Majorca, Spain
- Preventive Activities and Health Promotion Research Network (REDIAPP), Barcelona, Spain
- Son Serra Health Center, Majorca Department of Primary Care, Baleares Health Service [IbSalut], Carrer de Matamusinos, 22, 07013, Palma, Majorca, Spain
| | - María Rosa Pizá-Portell
- Santa Ponsa Health Center, Majorca Department of Primary Care, Baleares Health Service [IbSalut], Riu Síl, 25, 07180, Santa Ponça, Majorca, Spain
| | - María Clara Vidal-Thomàs
- Balearic Islands Health Research Institute (IdISBa), Edificio S, University Hospital Son Espases, Carretera de Valldemossa, 79, 07120, Palma, Majorca, Spain
- Primary Care Research Unit, Majorca Department of Primary Care, Baleares Health Service [IbSalut], Escola Graduada 3, 07001, Palma, Spain
- Preventive Activities and Health Promotion Research Network (REDIAPP), Barcelona, Spain
| | - Cristina Vidal-Ribas
- Santa Ponsa Health Center, Majorca Department of Primary Care, Baleares Health Service [IbSalut], Riu Síl, 25, 07180, Santa Ponça, Majorca, Spain
| | - Patricia Lorente-Montalvo
- Santa Ponsa Health Center, Majorca Department of Primary Care, Baleares Health Service [IbSalut], Riu Síl, 25, 07180, Santa Ponça, Majorca, Spain
| | - Elena Torres-Solera
- Primary Care Research Unit, Majorca Department of Primary Care, Baleares Health Service [IbSalut], Escola Graduada 3, 07001, Palma, Spain
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van Dulmen SA, Naaktgeboren CA, Heus P, Verkerk EW, Weenink J, Kool RB, Hooft L. Barriers and facilitators to reduce low-value care: a qualitative evidence synthesis. BMJ Open 2020; 10:e040025. [PMID: 33127636 PMCID: PMC7604848 DOI: 10.1136/bmjopen-2020-040025] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 08/28/2020] [Accepted: 09/30/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To assess barriers and facilitators to de-implementation. DESIGN A qualitative evidence synthesis with a framework analysis. DATA SOURCES Medline, Embase, Cochrane Library and Rx for Change databases until September 2018 were searched. ELIGIBILITY CRITERIA We included studies that primarily focused on identifying factors influencing de-implementation or the continuation of low-value care, and studies describing influencing factors related to the effect of a de-implementation strategy. DATA EXTRACTION AND SYNTHESIS The factors were classified on five levels: individual provider, individual patient, social context, organisational context, economic/political context. RESULTS We identified 333 factors in 81 articles. Factors related to the individual provider (n=131; 74% barriers, 17% facilitators, 9% both barrier/facilitator) were associated with their attitude (n=72; 55%), knowledge/skills (n=43; 33%), behaviour (n=11; 8%) and provider characteristics (n=5; 4%). Individual patient factors (n=58; 72% barriers, 9% facilitators, 19% both barrier/facilitator) were mainly related to knowledge (n=33; 56%) and attitude (n=13; 22%). Factors related to the social context (n=46; 41% barriers, 48% facilitators, 11% both barrier/facilitator) included mainly professional teams (n=23; 50%) and professional development (n=12; 26%). Frequent factors in the organisational context (n=67; 67% barriers, 25% facilitators, 8% both barrier/facilitator) were available resources (n=28; 41%) and organisational structures and work routines (n=24; 36%). Under the category of economic and political context (n=31; 71% barriers, 13% facilitators, 16% both barrier/facilitator), financial incentives were most common (n=27; 87%). CONCLUSIONS This study provides in-depth insight into the factors within the different (sub)categories that are important in reducing low-value care. This can be used to identify barriers and facilitators in low-value care practices or to stimulate development of strategies that need further refinement. We conclude that multifaceted de-implementation strategies are often necessary for effective reduction of low-value care. Situation-specific knowledge of impeding or facilitating factors across all levels is important for designing tailored de-implementation strategies.
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Affiliation(s)
- S A van Dulmen
- Scientific Institute for Quality of Healthcare, IQ Healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - C A Naaktgeboren
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrech, Utrecht University, Utrecht, The Netherlands
| | - Pauline Heus
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Eva W Verkerk
- Scientific Institute for Quality of Healthcare, IQ Healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - J Weenink
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Rudolf Bertijn Kool
- Scientific Institute for Quality of Healthcare, IQ Healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Lotty Hooft
- Cochrane Netherlands, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
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Isenor JE, Bai I, Cormier R, Helwig M, Reeve E, Whelan AM, Burgess S, Martin-Misener R, Kennie-Kaulbach N. Deprescribing interventions in primary health care mapped to the Behaviour Change Wheel: A scoping review. Res Social Adm Pharm 2020; 17:1229-1241. [PMID: 32978088 DOI: 10.1016/j.sapharm.2020.09.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/17/2020] [Accepted: 09/07/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Polypharmacy and inappropriate medication use are an increasing concern. Deprescribing may improve medication use through planned and supervised dose reduction or stopping of medications. As most medication management occurs in primary health care, which is generally described as the first point of access for day-to-day care, deprescribing in primary health care is the focus on this review. OBJECTIVE This scoping review aimed to identify and characterize strategies for deprescribing in primary health care and map the strategies to the Behaviour Change Wheel (BCW). METHODS A scoping review was conducted that involved searches of six databases (2002-2018) and reference lists of relevant systematic reviews and included studies. Studies that described and evaluated deprescribing strategies in primary health care were eligible. Two independent reviewers screened articles and completed data charting with charting verified by a third. Deprescribing strategies were mapped to the intervention functions of the BCW and linked to specific Behaviour Change Techniques (BCT). RESULTS Searches yielded 6871 citations of which 43 were included. Nineteen studies were randomized, 24 were non-randomized. Studies evaluated deprescribing in terms of medication changes, feasibility, and prescriber/patient perspectives. Deprescribing strategies involved various professionals (physicians, pharmacists, nurses), as well as patients and were generally multifaceted. A wide range of intervention functions were identified, with 41 BCTs mapped to Environmental restructuring, 38 BCTs mapped to Enablement, and 34 BCTs mapped to Persuasion. CONCLUSIONS Deprescribing strategies in primary health care have used a variety of BCTs to address individual professionals (e.g. education) as well as strategies that addressed the practice setting, including support from additional team members (e.g. pharmacists, nurses and patients). Further research is warranted to determine comparative effectiveness of different BCTs, which can help facilitate implementation of deprescribing strategies, thereby reducing polypharmacy, in primary health care.
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Affiliation(s)
- Jennifer E Isenor
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada.
| | - Isaac Bai
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada
| | - Rachel Cormier
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada
| | - Melissa Helwig
- W.K. Kellogg Health Sciences Library, Dalhousie University, Halifax, NS, Canada
| | - Emily Reeve
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada; Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Division of Health Sciences, University of South Australia, Adelaide, SA, Australia; Geriatric Medicine Research, Faculty of Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada
| | - Anne Marie Whelan
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada
| | - Sarah Burgess
- Pharmacy Department, Nova Scotia Health Authority, Halifax, NS, Canada
| | - Ruth Martin-Misener
- School of Nursing, Dalhousie University, 5869 University Avenue, Halifax, NS, Canada
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Lynch T, Ryan C, Hughes CM, Presseau J, van Allen ZM, Bradley CP, Cadogan CA. Brief interventions targeting long-term benzodiazepine and Z-drug use in primary care: a systematic review and meta-analysis. Addiction 2020; 115:1618-1639. [PMID: 31985127 PMCID: PMC7891570 DOI: 10.1111/add.14981] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 10/18/2019] [Accepted: 01/17/2020] [Indexed: 12/23/2022]
Abstract
AIMS To assess the effectiveness of brief interventions in primary care aimed at reducing or discontinuing long-term benzodiazepine/Z-drug (BZRA) use. METHOD Systematic review of randomized controlled trials of brief interventions in primary care settings aimed at reducing or discontinuing long-term BZRA use in adults taking BZRAs for ≥ 3 months. Four electronic databases were searched: PubMed, EMBASE, PsycINFO and CENTRAL. The primary outcome was BZRA use, classified as discontinuation or reduction by ≥ 25%. The Theoretical Domains Framework (TDF) was used to retrospectively code behavioural determinants targeted by the interventions. The Behaviour Change Technique (BCT) Taxonomy was used to identify the interventions' active components. Study-specific estimates were pooled, where appropriate, to yield summary risk ratios (RRs) and 95% confidence intervals (CIs). Pearson's correlations were used to determine the relationship between intervention effect size and the results of both the TDF and BCT coding. RESULTS Eight studies were included (n = 2071 patients). Compared with usual care, intervention patients were more likely to have discontinued BZRA use at 6 months (eight studies, RR = 2.73, 95% CI = 1.84-4.06) and 12 months post-intervention (two studies, RR = 3.41, 95% CI = 2.22-5.25). TDF domains 'knowledge', 'memory, attention and decision processes', 'environmental context and resources' and 'social influences' were identified as having been included in every intervention. Commonly identified BCTs included 'information about health consequences', 'credible source' and 'adding objects to the environment'. There was no detectable relationship between effect size and the results of either the TDF or BCT coding. CONCLUSION Brief interventions delivered in primary care are more effective than usual care in reducing and discontinuing long-term benzodiazepine/Z-drug use.
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Affiliation(s)
- Tom Lynch
- School of Pharmacy and Biomolecular SciencesRoyal College of Surgeons in IrelandDublinIreland
| | - Cristín Ryan
- School of Pharmacy and Pharmaceutical SciencesTrinity CollegeDublinIreland
| | | | - Justin Presseau
- Ottawa Hospital Research InstituteThe Ottawa HospitalOttawaCanada,School of Epidemiology and Public HealthUniversity of OttawaOttawaCanada,School of PsychologyUniversity of OttawaOttawaCanada
| | | | - Colin P. Bradley
- Department of General PracticeUniversity College CorkCorkIreland
| | - Cathal A. Cadogan
- School of Pharmacy and Biomolecular SciencesRoyal College of Surgeons in IrelandDublinIreland
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Morera-Fumero AL, Fernandez-Lopez L, Abreu-Gonzalez P. Melatonin and melatonin agonists as treatments for benzodiazepines and hypnotics withdrawal in patients with primary insomnia. A systematic review. Drug Alcohol Depend 2020; 212:107994. [PMID: 32409111 DOI: 10.1016/j.drugalcdep.2020.107994] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/29/2020] [Accepted: 03/26/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hypnotics (HYP) and benzodiazepines (BZD) are medicines prescribed for the insomnia treatment. Many patients present difficulties in discontinuing the treatment once established. Melatonin (MLT) has been prescribed as a treatment for BZD/HYP detoxification. AIMS The primary objective of this systematic review is to assess the efficacy of MLT and MLT agonists (melatoninergics) in improving the rate of BZD and/or HYP discontinuation among adults with primary insomnia attempting to discontinue BZD and/or HYP. The secondary objective is to evaluate the partial efficacy of melatoninergic drugs in the discontinuation of BZD and/or HYP consumption in subjects that could not stop their consumption. METHOD A search on Web of Science and Scopus was carried out from database inception to July 1st, 2019. RESULTS Three hundred and forty-nine articles were identified but only four were included in the final review. Two were cohort prospective, one placebo-control double blind and one double blind placebo-control cross-over designed study. Total withdrawal (TW) ranged from 0% to 25% in the placebo arm and from 64.3% to 77.8% in the MLT arm. In cohort studies TW figures ranged from 30.8% to 65%. Partial withdrawal ranged between 20% and 30.8% of patients that did not achieve TW with reduction figures of diazepam equivalent dose ranging from 25% to 75%. CONCLUSION MLT has a place in the physician armamentarium to treat the suspension/reduction of BZD/HYP consumption in patients with primary insomnia.
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Affiliation(s)
- Armando L Morera-Fumero
- Departamento de Medicina Interna, Dermatología y Psiquiatría. Facultad de Ciencias de la Salud, Universidad de La Laguna, La Laguna, Santa Cruz de Tenerife, Spain; Consultoría Psiquiátrica SC, Santa Cruz de Tenerife, Spain.
| | - Lourdes Fernandez-Lopez
- Departamento de Medicina Interna, Dermatología y Psiquiatría. Facultad de Ciencias de la Salud, Universidad de La Laguna, La Laguna, Santa Cruz de Tenerife, Spain; Sociedad para la Investigación y Asistencia en Salud Mental, Santa Cruz de Tenerife, Spain
| | - Pedro Abreu-Gonzalez
- Departamento de Ciencias Médicas Básicas: Unidad de Fisiología. Facultad de Ciencias de la Salud. Universidad de la Laguna, la Laguna, Santa Cruz de Tenerife, Spain
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31
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Trépel D, Ali S, Gilbody S, Leiva A, Mcmillan D, Bejarano F, Sempere E, Vicens C. Cost-effectiveness of brief structured interventions to discontinue long-term benzodiazepine use: an economic analysis alongside a randomised controlled trial. HRB Open Res 2020; 3:33. [PMID: 32743341 PMCID: PMC7372528 DOI: 10.12688/hrbopenres.13049.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2020] [Indexed: 11/21/2022] Open
Abstract
Background: In Spain, long-term use of benzodiazepine is prevalent in 7% of the population; however, this longer-term use lacks clinical benefits, costs €90million per year and side-effects further add extra cost through adverse health outcomes. This study aims to estimate the cost-effectiveness of primary care services stepped dose reduction of long-term benzodiazepines using either Structured Interview with Follow-up (SIF) or Without Follow-up (SIW), compared to Treatment as Usual (TAU). Design: Cost-effectiveness analysis was conducted alongside randomised control utilizing data from three arm cluster randomized trial. Setting: Primary care. Participants: 75 general practitioners were randomised to one of the three arms (TAU, SIW, SIF). Measurements: Cost and Cost per Quality-Adjusted Life Year (QALY) Results: Compared to usual care, providing SIW per participant costs an additional €117.94 and adding patient follow-up, €218.4. As a result of intervention, participants showed a gain of, on average, for SIW 0.0144 QALY (95% CI -0.0137 to 0.0425) and for SIF 0.0340 QALYs (0.0069 to 0.0612). The Incremental Cost Effectiveness Ratio was €8190.28/QALY (SIW) and €6423.53/QALY (SIF). At the Spanish reimbursement threshold (€45,000 per QALY) the chance interventions are cost effective is 79.8% for SIW and 97.7% for SIF. Conclusions: Brief structured interventions to discontinue long-term benzodiazepine use represent value for money, particularly with scheduled follow-up appointments, and would represent a cost-effective investment by the Spanish healthcare to reduce prevalence of long-term use.
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Affiliation(s)
- Dominic Trépel
- School of Medicine, Trinity College Dublin, Dublin, D02 PN40, Ireland
- Global Brain Health Institute, Trinity College Dublin, Dublin, D02 PN40, Ireland
- Global Brain Health Institute, University of California, San Francisco, San Francisco, CA, USA
| | - Shehzad Ali
- Mental Health and Additions Research Group, Department of Health Sciences, University of York, UK, Heslington, York,, YO10 5DD, UK
| | - Simon Gilbody
- Mental Health and Additions Research Group, Department of Health Sciences, University of York, UK, Heslington, York,, YO10 5DD, UK
| | - Alfonso Leiva
- Instituto de Investigación Sanitaria de Palma, Palma, 07120, Spain
| | - Dean Mcmillan
- Mental Health and Additions Research Group, Department of Health Sciences, University of York, UK, Heslington, York,, YO10 5DD, UK
| | - Ferran Bejarano
- Institut Català de la Salut, DAP Camp de Tarragona, Catalunya, Catalunya, Spain
| | - Ermengol Sempere
- Conselleria de Sanitat Universal i Salut Pública, Paterna Health Care Centre, Valencia, 46010, Spain
| | - Caterina Vicens
- Instituto de Investigación Sanitaria de Palma, Palma, 07120, Spain
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Turner JP, Martin P, Zhang YZ, Tannenbaum C. Patients beliefs and attitudes towards deprescribing: Can deprescribing success be predicted? Res Social Adm Pharm 2020; 16:599-604. [DOI: 10.1016/j.sapharm.2019.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 07/05/2019] [Accepted: 07/09/2019] [Indexed: 01/06/2023]
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Sanyal C, Turner JP, Martin P, Tannenbaum C. Cost‐Effectiveness of Pharmacist‐Led Deprescribing of
NSAIDs
in Community‐Dwelling Older Adults. J Am Geriatr Soc 2020; 68:1090-1097. [DOI: 10.1111/jgs.16388] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/03/2020] [Accepted: 02/03/2020] [Indexed: 11/28/2022]
Affiliation(s)
| | - Justin P. Turner
- Faculty of PharmacyUniversité de Montréal Montréal Québec Canada
- Centre de Recherche, Institut Universitaire de Gériatrie de Montréal Montréal Québec Canada
| | - Philippe Martin
- Faculty of PharmacyUniversité de Montréal Montréal Québec Canada
- Centre de Recherche, Institut Universitaire de Gériatrie de Montréal Montréal Québec Canada
| | - Cara Tannenbaum
- Faculty of PharmacyUniversité de Montréal Montréal Québec Canada
- Centre de Recherche, Institut Universitaire de Gériatrie de Montréal Montréal Québec Canada
- Faculty of MedicineUniversité de Montréal Montréal Québec Canada
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Coteur K, Van Nuland M, Vanmeerbeek M, Henrard G, Anthierens S, Van den Broeck K, De Sutter A, Creupelandt H, Devroey D, Van Overmeire R, Offermans AM, Kacenelenbogen N, Laenen A, Mathei C. Effectiveness of a blended care programme for the discontinuation of benzodiazepine use for sleeping problems in primary care: study protocol of a cluster randomised trial, the Big Bird trial. BMJ Open 2020; 10:e033688. [PMID: 32075832 PMCID: PMC7045121 DOI: 10.1136/bmjopen-2019-033688] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Problematic benzodiazepine use is a global health issue. Although the adverse side effects of long-term use of benzodiazepines are well known, it remains difficult to implement interventions for discontinuation in primary care. Considering the success of blended care for the treatment of sleeping disorders and the support of substance use disorders, evidence suggests that a blended care approach, combining face-to-face consultations with the general practitioner with web-based self-learning by the patient, is beneficial for the discontinuation of chronic benzodiazepine use for primary insomnia in general practice. Therefore, the aim of this study is to evaluate the effectiveness of such an approach for the discontinuation of benzodiazepine and zolpidem, zopiclone and zaleplon drugs ((z-)BZD) use in the long term and evaluate the implementation process. METHODS AND ANALYSIS This study is a multicentre, pragmatic, cluster randomised controlled trial with 1200 patients, included by 120 general practitioners. Allocation to usual or blended care happens at the level of the general practice in a 1:1 ratio using a block randomisation system stratified per language. The study population consists of adult primary care patients who have been using (z-)BZD for primary insomnia on a daily basis for at least 6 months. Primary outcome measure is the proportion of patients that discontinued (z-)BZD at 12 months assessed by toxicological screening for (z-)BZD in urine. Secondary outcomes include discontinuation of (z-)BZD at 6 months, quality of life and the number of defined daily doses of (z-)BZD prescribed. Data will be collected using a study-specific online platform and analysed using the intention-to-treat approach. The process of implementing blended care will be evaluated in a nested study. ETHICS AND DISSEMINATION This trial was approved by the Ethics Committee for Research of UZ/KU Leuven (ref. S61194). Study results will be disseminated via open-access, peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER NCT03937180.
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Affiliation(s)
- Kristien Coteur
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Marc Van Nuland
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Marc Vanmeerbeek
- Department of General Practice, Université de Liège, Liege, Belgium
| | - Gilles Henrard
- Department of General Practice, Université de Liège, Liege, Belgium
| | - Sibyl Anthierens
- Department of General Practice, University of Antwerp, Antwerpen, Belgium
| | | | - An De Sutter
- Department of Public Health and Primary Care, Ghent University, Gent, Belgium
| | - Hanne Creupelandt
- Department of Public Health and Primary Care, Ghent University, Gent, Belgium
| | - Dirk Devroey
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussel, Belgium
| | - Roel Van Overmeire
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussel, Belgium
| | - Anne-Marie Offermans
- Department of General Medicine, Université Libre de Bruxelles, Bruxelles, Belgium
| | | | - Annouschka Laenen
- Interuniversity Institute for Biostatistics and statistical Bioinformatics, Leuven, Belgium
| | - Catharina Mathei
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
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Bushnell GA, Crystal S, Olfson M. Prescription Benzodiazepine Use in Privately Insured U.S. Children and Adolescents. Am J Prev Med 2019; 57:775-785. [PMID: 31753258 PMCID: PMC6935869 DOI: 10.1016/j.amepre.2019.07.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 07/14/2019] [Accepted: 07/15/2019] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Benzodiazepines are commonly prescribed in the U.S. but entail safety concerns, including dependency. In pediatrics, many indications lack trial data. Authors aimed to describe youth initiating prescription benzodiazepine treatment, identify potential indications and prescribing concerns, estimate the duration of treatment by potential indication, and identify factors that predict long-term use. METHODS The study cohort included children (aged 3-12 years) and adolescents (aged 13-17 years) initiating prescription benzodiazepine treatment (≥3 days' supply) from January 2010 to September 2015 in a U.S. commercial claims database. Potential indications included selected ICD-9-CM diagnoses (≤30 days prior). Long-term (≥6 months) benzodiazepine treatment was estimated with Kaplan-Meier estimation and modified Poisson regression identified independent predictors of long-term benzodiazepine treatment (analysis completed in 2018). RESULTS Of 24,504 children and 61,046 adolescents initiating benzodiazepines, 62% of the children and 68% of the adolescents had a potential indication. Anxiety disorders were the most common indication, with mental health indications more common among adolescents (45%) than children (23%) and epilepsy and movement disorders higher in children. Recent opioid prescriptions were common before benzodiazepine initiation (children, 22%; adolescents, 21%). Six percent of the initiators became long-term benzodiazepine users. Potential indication, provider contact, psychotropic medication, and chronic conditions independently predicted long-term benzodiazepine treatment in adolescents and children. CONCLUSIONS U.S. children and adolescents are prescribed benzodiazepines for various mental health and other medical conditions, many lacking evidence of pediatric efficacy. Long-term benzodiazepine treatment, concurrent opioid prescriptions, psychotropic use, and prior substance use disorder diagnoses suggest safety risks among some youth prescribed benzodiazepines.
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Affiliation(s)
- Greta A Bushnell
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York.
| | - Stephen Crystal
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, New Jersey
| | - Mark Olfson
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York; Department of Psychiatry, Columbia University Irving Medical Center, New York, New York
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Davidson S, Thomson C, Prescott G. A Durable Minimal Intervention Strategy to Reduce Benzodiazepine Use in a Primary Care Population. Korean J Fam Med 2019; 41:126-132. [PMID: 31693838 PMCID: PMC7093675 DOI: 10.4082/kjfm.18.0159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 10/18/2018] [Indexed: 11/24/2022] Open
Abstract
Background Benzodiazepines are commonly prescribed drugs with approximately 10% of adults having used them in the past year. These drugs are clearly addictive, yet many patients are prescribed these for years, with long-term side effects. The present study aimed to investigate whether patients on repeat diazepam prescription had their prescription reviewed to reduce and to stop the repeat prescription wherever appropriate, and whether these changes were sustained at 24 months. Methods The present study used a minimal intervention strategy to reduce diazepam use in a semi-rural general practice. Patients with a current prescription for diazepam were invited to visit their general practitioner for a review. Dose reduction grids were formulated for each individual to facilitate a downward titration by 1 mg each wk/mo. Patients with psychiatric co-morbidity were also included. Interrupted time series methods were applied to the monthly data. The outcomes were evaluated at 12 and 24 months. Results Ninety-two patients had diazepam on repeat prescription with 87 (94.6%) attending the review appointment. Twenty-seven patients (29.3%) were under psychiatric review and were supported by the psychiatrist with a downward titration regime. At 24 months, 63 patients (81.8% of the 77 still at the practice) had stopped or were in the process of stopping regular use of diazepam. A statistically significant reduction in total monthly diazepam prescription was observed (from 2.2 to 0.7 defined daily dose/1,000 patients/d). Conclusion This minimal intervention strategy, in collaboration between primary and secondary care, produced a durable reduction in overall diazepam prescription at the general practice.
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Affiliation(s)
- Stephen Davidson
- Forensic Psychiatry, Rowanbank Clinic, NHS Greater Glasgow & Clyde, Glasgow, UK
| | | | - Gordon Prescott
- Medical Statistics Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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Peritogiannis V, Manthopoulou T, Mavreas V. Long-term Benzodiazepine Treatment in Patients with Psychotic Disorders Attending a Mental Health Service in Rural Greece. J Neurosci Rural Pract 2019; 7:S26-S30. [PMID: 28163499 PMCID: PMC5244055 DOI: 10.4103/0976-3147.196447] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Long-term benzodiazepine (BZD) treatment in patients with mental disorders is widespread in clinical practice, and this is also the case of patients with schizophrenia, although the evidence is weak and BZD prescription is discouraged by guidelines and medical authorities. Data on BZD prescription are usually derived from national or regional databases whereas information on the use of BZD by patients with schizophrenia and related psychoses in general population-based samples is limited. MATERIALS AND METHODS Information for 77 patients with psychotic disorders who were regularly attending follow-up appointments with the multidisciplinary Mobile Mental Health Unit of the prefectures of Ioannina and Thesprotia, Northwest Greece, during 1-year period (2015) was obtained from our database. RESULTS From the total of 77 engaged patients, 30 (39%) were regularly prescribed BZDs in the long term, as part of their treatment regimen. Prescribed BZDs were mostly diazepam and lorazepam, in 43.3% of cases each. The mean daily dose of these compounds was 13 mg and 3.77 mg, respectively. Statistical analysis showed a correlation of long-term BZD use with the history of alcohol/substance abuse. Most patients were receiving BZD continuously for several years, and the mean dose was steady within this interval. CONCLUSIONS A large proportion of patients with psychotic disorders were regularly prescribed BZD in long term. It appears that when BZDs are prescribed for some period in the course of a psychotic disorder, their use commonly exceeds the recommended interval and then becomes a regular part of the chronic treatment regimen. Future research should address the factors that may be related to the long-term BZD use by patients with psychotic disorders. Interventions for the reduction of regular BZD prescription should target the primary care setting and all those who treat first episode patients.
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Affiliation(s)
- Vaios Peritogiannis
- Mobile Mental Health Unit of the Prefectures of Ioannina and Thesprotia, Society for the Promotion of Mental Health in Epirus, Ioannina, Greece
| | - Thiresia Manthopoulou
- Mobile Mental Health Unit of the Prefectures of Ioannina and Thesprotia, Society for the Promotion of Mental Health in Epirus, Ioannina, Greece
| | - Venetsanos Mavreas
- Department of Psychiatry, University of Ioannina School of Medicine, Ioannina, Greece
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Geka M, Inada K, Shimizu S, Geka Y, Takahashi Y, Hamada Y, Nishimura K, Kimura T. [Effectiveness of Pharmacist-convened Multidisciplinary Clinical Team Meetings in Promoting Appropriate Benzodiazepine Receptor Agonist Use]. YAKUGAKU ZASSHI 2019; 139:931-937. [PMID: 31155538 DOI: 10.1248/yakushi.18-00207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Benzodiazepine receptor agonists (BZRAs) are used in the treatment of a wide variety of clinical conditions. Although clinical practice guidelines discourage high dosage or long-term use of BZRAs, they are prescribed in clinical settings. This study aimed to investigate whether the pharmacists at multidisciplinary clinical team meetings can help reduce BZRA use and promote appropriate use of these drugs. The psychiatric unit of the Tokyo Women's Medical University Hospital occupies two floors, with 31 beds on Floor A and 34 beds on Floor B. The multidisciplinary clinical team meetings were held once a week in each ward. During the meetings, the pharmacists comprehensively assessed the number of BZRA doses administered and the equivalent diazepam doses, presented their prescription recommendations aimed at dosage reduction, and shared their views with the entire clinical team. This intervention was commenced on Floor A in 2014 and on Floor B in 2015. The average number of BZRAs in each period and equivalent diazepam doses were assessed for 273 psychiatric inpatients hospitalized from April to June in 2013, 2014, and 2015. Changes in the number of BZRA doses administered were assessed per floor per year. The results showed a statistically significant decrease between years with and without interventions. The intervention of pharmacists allowed multidisciplinary clinical team members to gain the same understanding about BZRA use and formulation of drug therapy plans. The results suggest that the intervention of pharmacists at clinical team meetings can strategically lead to decreased BZRA dosages and their proper use.
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Affiliation(s)
- Mayumi Geka
- Department of Pharmacy, Tokyo Women's Medical University Hospital
| | - Ken Inada
- Department of Psychiatry, School of Medicine, Tokyo Women's Medical University
| | - Satoru Shimizu
- Department of Medical Education, School of Medicine, Tokyo Women's Medical University
| | - Yujiro Geka
- Department of Pharmacy, Tokyo Women's Medical University Hospital
| | - Yuka Takahashi
- Department of Pharmacy, Tokyo Women's Medical University Hospital
| | - Yukihiro Hamada
- Department of Pharmacy, Tokyo Women's Medical University Hospital
| | - Katsuji Nishimura
- Department of Psychiatry, School of Medicine, Tokyo Women's Medical University
| | - Toshimi Kimura
- Department of Pharmacy, Tokyo Women's Medical University Hospital
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Physicians' beliefs and attitudes about Benzodiazepines: a cross-sectional study. BMC FAMILY PRACTICE 2019; 20:71. [PMID: 31128589 PMCID: PMC6535184 DOI: 10.1186/s12875-019-0965-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 05/16/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND In 2015, Portugal was the OECD country with the highest reported consumption of BZD. Physician's perceptions and attitudes regarding BZD are main determinants of related prescription habits. This study aimed to characterize beliefs and attitudes of Portuguese physicians regarding the prescription, management challenges, benefits, risks and withdrawal effects of BZD. METHODS A cross-sectional, observational study with online data collection through anonymous self-administered questionnaire. Physicians registered with the Portuguese Medical Association were invited to participate through direct e-mail message. Physicians were asked to give their opinion (using a 5-points Likert scale) regarding the prescription of BZD, their benefits and risks in the management of insomnia and anxiety, the possible adverse effects of chronic use and alternative non-pharmacologic approaches. Descriptive statistics were used and groups were compared through logistic regression. RESULTS A total of 329 physicians participated in the study (56% family physicians). Mean age was 44.10 ± 15.2 years, with 19.03 ± 14.9 years of clinical experience. Fifty eight percent of participants were female. Physicians reported BZD's negative impact on cognitive function (89%), association with road traffic accidents (88%) and falls (79%). Also, 58% shared the belief that chronic use is justified if the patient feels better and without adverse events. Although 68% reported to feel capable of helping patients to reduce or stop BZD, 55% recognized difficulties in motivating them. Compared to other medical specialists (altogether), family physicians were significantly more aware about the adverse effects of BZD and considered that chronic use may not be justified. Conversely, more family physicians expressed concerns about their skills to motivate patients engaging in withdrawal programs and to support them during the process. CONCLUSION Our results show that physicians' awareness about risks of BZD chronic use is adequate though their attitudes and self-perceived skills towards promoting BZD withdrawal can be improved. Interventions in primary care are needed to capacitate physicians to better motivate patients for BZD withdrawal.
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Dou C, Rebane J, Bardal S. Interventions to improve benzodiazepine tapering success in the elderly: a systematic review. Aging Ment Health 2019; 23:411-416. [PMID: 29336611 DOI: 10.1080/13607863.2017.1423030] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Long-term benzodiazepine use in the elderly population is a significant public health problem that leads to impaired cognitive functioning, medication dependence and increased risks for adverse drug reactions. The aim of this review was to examine randomized controlled trials (RCTs) on the efficacy of different methods for tapering and discontinuing benzodiazepines. METHOD We used four databases (Ovid, PubMed, Academic Search Complete, Web of Science) to retrieve randomized controlled trials published in peer-reviewed journals that explored different methods for tapering benzodiazepine use in a primarily geriatric population. RESULTS Eleven papers met the inclusion criteria. Methods to assist in benzodiazepine tapering included patient education, cognitive behavioural therapy (CBT), and pharmaceutical adjuvants (SSRIs, melatonin, progesterone). Patient education was consistently effective in increasing benzodiazepine discontinuation success while CBT had mixed but promising results. The use of medications to help improve tapering success was inconclusive. CONCLUSIONS Patient education is a successful, time- and cost-effective intervention that can significantly help with benzodiazepine discontinuation success. CBT may also be an effective approach. However, cost can be an issue since public healthcare coverage in Canada does not cover psychotherapy. More research is needed in looking at pharmaceutical adjuvants and their role in assisting with benzodiazepine discontinuation.
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Affiliation(s)
- Carol Dou
- a University of British Columbia , Vancouver , Canada
| | | | - Stan Bardal
- a University of British Columbia , Vancouver , Canada
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Silva PAD, Almeida LYD, Souza JD. The use of benzodiazepines by women cared for at a Family Health Unit. Rev Esc Enferm USP 2019; 53:e03419. [PMID: 30726334 DOI: 10.1590/s1980-220x2017038903419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 08/24/2018] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Estimate the prevalence of benzodiazepine use by adult women at a Family Health Unit and identify the risk factors associated with this usage. METHOD Quantitative cross-sectional study that employed secondary data developed at a Family Health Unit in the state of São Paulo, Brazil. We collected the data from the following sources: medical charts, registration forms, and the archive of prescriptions from the pharmacy at the referred health unit. We employed the chi-squared, Student's t, and Mann-Whitney tests, as well as logistic regression analysis. RESULTS We identified 81 benzodiazepine users amongst 1,094 adult women (7.4%). Regarding the risk factors, the comparison between the groups of benzodiazepine users (n = 64) and non-users (n = 70) showed that having a chronic disease and using other psychotropic drugs were significantly associated with the use of benzodiazepines. CONCLUSION The prevalence found was lower than the described in previous studies performed in Primary Health Units. The group that must receive greater attention regarding the consumption of benzodiazepines is that of middle-aged women or older, with low education levels, and chronic illnesses.
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Affiliation(s)
- Paula Adriana da Silva
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | | | - Jacqueline de Souza
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Psiquiátrica e Ciências Humanas, Ribeirão Preto, SP, Brazil
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Vicens C, Leiva A, Bejarano F, Sempere E, Rodríguez-Rincón RM, Fiol F, Mengual M, Ajenjo A, Do Pazo F, Mateu C, Folch S, Alegret S, Coll JM, Martín-Rabadán M, Socias I. Intervention to reduce benzodiazepine prescriptions in primary care, study protocol of a hybrid type 1 cluster randomised controlled trial: the BENZORED study. BMJ Open 2019; 9:e022046. [PMID: 30705235 PMCID: PMC6359733 DOI: 10.1136/bmjopen-2018-022046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Benzodiazepines (BZDs) are mainly used to treat anxiety and sleep disorders, and are often prescribed for long durations, even though prescription guidelines recommend short-term use due to the risk of dependence, cognitive impairment, and falls and fractures. Education of general practitioners (GPs) regarding the prescription of BZDs may reduce the overuse and of these drugs.The aims of this study are to analyse the effectiveness of an intervention targeted to GPs to reduce BZD prescription and evaluate the implementation process. METHODS AND ANALYSIS The healthcare centres in three regions of Spain (Balearic Islands, Catalonia and Community of Valencia) will be randomly allocated to receive a multifactorial intervention or usual care (control). GPs in the intervention group will receive a 2-hour workshop about best-practice regarding BZD prescription and BZD deprescribing, monthly feedback about their BZD prescribing practices and access to a support web page. Outcome measures for each GP are the defined daily dosage per 1000 inhabitants per day and the proportion of long-term BZD users at 12 months. Data will be collected from the electronic prescription database of the public health system, and will be subjected to intention-to-treat analysis. Implementation will be evaluated by mixed methods following the five domains of the Consolidated Framework For Implementation Research. ETHICS AND DISSEMINATION This study was approved by the Balearic Islands Ethical Committee of Clinical Research (IB3065/15), l'IDIAP Jordi Gol Ethical Committee of Clinical Research (PI 15/0148) and Valencia Primary Care Ethical Committee of Clinical Research (P16/024). The results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN28272199.
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Affiliation(s)
- Caterina Vicens
- Son Serra-La Vileta Healthcare Centre, Balearic Health Service Ib-Salut, Palma, Spain
- Instituto de Investigación Sanitaria de Baleares (IdISBa), Palma, Spain
| | - Alfonso Leiva
- Instituto de Investigación Sanitaria de Baleares (IdISBa), Palma, Spain
- Primary Care Reseach Unit, Balearic Health Service Ib-Salut, Palma, Spain
| | - Ferran Bejarano
- DAP Camp de Tarragona, Catalunya Health Services-CatSalut, Tarragona, Spain
| | - Ermengol Sempere
- Paterna Healthcare Centre, Conselleria de Sanitat Universal, Agència Valenciana de Salut, Valencia, Spain
| | | | - Francisca Fiol
- Son Serra-La Vileta Healthcare Centre, Balearic Health Service Ib-Salut, Palma, Spain
| | - Marta Mengual
- DAP Camp de Tarragona, Catalunya Health Services-CatSalut, Tarragona, Spain
| | - Asunción Ajenjo
- Paterna Healthcare Centre, Conselleria de Sanitat Universal, Agència Valenciana de Salut, Valencia, Spain
| | - Fernando Do Pazo
- Pharmacy Department, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - Catalina Mateu
- Son Serra-La Vileta Healthcare Centre, Balearic Health Service Ib-Salut, Palma, Spain
- Instituto de Investigación Sanitaria de Baleares (IdISBa), Palma, Spain
| | - Silvia Folch
- DAP Camp de Tarragona, Catalunya Health Services-CatSalut, Tarragona, Spain
| | - Santiago Alegret
- Son Serra-La Vileta Healthcare Centre, Balearic Health Service Ib-Salut, Palma, Spain
| | - Jose Maria Coll
- Menorca Primary Care Management, Balearic Health Service Ib-Salut, Mahón, Spain
| | | | - Isabel Socias
- Instituto de Investigación Sanitaria de Baleares (IdISBa), Palma, Spain
- Manacor Healthcare Centre, Balearic Health Service Ib-Salut, Manacor, Spain
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Turner JP, Richard C, Lussier MT, Lavoie ME, Farrell B, Roberge D, Tannenbaum C. Deprescribing conversations: a closer look at prescriber-patient communication. Ther Adv Drug Saf 2018; 9:687-698. [PMID: 30546863 DOI: 10.1177/2042098618804490] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 08/28/2018] [Indexed: 12/15/2022] Open
Abstract
Background Little is known about the initiation, style and content of patient and healthcare provider communication around deprescribing. We report the findings from a content analysis of audio-recorded discussions of proton pump inhibitor (PPI) and benzodiazepine deprescribing in primary care. Methods Participants were healthcare providers (n = 13) from primary care practices (n = 3) and patients aged ⩾65 (n = 24) who were chronic users of PPIs or benzodiazepines. The EMPOWER educational brochures were distributed prior to (n = 15) or after (n = 9) the patient's usual healthcare provider appointment. Conversations were audio-recorded and coded using MEDICODE to analyze who initiated different themes, whether they followed a monologue or dialogue style, and to what extent the thematic content addressed issues pertaining to: 'dosage/instructions,' 'medication action and efficacy,' 'risk/adverse effects,' 'attitudes/emotions,' 'adherence' and 'follow up.' Descriptive analysis of the conversations was performed with comparison between patients who received the EMPOWER brochure before or after their appointments. Results Patients were mostly women (67%) with a mean age of 74 ± 6 years. For PPI users, prior education resulted in a greater proportion of themes initiated by patients (44% versus 17%) and maintaining dialogue-style conversations (48% versus 28%). Among benzodiazepine users, conversation initiation (52% versus 47%) and conversation style was similar between both groups. The content of deprescribing conversations for PPIs revealed that patients and their healthcare providers focused less on 'dosage/instructions,' and more on the 'medication action and efficacy' and the necessity for 'follow up.' Conversations about stopping benzodiazepines were more likely to stagnate on the 'if' rather than the 'how.' Conclusion The initiation, style and content of the conversations varied between PPI and benzodiazepine users, suggesting that healthcare providers will need to tailor deprescribing conversations accordingly.
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Affiliation(s)
- Justin P Turner
- Facultés de Pharmacie, Université de Montréal Research Center of Institut Universitaire de Gériatrie de Montréal, Québec, Canada
| | - Claude Richard
- Équipe de Recherche en Soins de Première Ligne, Centre Intégré de Santé et de Services Sociaux de Laval, Québec, Canada
| | - Marie-Thérèse Lussier
- Département de Médecine de Famille et de Médecine d'Urgence, Université de Montréal, Montréal, Québec, CanadaÉquipe de Recherche en Soins de Première Ligne, Centre Intégré de Santé et de Services Sociaux de Laval, Québec, Canada
| | - Marie-Eve Lavoie
- Équipe de Recherche en Soins de Première Ligne, Centre Intégré de Santé et de Services Sociaux de Laval, Québec, Canada
| | - Barbara Farrell
- Geriatric Day Hospital, Bruyère Continuing Care, Bruyère Research Institute and CT Lamont Primary Health Care Research Centre, Ottawa, Ontario, Canada Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | | | - Cara Tannenbaum
- Facultés de Médecine et de Pharmacie, Université de MontréalResearch Center of Institut Universitaire de Gériatrie de Montréal, Québec, Canada
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Mokhar A, Topp J, Härter M, Schulz H, Kuhn S, Verthein U, Dirmaier J. Patient-centered care interventions to reduce the inappropriate prescription and use of benzodiazepines and z-drugs: a systematic review. PeerJ 2018; 6:e5535. [PMID: 30345166 PMCID: PMC6190800 DOI: 10.7717/peerj.5535] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 08/08/2018] [Indexed: 12/30/2022] Open
Abstract
Background Benzodiazepines (BZDs) and z-drugs are effective drugs, but they are prescribed excessively worldwide. International guidelines recommend a maximum treatment duration of 4 weeks. Although these drugs are effective in the short-term, long-term BZD therapy is associated with considerable adverse effects, the development of tolerance and, finally, addiction. However, there are different interventions in terms of patient-centered care that aim to reduce the use of BZDs and z-drugs as well as assist health care professionals (HCPs) in preventing the inappropriate prescription of BZDs. Aim The aim of this systematic review was to identify interventions that promote patient-centered treatments for inappropriate BZD and z-drug use and to analyze their effectiveness in reducing the inappropriate use of these drugs. Methods To identify relevant studies, the PubMed, EMBASE, PsycINFO, Psyndex, and Cochrane Library databases were searched. Studies with controlled designs focusing on adult patients were included. Trials with chronically or mentally ill patients were excluded if long-term BZD and z-drug use was indicated. Study extraction was performed based on the Cochrane Form for study extraction. To assess the quality of the studies, we used a tool based on the Cochrane Collaboration’s tool for assessing the risk of bias in randomized trials. Results We identified 7,068 studies and selected 20 for systematic review. Nine interventions focused on patients, nine on HCPs, and two on both patients and HCPs. Intervention types ranged from simple to multifaceted. Patient-centered interventions that provided patient information effectively increased the appropriate use of BZDs. The educational approaches for HCPs that aimed to achieve appropriate prescription reported inconsistent results. The methods that combined informing patients and HCPs led to a significant reduction in BZD use. Conclusions This is the first review of studies focused on patient-centered approaches to reducing the inappropriate prescription and use of BZDs and z-drugs. The patient-centered dimension of patient information was responsible for a decrease in BZD and z-drug consumption. Further, in some studies, the patient-centered dimensions responsible for reducing the prescription and use of BZDs and z-drugs were the clinician’s essential characteristics and clinician-patient communication.
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Affiliation(s)
- Aliaksandra Mokhar
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Janine Topp
- Department of Health Services Research in Dermatology and Nursing, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Härter
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Holger Schulz
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Silke Kuhn
- Department of Psychiatry and Psychotherapy, Center for Interdisciplinary Addiction Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uwe Verthein
- Department of Psychiatry and Psychotherapy, Center for Interdisciplinary Addiction Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Dirmaier
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Deprescribing Benzodiazepines in Older Patients: Impact of Interventions Targeting Physicians, Pharmacists, and Patients. Drugs Aging 2018; 35:493-521. [PMID: 29705831 DOI: 10.1007/s40266-018-0544-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Benzodiazepines (BZDs; including the related Z-drugs) are frequently targets for deprescribing; long-term use in older people is harmful and often not beneficial. BZDs can result in significant harms, including falls, fractures, cognitive impairment, car crashes and a significant financial and legal burden to society. Deprescribing BZDs is problematic due to a complex interaction of drug, patient, physician and systematic barriers, including concern about a potentially distressing but rarely fatal withdrawal syndrome. Multiple studies have trialled interventions to deprescribe BZDs in older people and are discussed in this narrative review. Reported success rates of deprescribing BZD interventions range between 27 and 80%, and this variability can be attributed to heterogeneity of methodological approaches and limited generalisability to cognitively impaired patients. Interventions targeting the patient and/or carer include raising awareness (direct-to-consumer education, minimal interventions, and 'one-off' geriatrician counselling) and resourcing the patient (gradual dose reduction [GDR] with or without cognitive behavioural therapy, teaching relaxation techniques, and sleep hygiene). These are effective if the patient is motivated to cease and is not significantly cognitively impaired. Interventions targeted to physicians include prescribing interventions by audit, algorithm or medication review, and providing supervised GDR in combination with medication substitution. Pharmacists have less frequently been the targets for studies, but have key roles in several multifaceted interventions. Interventions are evaluated according to the Behaviour Change Wheel. Research supports trialling a stepwise approach in the cognitively intact older person, but having a low threshold to use less-consultative methods in patients with dementia. Several resources are available to support deprescribing of BZDs in clinical practice, including online protocols.
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Del Giorno R, Greco A, Zasa A, Clivio L, Pironi M, Ceschi A, Gabutti L. Combining prescription monitoring, benchmarking, and educational interventions to reduce benzodiazepine prescriptions among internal medicine inpatients; a multicenter before and after study in a network of Swiss Public Hospitals. Postgrad Med 2018; 130:627-636. [DOI: 10.1080/00325481.2018.1504594] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Rosaria Del Giorno
- Department of Internal Medicine and Nephrology, Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Angela Greco
- Quality and Patient Safety Service, La Carità Hospital, Ente Ospedaliero Cantonale, Locarno, Switzerland
| | - Anna Zasa
- Quality and Patient Safety Service, La Carità Hospital, Ente Ospedaliero Cantonale, Locarno, Switzerland
| | - Luca Clivio
- Department of Informatics, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Michela Pironi
- Central Pharmacy Service, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Alessandro Ceschi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland
| | - Luca Gabutti
- Department of Internal Medicine and Nephrology, Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Institute of Biomedicine, University of Southern Switzerland, Lugano, Switzerland
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Tanguay Bernard MM, Luc M, Carrier JD, Fournier L, Duhoux A, Côté E, Lessard O, Gibeault C, Bocti C, Roberge P. Patterns of benzodiazepines use in primary care adults with anxiety disorders. Heliyon 2018; 4:e00688. [PMID: 29998202 PMCID: PMC6039319 DOI: 10.1016/j.heliyon.2018.e00688] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 06/12/2018] [Accepted: 07/05/2018] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Benzodiazepines are among the most commonly prescribed drugs for anxiety disorders. While they are indicated as adjunctive treatment for short-term use according to clinical practice guidelines, previous studies have shown patterns of long-term use of benzodiazepines, which is problematic due to side effects, dependence and potential of abuse. The aims of this study were to examine among a large sample of primary care adults suffering from anxiety disorders: 1) benzodiazepine use patterns; and 2) correlates of long-term benzodiazepine use. METHODS Data were drawn from the "Dialogue" project, a large primary care study conducted in 64 primary care clinics in the province of Quebec, Canada. Following a mental health screening in waiting rooms, patients at risk of anxiety or depression completed the Composite International Diagnostic Interview-Simplified (CIDIS). A sample of 740 adults meeting DSM-IV criteria for Generalized Anxiety Disorder, Panic Disorder or Social Anxiety Disorder in the past 12 months took part in this study. RESULTS Benzodiazepines were used by 22.6% of participants with anxiety disorders in our primary care sample. A large majority of benzodiazepine users (88.4%) met our indicator of long-term use, as defined by utilization for more than 12 weeks including regular and as-needed use. Based on a logistic regression model, individual correlates associated with long-term benzodiazepine use included: being 30 years or older, having a comorbid physical illness, meeting criteria for comorbid agoraphobia, reporting the use of sleep-aids, and concurrent SSRI utilization. LIMITATION Data collection with self-reported questionnaires may be subject to information bias. CONCLUSIONS Despite knowledge of the risks of long-term use of benzodiazepines, this remains a pervasive problem. Clinicians need to be mindful of patterns and risk factors leading to long-term use of benzodiazepines in patients with anxiety disorders. Results of this study should raise awareness regarding appropriate prescription practices for benzodiazepines, including decision-making in initiation, duration of prescription, and use of strategies for discontinuation in current long-term benzodiazepine users.
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Affiliation(s)
- Marie-Michèle Tanguay Bernard
- Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Canada
- Family Medicine Unit of Estrie, CIUSSS de l'Estrie - CHUS, Canada
| | - Mireille Luc
- Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Canada
- Family Medicine Unit of Estrie, CIUSSS de l'Estrie - CHUS, Canada
| | | | - Louise Fournier
- CRCHUM, School of Public Health, University of Montreal, Canada
| | | | - Elodie Côté
- Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Canada
- Family Medicine Unit of Estrie, CIUSSS de l'Estrie - CHUS, Canada
| | - Olivier Lessard
- Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Canada
- Family Medicine Unit of Estrie, CIUSSS de l'Estrie - CHUS, Canada
| | - Catherine Gibeault
- Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Canada
- Family Medicine Unit of Estrie, CIUSSS de l'Estrie - CHUS, Canada
| | - Christian Bocti
- Faculty of Medicine and Health Sciences, University of Sherbrooke, Canada
- Department of Medicine, Division of Neurology, University of Sherbrooke, Canada
| | - Pasquale Roberge
- Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Canada
- Faculty of Medicine and Health Sciences, University of Sherbrooke, Canada
- CRCHUS Research Center, Canada
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Pruskowski J, Rosielle DA, Pontiff L, Reitschuler-Cross E. Deprescribing and Tapering Benzodiazepines #355. J Palliat Med 2018; 21:1040-1041. [DOI: 10.1089/jpm.2018.0264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Erwin WJ, Goodman C, Smith T. Effectiveness of a direct-to-consumer written health education program in the reduction of benzodiazepine and sedative-hypnotic use in an elderly population at a single Veterans Affairs medical center. Ment Health Clin 2018; 8:100-104. [PMID: 29955553 PMCID: PMC6007638 DOI: 10.9740/mhc.2018.05.100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Introduction The use of benzodiazepines and sedative-hypnotics in the elderly is associated with a significant risk of delirium, falls, fractures, cognitive impairment, and motor vehicle accidents. This quality improvement project applies a direct-to-consumer intervention to an elderly veteran population to reduce the use of these medications. Methods Patients aged 75 and older currently taking a benzodiazepine and/or a sedative-hypnotic were included in the project. Direct-to-consumer education intervention letters were mailed to patients within 30 days of their next appointment. Their providers were emailed a questionnaire after the patient's appointment. Providers were asked if the letter prompted a conversation regarding medication use, whether the provider initiated discussion regarding a taper, and whether a specific taper plan was developed. Medical records were reviewed to determine if a reduction in dose or discontinuation occurred. Results Fifty-nine direct-to-consumer education letters were mailed to the patients. Follow-up questionnaires were e-mailed to 44 providers, and 27 providers responded. Twenty-two percent of patients had their benzodiazepine and/or sedative hypnotic dose reduced or discontinued after their follow-up appointment. Sixty-seven percent of veterans initiated a conversation with their provider regarding their medication with 74% of providers discussing dose reduction. Fifty-six percent of recipients developed a specific taper plan with their provider. Discussion The data from this project suggests that direct-to-consumer patient education can reduce the exposure to benzodiazepines and sedative-hypnotics in an elderly veteran population. More data is needed on larger populations to further explore the benefit of direct-to-consumer interventions.
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Affiliation(s)
- William J Erwin
- Clinical Pharmacy Specialist, Fayetteville North Carolina Veterans Affairs Medical Center, Fayetteville, North Carolina, ,
| | - Courtney Goodman
- Clinical Pharmacy Specialist, W.G. (Bill) Hefner Veterans Affairs Medical Center, Salisbury, North Carolina
| | - Tammy Smith
- Clinical Pharmacy Specialist, W.G. (Bill) Hefner Veterans Affairs Medical Center, Salisbury, North Carolina
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