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Patient-centered care interventions to
reduce the inappropriate prescription
and use of benzodiazepines and z-drugs:
a systematic review
Aliaksandra Mokhar1, Janine Topp2, Martin Härter1, Holger Schulz1, Silke Kuhn3, Uwe Verthein3and Jörg Dirmaier1
1Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
2Department of Health Services Research in Dermatology and Nursing, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
3Department of Psychiatry and Psychotherapy, Center for Interdisciplinary Addiction Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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,
How to cite this articleMokhar et al. (2018), Patient-centered care interventions to reduce the inappropriate prescription and use of benzodiazepines and z-drugs: a systematic review. PeerJ 6:e5535; DOI 10.7717/peerj.5535
Submitted 17 January 2018 Accepted 8 August 2018 Published 8 October 2018 Corresponding author Aliaksandra Mokhar, a.mokhar@uke.de Academic editor Paul Tulkens
Additional Information and Declarations can be found on page 25
DOI 10.7717/peerj.5535 Copyright
2018 Mokhar et al. Distributed under
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.
Subjects Geriatrics, Pharmacology
Keywords Benzodiazepines, z-drugs, Inappropriate prescription, Long-term use, Older population, Health care professionals, Patient-centered care
INTRODUCTION
Benzodiazepines (BZDs) and z-drugs (BZD derivatives, e.g., zolpidem and zopiclone) are among the most commonly used anxiolytics and hypnotics worldwide (Fassaert et al., 2007;Rogers et al., 2007). While BZD and z-drugs have been demonstrated to be effective in short-term use (Canadian Agency for Drugs and Technologies in Health, 2014), their intake is associated with serious adverse effects, including increased risk of cognitive impairments (Barker et al., 2004;McAndrews et al., 2003;Paterniti, Dufouil & Alperovitch, 2002) as well as stumbling and falling, which may result in hip fractures (Takkouche et al., 2007;Zint et al., 2010) as withdrawal symptoms (Rickels et al., 1990). The main serious problem
associated with long-term use is the development of tolerance and dependence (Ashton, 2005;Voyer et al., 2009;Zint et al., 2010). The risks and adverse effects of BZDs are of particular relevance to older people. Therefore, the Beers Criteria Update Expert Panel for potentially inappropriate medication use recommends avoiding the prescription of BZDs to patients over the age of 65 years, regardless of their primary disease or symptoms (American Geriatrics Society Beers Criteria Update Expert Panel, 2012). Although guidelines and expert consensus confirm the risks associated with the long-term use of BZD, these drugs are still prescribed frequently (Fassaert et al., 2007;Rogers et al., 2007). Thus, despite increasing awareness of the associated risks, the prevalence of inappropriate use has not declined (Cunningham, Hanley & Morgan, 2010;Huerta et al., 2015).
“Inappropriate” BZD use is defined as BZD use that is associated with a significantly higher risk of adverse effects than treatment with an alternative evidence-based
intervention that is equally, if not more, effective (Beers & Ouslander, 1989;Opondo et al., 2012). Different motives have been given for the inappropriate use of BZDs. Patients report that they lack information on alternative pharmacological and nonpharmacological treatment options, the discontinuation of BZDs, and the potentially hazardous effects of inappropriate BZD use (Beers & Ouslander 1989;Fang et al. 2009). Furthermore, regarding the patients perspective, they are often unwilling to discontinue BZD use, as possible physiological and psychological dependencies might be present (Fang et al., 2009; Tannenbaum et al., 2014). Different reasons for the inappropriate prescription of BZDs have been assessed (Anthierens et al., 2007b;Opondo et al., 2012;Voyer et al., 2009). These reasons include lack of knowledge of possible evidence-based alternative treatment options, nonspecific knowledge about BZDs among physicians and other specialists, especially in geriatric care, a lack of clarity about how to appropriately prescribe the drug and difficulties applying medication guidelines to clinical practice (Ashton, 2005;Opondo
et al., 2012). Although physicians report being cautious about initiating BZD treatments, the psychosocial problems of patients are often severe, and the knowledge of how to handle these severe problems using alternative strategies is often limited (Anthierens et al., 2007a; Parr et al., 2006). Given the variety of severe risks and adverse effects, including possible dependency, the high prevalence of BZD use in older people in general and the high number of long-term users in particular, interventions that address this issue need to be identified (Gould et al., 2014;Oude Voshaar et al., 2006;Smith & Tett, 2010). To address this need, numerous studies have focused on the difficulties in physician-patient
communication and patient information involved in the inappropriate use and prescription of BZDs. These studies have investigated specific interventions that are designed to educate patients, provide patient information material, improve physician-patient communication, or build a relationship between physician-patients and physicians (Gould et al., 2014;Mugunthan, McGuire & Glasziou, 2011). These interventions can be considered to fall under the umbrella term patient-centeredness (Scholl et al., 2014;Zill et al., 2015). Patient-centered care is a comprehensive care concept (Bardes, 2012). Various definitions have tried to encompass the complexity of this idea (Scholl et al. 2014;Zill et al. 2015;Mead & Bower, 2000). Recently,Scholl et al. (2014)merged existing definitions and developed a comprehensive model of patient-centeredness. These researchers defined 15 dimensions of patient-centeredness and, according to expert consensus, isolated the five most relevant dimensions (Scholl et al., 2014). In addition to being treated as a unique individual, the patient’s involvement in his or her own care, patient empowerment, patient information, and clinician-patient communication were rated as the most relevant aspects (Zill et al., 2015). The latter dimensions are mainly understood to be the activities of patient-centered care, which has become an international demand for high-quality medicine (Mead & Bower, 2000;Phelan, Stradins & Morrison, 2001).
An increased emphasis on patient-centeredness could address the causes of inappropriate BZD use and decrease its prevalence by focusing on patients’ values. Patients’ beliefs, preferences, and information need to play a greater role in the care process. Putting the individual patient rather than his or her disease at the center of the treatment plan has increasingly been advocated, and numerous medical experts recommend the implementation of this strategy in routine care (Committee on Quality of Health Care in America IoMI, 2001). Research in various sectors of health care attests to improved care processes as a result of patient-centered approaches. Patients have reported that such approaches restored their satisfaction and self-management abilities and significantly improved their quality of life (Rathert, Wyrwich & Boren, 2012).
Research of the physician’s perspective describes the need for professional expertise, specific communication skills, and the ability to inform patients based on the
evidence-based knowledge presented in guidelines and expert consensuses for clinical practice. Some studies have found that good physician-patient communication is associated with important patient health outcomes (Mercer et al., 2008;Zolnierek & Dimatteo, 2009). In addition to dimensions regarding physicians’ abilities, there are communication factors related to patient-centered activities where physicians provide
information and better educate patients by sharing specific information and using informational resources and tools (Scholl et al., 2014). Furthermore, recent research indicates that interventions that promote patient-centered care have a positive influence on patient-related outcomes (Dwamena et al., 2012;Mead & Bower, 2002).
The high prevalence of inappropriate BZD use and the possible reasons for this use combined with the knowledge of the general benefits of a patient-centered approach in health care highlight the need to consider a patient-centered approach for patients using BZDs. By focusing on the five most important aspects of patient-centered care, this systematic review aimed to identify patient-centered interventions for reducing the inappropriate prescription and use of BZDs and z-drugs.
METHODS
This systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO): CRD42014015616. The reporting guidelines used for this review were based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (Liberati et al., 2009;Moher et al., 2009). A study protocol was not published.
Search strategy
A search was performed using the following databases: Medline (via Ovid),
EMBASE, PsycINFO, Psyndex, and the Cochrane Library. The following search terms were used: BZD(s) and/or z-drug(s) and/or anxiolyt, hypnotic in combination with information, communicate, educate, support, system, aid, program, process, material, health intervent, shared decision, informed decision, choice, and train. A sample syntax can be found in the appendix. The search was limited to studies published in English or German. The search began in September 2014 and was completed in October 2014.
Eligibility criteria
Studies were included in this review if they met the following criteria: had a controlled design, assessed middle-aged adults (45 years and older), used interventions focused on users of BZD or z-drugs and/or health care professionals (HCPs) involved in the care process, and had a primary outcome of interest of a reduction in BZD use and/or prescriptions. We excluded case series, review papers, meta-analyses, double publications, experimental research, protocols, and animal research. Moreover, studies were excluded if they focused on children or on chronically or seriously mentally ill patients, that is, if the use of BZDs was indicated (e.g., for severe psychiatric disorders such as
schizophrenia). Psychopharmacological studies that examined medication phenomena only with respect to the drugs’ effects were also excluded. The types of interventions included were predominantly educational or informational in nature.
As part of our search strategy, we also performed a secondary search consisting of reference tracking for all full text documents included and a consultation of experts in the respective health care fields.
Study selection
First, duplicates were removed. Second, two independent researchers (AM, JT, or EC) screened the selected articles, first by title and then by abstract, for interventions related to the research topic. When the title and abstract were relevant or when eligibility was uncertain, the full text was retrieved. Any uncertainty concerning eligibility was resolved after an assessment of the full text and a discussion within the research team.
Data extraction and quality assessment
The collected data were extracted using a standardized sheet we had developed previously that was based on the Cochrane Extraction Form (Sambunjak Cumpston & Watts, 2017). The extraction form includes information about participants’ characteristics (age, gender), the treatment setting, inclusion and exclusion criteria, the randomization process, the intervention description, the duration of the intervention, outcomes, follow-ups, results, and significance. The interventions included were classified by the target population: BZD users, HCPs, or both groups. Data were extracted independently by two authors (AM and JT). Additionally, to consider the potential limitations of the studies included, the quality (or risk of bias) of these studies was assessed by two authors (AM and JT) using the Cochrane Collaboration’s tool for assessing the risk of bias in randomized trials
(Higgins et al., 2011). The quality assessment form was based on six dimensions: random sequence generation, allocation concealment, blinding of participants, and personnel, blinding of outcome assessments, incomplete outcome data and selective reporting. Data analysis
We used a qualitative analysis to synthesize the data extracted from the included studies (Dixon-Woods et al., 2005). Intervention approaches were classified into the following categories: those targeting patients, those with HCPs and multifaceted interventions. Furthermore, we subdivided the interventions into three patient-centered categories: physicians’ essential characteristics, clinician-patient communication, and patient information. A meta-analysis could not be conducted because the interventions were too heterogeneous.
RESULTS
The review findings are presented in three steps. First, the studies are described and illustrated with charts. Then, they are subdivided into three sets, namely, patients, HCPs, and both groups combined. Next, the findings are described by an analysis of study quality, and then, the results are summarized in terms of patient-centered dimensions.
We identified 7,068 studies through the electronic search and 11 studies through our secondary search strategy. After the removal of duplicates (4,628) and after the screening process, 20 studies remained relevant and met the inclusion criteria (seeFig. 1). Description of identified studies
All studies were published in English between 1992 and 2014. The interventions were conducted in the UK (four studies), Australia (four studies), the USA (two studies),
the Netherlands (two studies), Canada (two studies), Spain (three studies), Ireland (one study), Belgium (one study), and Sweden (one study). All studies were based on at least a controlled design. Eight studies used an explicit randomized controlled design, an additional nine used a controlled design (including intervention studies), and four used a cluster-randomized design. The study durations varied between 4 weeks and 29 months, with a mean of 6 months. Furthermore, the studies were conducted in different clinical settings that targeted inpatients, outpatients, community residents, or nursing home residents. The majority of the studies were conducted in general practices
(11 studies) and nursing homes (five studies). One study each was carried out in a medical center, a hospital, an outpatient service (Medicaid), and a community pharmacy.
While nine studies directly addressed BZD users (long-term, chronic, inappropriate), nine studies focused only on HCPs, specifically general practitioners and nurses. Two studies investigated the effect of interventions on both target patients and HCPs (physicians, nurses, and pharmacists). A systematic overview of relevant information for all interventions is shown inTables 1–3.
Figure 1 Flow diagram of studies reviewed. Full-size DOI: 10.7717/peerj.5535/fig-1
Table 1 Description of included studies: patients. Refer ence Title Loca tion Design Sett ing Dur ation (mon ths) Samp le total n Samp le descr iption: de fi nitio n, mean age, sex distr ibution, grou ps Intervent ion Dim ensio n of patient-center ed-care model Findings Bas hir, King & Ashwort h (1994) Cont rolled evaluation of brief inte rv en ti o n b y general pra ct it io n er s to reduce chroni c use of b en zo d ia ze p in es UK CT Gener al prac tices 6 109 Chr onic B ZDs users, M = 62 ye ar s, 61 % women inte rv en ti o n gr o u p (51) contro l group (58) A self-h elp bookle t include d general info rmati on abo ut ben zodia zepine and te ch n iq u es o f co p in g wit h fears and anxi ety suppo rted with phy sician ’s advice Pat ient in fo rm at io n E ig h te en p er ce n t o f p at ie n ts in the inter vention grou p (9/ 50) had a red uction in ben zodiaze pine pre scribing recorded in th e n o te s co m p ar ed w it h 5% o f th e 55 p at ie n ts in the contro l group (p < 0.05) Cor mack et al. (1994) Eva luation of an easy, cost-ef fe ct iv e st ra te gy for cut ting b en zo d ia ze p in e use in ge neral p ra ct ic e UK CT Gener al prac tices 6 209 Lon g-term regula r users of BZDs, M = 69 ye ar s, 4: 1 women to men letter group (65 ) letter plus advice group (75 ) con trol group (69 ) Disconti nuation lette r aske d the pat ient to red uce or sto p the m ed ic at io n gr ad u al ly and prov ide info rmati on abo ut red ucing m ed ic at io n an d p ra ct ic al sugg estions for n o n p h ar m ac o lo gi ca l cop ing strategi es plus 4-m onthly info rmati on shee ts Pat ient in fo rm at io n After 6 mont hs, bot h inter vention grou ps ha d red uced their co n su m p ti o n to appr oxim ately two th irds of the original intake of ben zodiaze pines and there was a stati stically signi fi ca nt diffe rence betwe en th e grou ps. 18% of those recei ving th e in te rv en ti o n s re ce iv ed n o pre scriptio ns at all during the 6 m onth monito ring per iod Go rgels et al. (2005) D is co n ti n u at io n of long-ter m b en zo d ia ze p in e use by send ing a letter to use rs in fa m il y p ra ct ic e: a prospec tive contro lled in te rv en ti o n study Net her-land s CT Family prac tices 6– 21 4,416 Lon g-term BZDs users, M = 68 ye ar s, 65 – 69% wome n ex p er im en ta l group (2,59 5) contro l grou p (1,821) P at ie n t in fo rm at io n as a dis continuat ion lette r ad vi se d to gr ad u al ly st o p ben zodia zepine use suppo rted with p at ie n t-p h ys ic ia n -com muni cation, whic h ev aluated actua l ben zodia zepine use Pat ient in fo rm at io n At 6 mont hs a large red uction in ben zodiaze pine p re sc ri p ti o n w as p re se n t of 24% in the expe rimental group, vs. 5% in the contro l grou p. At 21 months again a st ea d y re d u ct io n in ben zodiaze pine pre scriptio n of 26% was observ ed in the expe rimental group, vs. 9% in the contro l grou p, indic ating that the sho rt-term gain of the inter vention was pre served (Continued )
Table 1 (continued ). Refer ence Title Loca tion Design Sett ing Dur ation (mon ths) Samp le total n Samp le descr iption: de fi nitio n, mean age, sex distr ibution, grou ps Intervent ion Dim ensio n of patient-center ed-care model Findings Tanne nbaum et al. (2014 ) Red uction of inappro priate b en zo d ia ze p in e p re sc ri p ti o n s among older adults through direct patient ed u ca ti o n : T h e EMPOWE R Cluster Cana da RCT Comm unity pha rmacies 6 303 Lon g-term BZDs users, M = 75 ye ar s, 69% wome n in te rv en ti o n gr o u p (138) con trol group (155) P at ie n t in fo rm at io n vi a a p er so n al iz ed b o o k le t co m p ri si n g a se lf -as se ss m en t co m p o n en t includi ng risks and adv ice abo ut drug inter actions and ment ioning ev idence, tap ering recomm enda tions and thera peutic substi tutes as well as kno wledge state ments and pee r champ ion th eories to creat e cogni tive dis sonance abo ut the safe ty of the ben zodia zepine intake an d au gm en t se lf -ef fi cacy Pat ient in fo rm at io n At 6 mont hs, 27% of the inter vention grou p had d is co n ti n u ed ben zodiaze pine use com pared with 5% of the con trol grou p (ri sk d if fe re n ce , 23 % [9 5% C I, 14 – 32 % ]; in tr ac lu st er co rr el at io n , 0. 00 8; numbe r needed to tr ea t, 4) . D o se re d u ct io n o cc u rr ed in an ad d it io n al 11% (95%CI, 6– 16%) Te n Wold e et al. (2008 ) Lon g-term ef fe ct iv en es s o f co m p u te r-generated tailored patient ed u ca ti o n o n b en zo d ia ze p in es : a rand omized contro lled trial Net her-land s RCT Gener al prac tices 12 695 Chr onic B ZDs users, M = 62 .3 ye ar s, 68.1 wome n single tailored letter (16 3) m u lt ip le ta il o re d letter (186) general p ra ct it io n er le tt er (159) P at ie n t in fo rm at io n ei th er vi a two indi vidual tailo red letters aimin g to red uce the posi tive outcom e expect ation of ben zodia zepines by beari ng in mind ben efi ts of its withd rawal and in this case incre asing self-ef fi cacy expect ations or a short ge neral p ra ct it io n er le tt er th at mode lled usua l care Pat ient in fo rm at io n Among parti cipants with th e in te n ti o n to dis continue usage at bas eline, both tailo red inter ventions led to high per centage s of those who ac tu al ly d is co n ti n u ed usage (single tailo red inter vention 51.7% ; mult iple tailored inter vention 35.6% ; ge n er al p ra ct it io n er le tt er 14.5% ) Stew art et al. (2007) Gener al p ra ct it io n er s reduced ben zo d ia ze p in e p re sc ri p ti o n s in an inter venti on study: a multileve l applicat ion Net her-land s CT Gener al prac tices 12 8,179 Chr onic B ZDs users, M = 64 .6 3 ye ar s, 73.2% wome n in te rv en ti o n gr o u p (19 genera l p ra ct ic es ) co n tr o l group (12 8 ge neral p ra ct ic es ) P at ie n t in fo rm at io n as a dis continuat ion lette r o u tl in ed in fo rm at io n abo ut the risks of con tinuous use of ben zodia zepines and recomm ende d their w it h d ra w al b y in vi ti n g pat ients to an ap p o in tm en t to d is cu ss th is p ro ce d u re , fo ll o w ed b y an in fo rm at io n le afl et abo ut BZDs Pat ient in fo rm at io n and clini cian-patient communi cation Sending a lette r to chronic long -term use rs of ben zodiaze pines adv ising decre asing or sto pping ben zodiaze pine use in ge neral practice resulted in a 16% red uctio n after 6 mont hs and a 14% red uction after 1 year
Table 1 (continued ). Refer ence Title Loca tion Design Sett ing Dur ation (mon ths) Samp le total n Samp le descr iption: de fi nitio n, mean age, sex distr ibution, grou ps Intervent ion Dim ensio n of patient-center ed-care model Findings Heath er et al. (2004) Ran domized contro lled trial of two brief in te rv en ti o n s against long-term ben zo d ia ze p in e use: outcom e of in te rv en ti o n UK RCT Gener al prac tices 6 284 Lon g-term BZDs users, M = 69.1 ye ar s, 48 % fe m al es letter group (93 ) co n su lt at io n gr o u p (98) contro l group (93) P at ie n t in fo rm at io n vi a self-h elp bookle t in cl u d ed in fo rm at io n ab o u t tr an q u il iz er s, sleepi ng tab lets and thei r wit hdrawal ac co m p an ie d by a le afl et abo ut sleepi ng prob lems and a dis continuat ion lette r w hich info rme d abo ut ris ks and adv ised to stop the intake, su p p o rt ed w it h p at ie n t-phy sician-com muni cation includi ng general info rmati on abo ut ben zodia zepines as well as ad va n ta ge s o f an d gui delines for wit hdrawal Pat ient in fo rm at io n and clini cian-patient communi cation R es u lt s sh o w ed si gn ifi cantly larger reduct ions in BZDS co n su m p ti o n in th e le tt er (24 % ove rall) and con sultat ion (22%) grou ps than the contro l grou p (16 %) but no sign ifi cant d if fe re n ce b et w ee n th e tw o in te rv en ti o n s Vice ns et al. (2006) Withd rawal from long-ter m b en zo d ia ze p in e use: rand omize d trial in family p ra ct ic e Sp ain RCT Public pri mary ca re ce nters 12 139 Lon g-term BZDs users, M = 59 ye ar s, 82% wome n in te rv en ti o n gr o u p (73)con trol group (66) P at ie n t in fo rm at io n vi a phy sicians ’ inter view gi ven on the fi rst and follow up visits: fi rst vi sit co n ce n tr at ed m o st ly o n ge n er al in fo rm at io n abo ut ben zodiaze pines an d th ei r ri sk s/ ef fe ct s, while th e follow up vi sits focu sed on positive re in fo rc em en t o f ac hievem ents Pat ient in fo rm at io n and clini cian-patient communi cation After 12 months ,33 (45.2%) patie nts in th e inter vention grou p and six (9.1% ) in the con tro l gr o u p h ad d is co n ti n u ed ben zodiaze pine use; relative risk = 4.97 (95 % con fi d en ce in te rv al [C I] = 2.2 – 11.1), abs olute risk red uction = 0.36 (95 % CI = 0.22 – 0. 50 ). Si xt ee n (21 .9%) subje cts from th e inter vention group and 11 (16 .7%) con trols reduce d their initial dose by more than 50% (Continued )
Table 1 (continued ). Refer ence Title Loca tion Design Sett ing Dur ation (mon ths) Samp le total n Samp le descr iption: de fi nitio n, mean age, sex distr ibution, grou ps Intervent ion Dim ensio n of patient-center ed-care model Findings Vice ns et al. (2014) Compa rative ef fi cacy of two in te rv en ti o n s to d is co n ti n u e long-ter m b en zo d ia ze p in e use: clus ter randomi zed contro lled trial in prim ary care Sp ain RCT Gener al prac tices 12 532 Lon g-term BZDs users, M = 64 ye ar s, 72% wome n st ru ct u re d in te rv en ti o n (S IF ) (1 91 ) st ru ct u re d in te rv en ti o n w it h written inst ru ct io n s (S IW ) (168) con trol group (173) E d u ca ti o n al in te rv en ti o n fo r p at ie n ts w it h fort nightly follow -up vi si ts to su p p o rt gr ad u al tap ering (SI F) and w ri tt en in fo rm at io n m at er ia l fo r p at ie n ts rathe r th an follow -up vi sits (SI W); patient info rmati on vi a ed u ca ti o n al in te rv ie w include d an info rmati on o n b en zo d ia ze p in e d ep en d en ce , ab st in en ce and withd rawal symp toms ,risks of long-te rm use and re as su ra n ce ab o u t red ucing m edication as well as a self-h elp lea fl et to im p ro ve sl ee p q u al it y Pat ient in fo rm at io n , cl in ic ia n -p at ie n t communi cation and ess ential ch ar ac te ri st ic s of the clini cian At 12 mont hs, 76 of 168 (4 5% ) p at ie n ts in th e SI W grou p and 86 of 191 (45%) in the SIF group had d is co n ti n u ed ben zodiaze pine use com pared with 26 of 173 (15 %) in the con trol grou p. Both inter ventions led to signi fi cant red uctions in long -ter m ben zodiaze pine use in p at ie n ts w it h o u t se ve re com orbidity
Table 2 Description of included studies: health care professionals. Refer ence Tit le Locat ion Desi gn Setting Dur ation Samp le to tal n S am p le d es cr ip ti o n : d efi n ition, mean ag e, sex d istributi on, grou ps Inter vention Dimen sion of patie nt-centere d-care m odel Findings Avorn et al. (1992) A rand omize d trial of a prog ram to reduce the use of psych oactive drug s in nursing home USA RCT Nursing hom e 5 months 823 Lon g-time users of psych oactive drug s and BZDs , not reported inter vention grou p of 6 nursing hom es (43 1) contro lgrou p of 6 nursing hom es (39 2) E d u ca ti o n al p ro gr am to im p ro ve m ed ic al co m p et en ce b as ed o n th e p ri n ci p le s of “a ca d em ic detailin g, ” whic h focu ses on dir ect pat ient ca re, al te rn at iv es to psychoac tive drug s and recognit ion of advers e drug reactio ns face-to -fa ce ed u ca ti o n al se ss io n s by clini cal pharma cists for p re sc ri b er s an d w ri tt en in fo rm at io n m at er ia l fo r p re sc ri b er s Essential char acteris tics of the clinician and clinician-pat ient com munica tion Signi fi can t reduce psych oactive drug use in expe riment al grou p than in con trol (27% vs. 8%, p = 0.02) . The com parable fi gures for th e d is co n ti n u at io n o f long -actin g ben zodiaze pines wer e 20% vs. 9% (no signi fi ca nt) Batt y et al. (2001) In vestigati ng inter vention strategi es to incre ase the appropri ate use of b en zo d ia ze p in es in elderly med ical in-p at ie n ts UK RCT Hospita ls 6– 12 months 1, 414 In appropri ate BZDs users, M = 75 ye ars, n o t re p o rt ed ve rb al inter vention (not rep orted) bulle tin inter vention (not rep orted) con trol grou p (not rep orted) Verb al inter vention d el iv er ed in an in te ra ct iv e lecture format by a physician and a p h ar m ac is t to an au d ie n ce ar ra n ge d b y th e h o sp it al co n ta ct . B u ll et in in te rv en ti o n in vo lv ed d is se m in at io n o f p ri n te d m at er ia l to p h ys ic ia n s, pharma cist and nurses involv ed in the ca re at the h o sp it al Essential char acteris tics of the clinician and clinician-pat ient com munica tion A p p ro p ri at e p re sc ri b in g follow ing ve rbal inter vention incre ased su b st an ti al ly fr o m 29 % to 44% but this did not achiev e stati stical signi fi ca nce. There was a re d u ct io n in ap p ro p ri at e p re sc ri b in g follow ing bulle tin inter vention (42 – 33% ) and no ch ange follow ing con trol inter vention (42 – 42% ) Berin gs, Blond eel & Hab ra ke n (1994) Th e effe ct of in d u st ry -indepe ndent drug info rmation on the p re sc ri b in g o f b en zo d ia ze p in es in ge neral p ra ct ic e Belgium RCT General p ra ct ic es 4 weeks 128 Ge neral pract it io n er s, not reported oral and written info rmation (44 ) wri tten info rmation (43 ) n o in fo rm at io n (41 ) E d u ca ti o n al m ai l ar gu in g for the ratio nal and short-te rm p re sc ri b in g o f b en zo d ia ze p in es , containe d speci fi c in fo rm at io n re ga rd in g th e li m it ed ef fe ct iv en es s o f long-ter m benzod iazepine use, ris ks and diffe rent forms of habi tuation and dependen ce supported by an in d ep en d en t m ed ic al re p re se n ta ti ve w h o se o ra l messag e was con gruent with the written mat erials and who answered any questio ns Essential char acteris tics of the clinician T h e ab so lu te re d u ct io n in th e numbe r of pre scribed pac kages was highes t in condit ion one (oral and written info rmati on) with a mean dec rease of 24% com pared to the bas eline. A reduct ion of 14% w as found in physi cians of con dition two (written info rmati on) and of 3% in th e contro l grou p (Continued )
Table 2 (continued ). Refer ence Title Loca tion Design Settin g Dur ation Samp le total n S am p le d es cr ip ti o n : de fi nition, mean age, sex d is tr ib u ti o n , g ro u p s Inter vention Dim ension of pati ent-center ed-care model Findings M idlöv etal. (2006) Effects of ed u ca ti o n al outr each visits o n p re sc ri b in g o f b en zo d ia ze p in es and antips ychoti c drug s to elderly patien ts in prim ary health care in southe rn Swede n Sw eden RCT Gener al p ra ct ic es 12 mont hs 54 Physici ans in ge neral p ra ct ic es , n o t rep orted (not rep orted) inter vention grou p (23 ) con trol grou p (31 ) Phy sician ’s and pharma cist ’s vi sits in 2– 8 week inter vals: th e fi rst visit dealt w ith d if fe re n t ca u se s of conf usion in the elderly like med icatio ns, infectio ns and othe r il ln es se s w h il e d is cu ss in g as so ci at ed li te ra tu re , where as the sec ond vi sit focused on the effect s and ri sk s o f b en zo d ia ze p in e use with medium or long acting durati on of med ication acti on Essenti al ch ar ac te ri st ic s of the clinici an One year after the ed u ca ti o n al o u tr ea ch vi sits there wer e signi fi cant decre ases in the active grou p com pared to con trol gr o u p in th e p re sc ri b in g of med ium-and long -ac ting B ZDs and tot al B ZDs but not so for an ti p sy ch o ti c d ru gs Piml ott et al. (2003) E d u ca ti n g physi cians to red uce b en zo d ia ze p in e use by elderly patien ts: a rand omized con trolled trial Cana da RCT Gener al p ra ct ic es 12 mont hs 374 Gener al p ra ct it io n er s, M = 50.6/ 50.7 ye ars, not rep orted inter vention grou p (16 8) contro lgrou p (20 6) F ee d b ac k p ac k ag es w er e m ai le d th at p re se n te d b ar graph s com paring the p re sc ri b er w it h h is o r h er peers and a hypothe tical “b es t p ra ct ic e” suppo rted b y ev id en ce -b as ed ed u ca ti o n al m at er ia l Essenti al ch ar ac te ri st ic s of the clinici an Although th e propo rtion of long -actin g ben zodia zepine pre scriptio ns dec reased by 0.7% in the in te rv en ti o n gr o u p betw een the bas eline per iod and the end of the inter vention period (from 20.3% , or a mean o f 29 .5 p re sc ri p ti o n s, to 19.6% ,or a m ean of 27.7 pre scriptio ns) and incre ased by 1.1% in th e con trol grou p (from 19.8% ,or a m ean of 26.4 pre scriptio ns, to 20.9% , or a m ean of 27.7 pre scriptio ns) (p = 0.036 ), this diffe rence was not clini cally signi fi cant
Table 2 (continued ). R ef er en ce T it le L o ca ti o n D es ig n S et ti n g D u ra ti o n S am p le total n Samp le descr iption: de fi nition , m ean age, sex d is tr ib u ti o n , g ro u p s Intervention Dim ensio n of patient-center ed-care model Finding s Pit et al. (2007 ) A Qu ality Use of Me dicines prog ram for ge neral prac titioners and o ld er p eo p le : a cluste r rand omize d con trolled trial Aus tralia RCT Gener al practices 12 mont hs 20 phy sicians n = 20 ge neral p ra ct it io n er s in 16 p ra ct ic es w it h n = 84 9 p at ie n ts , older than 65 years in te rv en ti o n gr o u p (397) con trol grou p (352) E d u ca ti o n al se ss io n s b y pharma cists expla ining h o w to co n d u ct med icatio n rev iews with emp hasis on ben zodiaze pines, ac co m p an ie d by w ri tt en sour ces of info rmation on p re sc ri b in g m ed ic at io n ; risk assessm ent containe d 31 items ass essing risk factor s for m edication mis adventure Esse ntial ch ar ac te ri st ic s of the clini cian Compa red with the contro l grou p, p ar ti ci p an ts in th e in te rv en ti o n gr o u p h ad increased odds of having an imp roved m ed ic at io n u se composite score (odd s ra ti o [O R ], 1. 86 ; 95 % CI, 1.21 – 2.85) at 4-month follow -up but not at 12 months R ob er ts et al. (2001 ) Outcome s of a rand omize d con trolled trial of a cl in ic al pha rmacy in te rv en ti o n in 52 nursing hom es Aus tralia RCT Nursi ng homes 12 mont hs 52 nursi ng hom es 52 n ursing hom es with n = 3.230 p at ie n ts , n o t reported inte rv en ti o n gr o u p of 13 nursing homes (90 5) contro l group of 39 nursing hom es (2 325) Clinical pharmacy service mode l bas ed on issues suc h as drug policy and spe ci fi c resident prob lems, together with ed u ca ti o n an d m ed ic at io n review and prob lem-b as ed ed u ca ti o n al sessio ns for nurse s ad d re ss in g b as ic ge ri at ri c pharma cology and some co m m o n p ro b le m s in long -term care med icatio n; review by pharma cists high lightin g the potent ial for adv erse drug effects, ceasi ng one o r m o re d ru g th er ap y, non-drug inter vention and adverse effect and d ru g re sp o n se m o n it o ri n g Esse ntial ch ar ac te ri st ic s of the clini cian This inter vention resulted in a red uctio n in drug use with n o chang e in morbidity indices or survival. Th e use of b en zo d ia ze p in es w as signi fi cantly red uced in the inter vention grou p. O ve ra ll , d ru g u se in th e in te rv en ti o n gr o u p w as reduced by 14.8% relative to th e con trols Smith et al. (1998 ) A rand omize d con trolled trial of a drug use rev iew in te rv en ti o n for sed ative hy pnotic med icatio ns USA RCT Me dicaid recip ie n ts (o u tp at ie n ts ) 6 mont hs 189 BZDs use rs, 55 ye ars and olde r, 61 – 63% women inte rv en ti o n gr o u p (99) contro l grou p (89) Written info rmation con sisted of: a letter des cribing the drug use an d ed u ca ti o n co u n ci l gu id el in es fo r se d at iv e h yp n o ti c p re sc ri b in g; a p re sc ri b er -s p ec ifi c pro fi le abo ut sed ative hypnotic p re sc ri b in g; a p at ie n t pro fi le for each of the p re sc ri b er s p at ie n ts id en tifi ed as over utilizers Esse ntial ch ar ac te ri st ic s of the clini cian The inter vention achiev ed a st at is ti ca ll y si gn ifi ca nt decrease in targeted drug use, and the am o u n t o f re d u ct io n is likely to have decre ased the risk of fractures as so ci at ed w it h b en zo d ia ze p in e u se (Continued )
Table 2 (continued ). Re ference Title Loca tion Design Setti ng Dur ation Samp le total n Samp le descrip tion: de fi nition, me an age, sex d is tr ib u ti o n , g ro u p s Inter vention Dim ension of p atient-center ed-care model Findings Sm ith & Tett (2010) An inter vention to im p ro ve ben zodiaze pine use — a new appr oach Aus tralia CT Gener al prac tices (o u tp at ie n ts ) 6 mont hs 429 phy sicians 429 physi cians in te rv en ti o n gr o u p (n o t re p o rt ed ) con trol grou p (n o t re p o rt ed ) In formati on ema ils co n si st ed o f ed u ca ti o n al facts relating to b en zo d ia ze p in es , includin g info rmati on on com mon sid e effe cts, indic ations, pre cautions an d re co m m en d at io n s re ga rd in g p re sc ri b in g as well as char acte ristics and al te rn at iv e n o n -d ru g te ch n iq u es ; th e w eb si te containe d links to A u st ra li an D ep ar tm en t o f Heal th and Agei ng w eb si te s w h ic h p ro vi d ed co n su m er in fo rm at io n o n med icines including sleeping tablet s Essen tial ch ar ac te ri st ic s of th e clini cian A signi fi ca ntly smal ler num ber of aged ca re re si d en ts w er e on ben zodia zepines for 6 mont hs or more (p < 0.05) after the in te rv en ti o n co m p ar ed wit h before
Table 3 Description of included studies: patients and health care professionals. Refer ence Title Loca tion Design Sett ing Duration (months ) Samp le total n Samp le descr iption: de fi nition , m ean age, sex d is tr ib u ti o n , groups Intervention Dimen sion of patien t-centered -care m odel Findings Patte rson et al. (2010) An Evaluatio n of an Adapted U.S. Mode l of P harmace utical Care to Improv e Psychoac tive Prescribin g for Nursing Home R es id en ts in Northern Irela nd (F le et w o o d Northern Irela nd Study) Irela nd RCT Nursi ng homes 12 22 nursi ng hom es 22 nursi ng hom es w ith n = 334 re si d en ts , M = 82.7, 73% female inte rv en ti o n grou p (173) con trol grou p (16 1) 12 mont hly visits from pharma cist to review pre scriptio n rec ords of nursin g hom e reside nts; col laborati on of pharma cists wit h pre scribers and pat ients to im p ro ve p re sc ri p ti o n patte rns; pharma cist ’s visits ass essed th e p h ar m ac eu ti ca l ca re n ee d s o f ea ch re si d en t to id en ti fy potent ial and actual med icatio n-related prob lems and reviewe d th e re si d en ts ’ med ication with the ai m of opti mizing psych oactive pre scriptio n Essential char acteris tics of the clinician, clini cian-patie nt-com munica tion and patient info rmati on T h e p ro p o rt io n o f re si d en ts takin g inappro pri ate p sy ch o ac ti ve m ed ic at io n s at 12 mont hs in the in te rv en ti o n h o m es (2 5/ 12 8, 19.5% ) was much lowe r th an in the con trol hom es (62/ 124 , 50.0% ) (odd s ratio 50.26 , 95% con fi dence int erval 50.14 – 0.49) after adju stment for clus terin g wit hin hom es West bury et al. (2010) A n ef fe ct iv e ap p ro ac h to decre ase an ti p sy ch o ti c an d b en zo d ia ze p in e u se in nursing homes : th e R ed U Se p ro je ct Aus tralia CT Nursi ng homes 6 25 nursi ng hom es 25 nursi ng hom es w ith n = 1,591 re si d en ts , n o t rep orted in te rv en ti o n grou p 13 nursi ng hom es con trol grou p n = 12 nursi ng hom es Consci ousness raising two drug use evalua tion (D U E ) cy cl es ed u ca ti o n al ses sions promoti onal mat erials (newsle tters , p am p h le ts , p o st er s) an d ed u ca ti o n al se ss io n s an d mat erials focused on info rming health p ro fe ss io n al s an d p ar ti ci p an ts ab o u t ri sk s and modest bene fi ts as so ci at ed w it h an ti p sy ch o ti c m ed ic at io n s for dem entia and ben zodiaze pines for sleep dis turbance and anxi ety mana gement in elderly peo ple Essential char acteris tics of the clinician, clini cian-pa tient com munica tion and patient in-forma tion Over the 6-mont h trial, there was a signi fi cant red uction in the per centage of in te rv en ti o n h o m e re si d en ts reg ularly taking ben zodia zepines (31 .8 – 26.9% , p < 0.005). F o r re si d en ts ta k in g b en zo d ia ze p in es at b as el in e, there wer e signi fi cantly more d o se re d u ct io n s/ ce ss at io n s in in te rv en ti o n h o m es th an in contro l homes (be nzodiaze pines: 39.6% vs. 17.6% , p < 0.0001)
Quality assessments
The studies included in this survey differed considerably with respect to
methodological quality (Higgins et al., 2011). Detailed evaluations for all studies are included inTable 4. Three categories were used to describe assessment quality: low, high, and unclear risk of bias (“yes” signified low risk; “no,” high risk; and “unclear,” all other cases). In a second step, quantitative levels were introduced; to meet the “low risk” level, all items in the question were required to have a low risk of bias. The “high risk” and “unclear” levels needed one item with a high risk of bias or an unclear risk of bias, respectively.
Regarding randomization, six studies were excluded from the assessment because of their study design (controlled trial) (Bashir, King & Ashworth, 1994;Cormack et al., 1994;Smith & Tett, 2010;Stewart et al., 2007;Westbury et al., 2010). In the remaining studies, the randomization was described clearly. Regarding allocation, six studies described in detail an allocation that was performed successfully (Cormack et al., 1994;Patterson et al., 2010;Tannenbaum et al., 2014;Ten Wolde et al., 2008;
Table 4 Risk of bias.
Reference RANDOM sequence generation Allocation concealment Blinding of participants and personnel Blinding of outcome assessment Incomplete outcome data Selective reporting
Interventions for patients
Bashir, King & Ashworth (1994) N.R. H H U L U
Cormack et al. (1994) N.R. L H U U U
Gorgels et al. (2005) N.R. H H U L U
Tannenbaum et al. (2014) L L L L L L
Ten Wolde et al. (2008) L L U U H U
Stewart et al. (2007) N.R. H H L U U Heather et al. (2004) L U H L H U Vicens et al. (2006) L L H U L U Vicens et al. (2014) L L H L L U Interventions for HCPs Avorn et al. (1992) L U U U H U Batty et al. (2001) L U H H U U
Berings, Blondeel & Habraken (1994) L U H U U U
Midlöv et al. (2006) L U H U U U
Pimlott et al. (2003) L U L L U U
Pit et al. (2007) L U H L H U
Roberts et al. (2001) L U H U H U
Smith et al. (1998) L U H U H U
Smith & Tett (2010) N.R. U H H H U
Interventions for patients and HCPs
Patterson et al. (2010) L L H U L U
Westbury et al. (2010) N.R. H H U U U
Note:
Rating: L, low risk of bias; H, high risk of bias; U, unclear risk of bias; N.R., no relevance (controlled study design).
