The pattern of anxiolytic and hypnotic management by Australian general practice trainees

Medications and cognitive risk in Aboriginal primary care: a cross-sectional study

BACKGROUND

Aboriginal and Torres Strait Islander people are ageing with high rates of comorbidity, yet little is known about suboptimal prescribing in this population.

AIM

The prevalence of potentially suboptimal prescribing and associated risk factors were investigated among older patients attending primary care through Aboriginal Community Controlled Health Services (ACCHSs).

METHODS

Medical records of 420 systematically selected patients aged ≥50 years attending urban, rural and remote health services were audited. Polypharmacy (≥ 5 prescribed medications), potentially inappropriate medications (PIMs) as per Beers Criteria and anticholinergic burden (ACB) were estimated and associated risk factors were explored with logistic regression.

RESULTS

The prevalence of polypharmacy, PIMs and ACB score ≥3 was 43%, 18% and 12% respectively. In multivariable logistic regression analyses, polypharmacy was less likely in rural (odds ratio (OR) = 0.43, 95% confidence interval (CI) = 0.24-0.77) compared to urban patients, and more likely in those with heart disease (OR = 2.62, 95% CI = 1.62-4.25), atrial fibrillation (OR = 4.25, 95% CI = 1.08-16.81), hypertension (OR = 2.14, 95% CI = 1.34-3.44), diabetes (OR = 2.72, 95% CI = 1.69-4.39) or depression (OR = 1.91, 95% CI = 1.19-3.06). PIMs were more frequent in females (OR = 1.88, 95% CI = 1.03-3.42) and less frequent in rural (OR = 0.41, 95% CI = 0.19-0.85) and remote (OR = 0.58, 95% CI = 0.29-1.18) patients. Factors associated with PIMs were kidney disease (OR = 2.60, 95% CI = 1.37-4.92), urinary incontinence (OR = 3.00, 95% CI = 1.02-8.83), depression (OR = 2.67, 95% CI = 1.50-4.77), heavy alcohol use (OR = 2.83, 95% CI = 1.39-5.75) and subjective cognitive concerns (OR = 2.69, 95% CI = 1.31-5.52). High ACB was less common in rural (OR = 0.10, 95% CI = 0.03-0.34) and remote (OR = 0.51, 95% CI = 0.25-1.04) patients and more common in those with kidney disease (OR = 3.07, 95% CI = 1.50-6.30) or depression (OR = 3.32, 95% CI = 1.70-6.47).

CONCLUSION

Associations between potentially suboptimal prescribing and depression or cognitive concerns highlight the importance of considering medication review and deprescribing for these patients.

'Low-value' clinical care in general practice: a cross-sectional analysis of low-value care in early-career GPs' practice

Nonevidence-based and 'low-value' clinical care and medical services are 'questionable' clinical activities that are more likely to cause harm than good or whose benefit is disproportionately low compared with their cost. This study sought to establish general practitioner (GP), patient, practice, and in-consultation associations of an index of key nonevidence-based or low-value 'questionable' clinical practices. The study was nested in the Registrar Clinical Encounters in Training study-an ongoing (from 2010) cohort study in which Australian GP registrars (specialist GP trainees) record details of their in-consultation clinical and educational practice 6-monthly. The outcome factor in analyses, performed on Registrar Clinical Encounters in Training data from 2010 to 2020, was the score on the QUestionable In-Training Clinical Activities Index (QUIT-CAI), which incorporates recommendations of the Australian Choosing Wisely campaign. A cross-sectional analysis used negative binomial regression (with the model including an offset for the number of times the registrar was at risk of performing a questionable activity) to establish associations of QUIT-CAI scores. A total of 3206 individual registrars (response rate 89.9%) recorded 406 812 problems/diagnoses where they were at risk of performing a questionable activity. Of these problems/diagnoses, 15 560 (3.8%) involved questionable activities being performed. In multivariable analyses, higher QUIT-CAI scores (more questionable activities) were significantly associated with earlier registrar training terms: incidence rate ratios (IRRs) of 0.91 [95% confidence interval (CI) 0.87, 0.95] and 0.85 (95% CI 0.80, 0.90) for Term 2 and Term 3, respectively, compared to Term 1. Other significant associations of higher scores included the patient being new to the registrar (IRR 1.27; 95% CI 1.12, 1.45), the patient being of non-English-speaking background (IRR 1.24; 95% CI 1.04, 1.47), the practice being in a higher socioeconomic area decile (IRR 1.01; 95% CI 1.00, 1.02), small practice size (IRR 1.05; 95% CI 1.00, 1.10), shorter consultation duration (IRR 0.99 per minute; 95% CI 0.99, 1.00), and fewer problems addressed in the consultation (IRR 0.84; 95% CI 0.79, 0.89) for each additional problem]. Senior registrars' clinical practice entailed less 'questionable' clinical actions than junior registrars' practice. The association of lower QUIT-CAI scores with a measure of greater continuity of care (the patient not being new to the registrar) suggests that continuity should be supported and facilitated during GP training (and in established GPs' practice).

Prevalence of insomnia and hypnotic use in Norwegian patients visiting their general practitioner

BACKGROUND

Sleep problems are common in the general population, but there are few studies on the prevalence of sleep problems and hypnotic use among patients in general practice.

OBJECTIVES

To estimate the prevalence of insomnia (based on the Diagnostic and Statistical Manual of Mental Disorders [DSM], version 5), self-reported sleep problems and hypnotic use among patients in general practice, and explore whether the prevalence depended on patient characteristics.

METHODS

A cross-sectional study with questionnaire data collected by 114 final-year medical students while deployed in different general practices in Norway during 2020. A total of 1,848 consecutive and unselected patients (response rate 85.2%) visiting their general practitioners (GPs) completed a one-page questionnaire, that included the validated Bergen Insomnia Scale (BIS), questions on for how long they have had a sleep problem, hypnotic use, and background characteristics. Associations were estimated using a modified Poisson regression model.

RESULTS

The prevalence of chronic insomnia according to BIS was 48.3%, while 46.9% reported chronic sleep problems (sleep problems of ≥3 months) and 17.8% reported hypnotic use. Females, patients with low compared with higher education, and patients who slept shorter or longer than 7-8 h, had higher risk of chronic insomnia disorder (CID), chronic self-reported sleep problems (CSP), and hypnotic use. The oldest age group (≥65 years) had lower risk of chronic insomnia compared with the youngest (18-34) but twice the probability of hypnotic use.

CONCLUSIONS

CID, CSP, and hypnotic use were prevalent among patients visiting their GP. Insomnia can be effectively treated and deserves more attention among GPs.

Trends in the prescription of drugs used for insomnia: an open-cohort study in Australian general practice, 2011-2018

BACKGROUND

Despite an increase in the prevalence of sleep problems, few studies have investigated changes in the prescribing of drugs that are often used to manage insomnia.

AIM

To explore changes in the pattern of benzodiazepine (BZD), Z-drug (zolpidem, zopiclone), and non-BZD prescriptions.

DESIGN AND SETTING

Open-cohort study comprising 1 773 525 patients (55 903 294 consultations) who attended one of 404 Australian general practices at least three times in two consecutive years between 2011 and 2018.

METHOD

Data were extracted from MedicineInsight, a database of 662 general practices in Australia. Prescription rates per 1000 consultations, the proportion of repeat prescriptions above recommendations, and the proportion of prescriptions for patients with a recent (within 2 years) recorded diagnosis of insomnia were analysed using adjusted regression models.

RESULTS

Rates of BZD, Z-drug, and non-BZD prescriptions were 56.6, 4.4, and 15.5 per 1000 consultations in 2011 and 41.8, 3.5, and 21.5 per 1000 consultations in 2018, respectively. Over the whole study period, temazepam represented 25.3% of the prescriptions and diazepam 21.9%. All BZD and zolpidem prescriptions declined over the whole study period (annual change varying from -1.4% to -10.8%), but non-BZD and zopiclone prescriptions increased in the same period (annual change 5.0% to 22.6%). Repeat prescriptions that exceeded recommended levels remained at <10% for all medications, except melatonin (64.5%), zolpidem (63.3%), zopiclone (31.4%), and alprazolam (13.3%). In 2018, >50% of Z-drug and melatonin prescriptions were for patients with insomnia. There was an annual increase of 0.8-5.9% in the proportion of prescriptions associated with a recently recorded diagnosis of insomnia.

CONCLUSION

Overall, BZD prescriptions in Australia declined between 2011 and 2018. However, the prescription of some of these drugs increased for patients with a recently recorded diagnosis of insomnia. This is concerning because of the potential adverse effects of these medications and the risk of dependence.

The effect of cognitive behavioural therapy for insomnia on sedative-hypnotic use: A narrative review

Although cognitive behavioural therapy for insomnia (CBTi) is the recommended 'first-line' treatment for insomnia, most patients are initially treated with sedative-hypnotic medications. Given the risk of impaired cognitive and psychomotor performance, serious adverse events, and long-term dependence associated with sedative-hypnotics, guidelines recommend that prescriptions should be limited to short-term use and that patients are provided with support for withdrawal where possible. CBTi is an effective insomnia treatment in the presence of sedative-hypnotic use. Furthermore, guidelines recommended that CBTi techniques are utilised to facilitate withdrawal from sedative-hypnotics. However, there is very little research evaluating the effect of CBTi on reduced medication use. The current narrative review integrates 95 studies including over 10,000 participants, investigating the effect of CBTi on reduced sedative-hypnotic use in different populations (e.g., hypnotic-dependent patients, older adults, military personnel), settings (e.g., primary care settings, psychiatric inpatients), CBTi modalities (e.g., self-administered reading/audio materials, digital, and therapist-administered), and in combination with gradual dose reduction programs. Based on this research, we discuss the theoretical mechanistic effects of CBTi in facilitating reduced sedative-hypnotic use, provide clear recommendations for future research, and offer pragmatic clinical suggestions to increase access to CBTi to reduce dependence on sedative-hypnotics as the 'default' treatment for insomnia.

Changes in Australian Early-Career General Practitioners' Benzodiazepine Prescribing: a Longitudinal Analysis

BACKGROUND

Australian and international guidelines recommend benzodiazepines and related drugs (hereafter "benzodiazepines") as second-line, short-term medications only. Most benzodiazepines are prescribed by general practitioners (GPs; family physicians). Australian GP registrars ("trainees" or "residents" participating in a post-hospital training, apprenticeship-like, practice-based vocational training program), like senior GPs, prescribe benzodiazepines at high rates. Education within a training program, and experience in general practice, would be expected to reduce benzodiazepine prescribing.

OBJECTIVE

To establish if registrars' prescribing of benzodiazepines decreases with time within a GP training program DESIGN: Longitudinal analysis from the Registrar Clinical Encounters in Training multi-site cohort study PARTICIPANTS: Registrars of five of Australia's 17 Regional Training Providers. Analyses were restricted to patients ≥ 16 years.

MAIN MEASURES

The main outcome factor was prescription of a benzodiazepine. Conditional logistic regression was used, with registrar included as a fixed effect, to assess within-registrar changes in benzodiazepine-prescribing rates. The "time" predictor variable was "training term" (6-month duration Terms 1-4). To contextualize these "within-registrar" changes, a mixed effects logistic regression model was used, including a random effect for registrar, to assess within-program changes in benzodiazepine-prescribing rates over time. The "time" predictor variable was "year" (2010-2015).

KEY RESULTS

Over 12 terms of data collection, 2010-2015, 1161 registrars (response rate 96%) provided data on 136,809 face-to-face office-based consultations. Two thousand six hundred thirty-two benzodiazepines were prescribed (for 1.2% of all problems managed). In the multivariable model, there was a significant reduction in within-program benzodiazepine prescribing over time (year) (p = < 0.001, OR = 0.94, CI = 0.90, 0.97). However, there was no significant change in 'within-registrar' prescribing over time (registrar Term) (p = 0.92, OR = 1.00 [95% CI = 0.94-1.06]).

CONCLUSIONS

Despite a welcome temporal trend for reductions in overall benzodiazepine prescribing from 2010 to 2015, there is still room for improvement and our findings suggest a lack of effect of specific GP vocational training program education and, thus, an opportunity for targeted education.

Teaching young GPs to cope with psychosocial consultations without prescribing: a durable impact of an e-module on determinants of benzodiazepines prescribing

BACKGROUND

Despite guidelines and campaigns to change prescribing behavior, General Practitioners (GPs) continue to overprescribe benzodiazepines (BZDs). New approaches to improve prescribing are needed. Using behavior change techniques and tailoring interventions to user characteristics are vital to promote behavior change. This study evaluated the impact of an e-module on factors known to determine BZD prescribing practice.

METHODS

A tailored e-module that focuses on avoiding initial BZD prescriptions (and using psychological interventions as an alternative) was developed and offered to GPs in vocational training. Three self-report assessments took place: at baseline, immediately after the module (short term) and at least six months after completion (long term). Assessed determinants include GPs' attitudes concerning treatment options, perceptions of the patient and self-efficacy beliefs. Readiness to adhere to prescribing guidelines was evaluated through assessing motivation, self-efficacy and implementability of non-pharmacological interventions. Changes in determinants were analyzed using the Wilcoxon signed-rank test. Changes in readiness to adhere to guidelines was analyzed using the nonparametric McNemar Bowker test.

RESULTS

A desirable, significant and durable impact on determinants of BZD prescribing was observed. GPs (n = 121) underwent desirable changes in their attitudes, perceptions and self-efficacy beliefs and these changes remained significant months after the intervention. Barriers to using a non-pharmacological approach often cited in literature remained absent and were not highlighted by the intervention. Furthermore a significant impact on GPs' readiness to adhere to guidelines was observed. Participants reported change in their ability to cope with psychosocial consultations and to have tried using non-pharmacological interventions.

CONCLUSIONS

Tailoring an e-intervention to target group (GPs) characteristics appears to be successful in promoting behavioral change in GPs undertaking vocational training. Significant and lasting changes were observed in determinants of prescribing BZDs. The e-intervention resulted in a positive impact on participants' readiness to adhere to BZD prescribing guidance and their coping with psychosocial consultations. Investigating which mechanisms of change are responsible for the observed effectiveness could help to refine and improve future interventions.