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Pétein C, Dujardin N, de Montigny M, Dewez E, Spinewine A, Henrard S. Deprescribing benzodiazepine receptor agonists in older adults: a mixed-methods study to adapt the Canadian D-PRESCRIBE intervention to the Belgian community setting. BMJ Open 2024; 14:e085396. [PMID: 39153767 PMCID: PMC11331838 DOI: 10.1136/bmjopen-2024-085396] [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: 02/14/2024] [Accepted: 07/16/2024] [Indexed: 08/19/2024] Open
Abstract
OBJECTIVE Guidelines recommend deprescribing benzodiazepine receptor agonists (BZRA) in older adults, yet implementation in clinical practice remains limited. Adapting effective, evidence-based interventions to a new context is a resource-saving strategy. In Canada, the D-PRESCRIBE intervention comprised a patient educational brochure and a pharmaceutical opinion inviting physicians to revise BZRA prescribing and consider safer alternatives. Due to its effectiveness on BZRA deprescribing among Canadian older adults, we aimed to adapt the D-PRESCRIBE intervention to the Belgian community setting. DESIGN Recommendations from the ADAPT guidance, that provides a systematic approach for adapting interventions to new contexts, were followed. We conducted a mixed-methods study that comprised (1) group discussions and cognitive interviews to assess the acceptability and need for adaptation of the intervention's components and (2) a survey on the adapted pharmaceutical opinion. A research committee involving stakeholders' representatives decided on the adaptations, respecting the core functions of both tools. Changes in intervention components were reported following the Model for Adaptation Design and Impact framework. SETTING Belgian French-speaking community setting. PARTICIPANTS Six older adults (≥65 years), six general practitioners (GPs) and seven pharmacists participated in the group discussions or interviews. 46 GPs and 91 pharmacists responded to the survey. RESULTS Participants welcomed the brochure positively. Still, some changes in the vocabulary, wording, photos and icons were made for several purposes including making the patient feel concerned about the brochure and softening the use of fear. The pharmaceutical opinion aroused mixed perceptions. Its name, layout and content were adapted to enhance its acceptability and fit with our healthcare system, practices and national guidelines. The survey highlighted several enablers and barriers to its use from the perspectives of GP and pharmacist. CONCLUSIONS The Canadian D-PRESCRIBE intervention was adapted to the Belgian setting following a thorough and transparent process. Its feasibility will be tested in a future pilot study (NCT:05929417).
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Affiliation(s)
- Catherine Pétein
- Clinical Pharmacy and Pharmacoepidemiology Research Group, UCLouvain, Louvain Drug Research Institute, Brussels, Belgium
| | - Nathalie Dujardin
- Academic Center for Pharmaceutical Care, Faculté de Pharmacie et des Sciences Biomédicales, UCLouvain, Brussels, Belgium
| | - Manon de Montigny
- Centre académique de Médecine Générale, Faculté de Médecine et Médecine dentaire, UCLouvain, Brussels, Belgium
| | - Evelyne Dewez
- Ligue des Usagers des Services de Santé (LUSS), Namur, Belgium
| | - Anne Spinewine
- Clinical Pharmacy and Pharmacoepidemiology Research Group, UCLouvain, Louvain Drug Research Institute, Brussels, Belgium
- Pharmacy Deparment, CHU UCL Namur, UCLouvain, Yvoir, Belgium
| | - Séverine Henrard
- Clinical Pharmacy and Pharmacoepidemiology Research Group, UCLouvain, Louvain Drug Research Institute, Brussels, Belgium
- Institute of Health and Society (IRSS), UCLouvain, Brussels, Belgium
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Le TM, Campbell S, Andraos A, Ahlmark P, Hoang H, Isserman S, Goldzweig CL, Mays AM, Bradley K, Keller MS. Implementation of an intervention aimed at deprescribing benzodiazepines in a large US healthcare system using patient education materials: a pre/post-observational study with a control group. BMJ Open 2024; 14:e080109. [PMID: 38569687 PMCID: PMC11146350 DOI: 10.1136/bmjopen-2023-080109] [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: 09/20/2023] [Accepted: 03/18/2024] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVES Long-term benzodiazepine use is common despite known risks. In the original Eliminating Medications Through Patient Ownership of End Results (EMPOWER) Study set in Canada, patient education led to increased rates of benzodiazepine cessation. We aimed to determine the effectiveness of implementing an adapted EMPOWER quality improvement (QI) initiative in a US-based healthcare system. DESIGN We used a pre-post design with a non-randomised control group. SETTING A network of primary care clinics. PARTICIPANTS Patients with ≥60 days' supply of benzodiazepines in 6 months and ≥1 risk factor (≥65 years of age, a concurrent high-risk medication prescribed or a diazepam equivalent daily dose ≥10) were eligible. INTERVENTION In March 2022, we engaged 22 primary care physicians (PCPs), and 308 of their patients were mailed an educational brochure, physician letter and flyer detailing benzodiazepine risks; the control group included 4 PCPs and 291 of their patients. PRIMARY AND SECONDARY MEASURES The primary measure was benzodiazepine cessation by 9 months. We used logistic regression and a generalised estimating equations approach to control for clustering by PCP, adjusting for demographics, frailty, number of risk factors, and diagnoses of arthritis, depression, diabetes, falls, and pain. RESULTS Patients in the intervention and control groups were comparable across most covariates; however, a greater proportion of intervention patients had pain-related diagnoses and depression. By 9 months, 26% of intervention patients (81 of 308) had discontinued benzodiazepines, compared with 17% (49 of 291) of control patients. Intervention patients had 1.73 greater odds of benzodiazepine discontinuation compared with controls (95% CI: 1.09, 2.75, p=0.02). The unadjusted number needed to treat was 10.5 (95% CI: 6.30, 34.92) and the absolute risk reduction was 0.095 (95% CI: 0.03 to 0.16). CONCLUSIONS Results from this non-randomised QI initiative indicate that patient education programmes using the EMPOWER brochures have the potential to promote cessation of benzodiazepines in primary care.
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Affiliation(s)
- Tammy M Le
- David Geffen School of Medicine, Los Angeles, California, USA
| | - Scott Campbell
- Cedars-Sinai Medical Care Foundation, Los Angeles, California, USA
| | - Alexa Andraos
- Cedars-Sinai Medical Care Foundation, Los Angeles, California, USA
| | - Pedro Ahlmark
- Cedars-Sinai Medical Care Foundation, Los Angeles, California, USA
| | - Ha Hoang
- Enterprise Data Intelligence, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sean Isserman
- Enterprise Data Intelligence, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | - Allison M Mays
- Section of Geriatrics, Division of General Internal Medicine, Medicine, Cedars-Sinai Medical Center, Beverly Hills, California, USA
| | | | - Michelle S Keller
- Division of General Internal Medicine, Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Health Policy and Management, Jonathan and Karin Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA
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Niznik JD, Shmuel S, Pate V, Thorpe CT, Hanson LC, Rice C, Lund JL. Validating claims-based definitions for deprescribing: Bridging the gap between clinical and administrative data. Pharmacoepidemiol Drug Saf 2024; 33:e5784. [PMID: 38556843 PMCID: PMC11145562 DOI: 10.1002/pds.5784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 03/05/2024] [Accepted: 03/13/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Limited research has evaluated the validity of claims-based definitions for deprescribing. OBJECTIVES Evaluate the validity of claims-based definitions of deprescribing against electronic health records (EHRs) for deprescribing of benzodiazepines (BZDs) after a fall-related hospitalization. METHODS We used a novel data linkage between Medicare fee-for-service (FFS) and Part D with our health system's EHR. We identified patients aged ≥66 years with a fall-related hospitalization, continuous enrollment in Medicare FFS and Part D for 6 months pre- and post-hospitalization, and ≥2 BZD fills in the 6 months pre-hospitalization. Using a standardized EHR abstraction tool, we adjudicated deprescribing for a sub-sample with a fall-related hospitalization at UNC. We evaluated the validity of claims-based deprescribing definitions (e.g., gaps in supply, dosage reductions) versus chart review using sensitivity and specificity. RESULTS Among 257 patients in the overall sample, 44% were aged 66-74 years, 35% had Medicare low-income subsidy, 79% were female. Among claims-based definitions using gaps in supply, the prevalence of BZD deprescribing ranged from 8.2% (no refills) to 36.6% (30-day gap). When incorporating dosage, the prevalence ranged from 55.3% to 65.8%. Among the validation sub-sample (n = 47), approximately one-third had BZDs deprescribed in the EHR. Compared to EHR, gaps in supply from claims had good sensitivity, but poor specificity. Incorporating dosage increased sensitivity, but worsened specificity. CONCLUSIONS The sensitivity of claims-based definitions for deprescribing of BZDs was low; however, the specificity of a 90-day gap was >90%. Replication in other EHRs and for other low-value medications is needed to guide future deprescribing research.
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Affiliation(s)
- Joshua D Niznik
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina, USA
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Shahar Shmuel
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Virginia Pate
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Carolyn T Thorpe
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina, USA
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina, USA
| | - Colleen Rice
- Translational and Clinical Sciences Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jennifer L Lund
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
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Ashkanani FZ, Rathbone AP, Lindsey L. The role of pharmacists in deprescribing benzodiazepines: A scoping review. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2023; 12:100328. [PMID: 37743854 PMCID: PMC10511800 DOI: 10.1016/j.rcsop.2023.100328] [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: 05/23/2023] [Revised: 07/14/2023] [Accepted: 09/01/2023] [Indexed: 09/26/2023] Open
Abstract
Background Polypharmacy can increase the risk of adverse drug events, hospitalisation, and unnecessary healthcare costs. Evidence indicates that discontinuing certain medications, such as benzodiazepines, can improve health outcomes, by resolving adverse drug effects. This scoping review aims to explore the pharmacists' role in deprescribing benzodiazepines. Method A scoping review has been conducted to distinguish and map the literature, discover research gaps, and focus on targeted areas for future studies and research. A systematic search strategy was conducted to identify relevant studies from PubMed, Medline, and EMBASE databases. The eligibility criteria involved studies that focused on the role of pharmacists in benzodiazepine deprescribing, quantitative and qualitative studies conducted in humans, full-text articles published in English. Results Twenty studies were identified, revealing three themes: 1) pharmacists' involvement in benzodiazepine deprescribing, 2) the impact of their involvement, and 3) obstacles impeding the process. Pharmacists involved in deprescribing procedures, mainly through completing medication reviews, collaborative work with other healthcare providers, and education. Pharmacists' involvement in benzodiazepine deprescribing intervention led to better health and economic outcomes. Withdrawal symptoms after medication discontinuation, dependence on medication, and lack of time and guidelines were identified in the literature as barriers to deprescribing. Conclusion Pharmacists' involvement in deprescribing benzodiazepines is crucial for optimizing medication therapy. This scoping review examines the pharmacists' role in benzodiazepine deprescribing. The findings contribute to enhancing healthcare outcomes and guiding future research in this area.
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Affiliation(s)
- Fatemah Zakariya Ashkanani
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, King George VI Building, Newcastle upon Tyne, Tyne and Wear NE2 7RU, United Kingdom
| | - Adam Pattison Rathbone
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, King George VI Building, Newcastle upon Tyne, Tyne and Wear NE2 7RU, United Kingdom
| | - Laura Lindsey
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, King George VI Building, Newcastle upon Tyne, Tyne and Wear NE2 7RU, United Kingdom
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Melo TAR, Bezerra CO, Fernandes BD, Rotta I, Reis WCT, Aguiar PM. Pharmacists' contribution to benzodiazepine deprescribing in older outpatients: a systematic review and meta-analysis. Int J Clin Pharm 2023; 45:1037-1049. [PMID: 37713028 DOI: 10.1007/s11096-023-01637-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/12/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Consolidated and reliable evidence regarding the effectiveness of pharmacist interventions for deprescribing benzodiazepines in older outpatients is lacking. AIM This study evaluated and summarized the impact of pharmacist interventions on benzodiazepine deprescribing among older outpatients. METHOD A literature search was conducted until August 2022 in PubMed, PsycINFO, and the Cochrane Central Register of Controlled Trials databases. The review included randomized controlled trials that assessed the impact of pharmacist interventions on deprescribing benzodiazepine in older outpatients. Two independent investigators conducted the study selection, data extraction, and risk of bias assessment. Meta-analyses were conducted using random-effect models in the RStudio software. RESULTS A total of 893 records were identified. Five studies, including 3,879 patients, met the inclusion criteria and were included in the systematic review. All five studies used health education as an intervention strategy, and three also conducted medication reviews. There was no evidence of the pharmacist's authority to modify prescriptions during benzodiazepine deprescribing. One study was classified as having a low risk of bias, whereas the other had some concerns or a high risk of bias. Three studies were included in the meta-analysis and a significant impact of pharmacist interventions on benzodiazepines deprescribing rates in older outpatients was observed (RR = 2.75 [95%CI 1.29; 5.89]; p = 0.04; I2 = 69%; low certainty of evidence). CONCLUSION Pharmacists may contribute to deprescribing benzodiazepines in older outpatients. Further studies are needed to increase the reliability of these findings. PROSPERO registration number: CRD42022358563.
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Affiliation(s)
- Thiago Afonso Rodrigues Melo
- Department of Pharmacy, Faculty of Pharmaceutical Sciences, University of São Paulo, Av. Prof. Lineu Prestes, 580, Conj. das Químicas, Bloco 13, Cidade Universitária Butantã, São Paulo, Brazil
| | - Cleyton Oliveira Bezerra
- Municipal Health Department, Multiprofessional Residency Program in Family and Community Health, João Pessoa, PB, Brazil
| | | | - Inajara Rotta
- Department of Pharmacy, Federal University of Paraná, Curitiba, PR, Brazil
| | | | - Patricia Melo Aguiar
- Department of Pharmacy, Faculty of Pharmaceutical Sciences, University of São Paulo, Av. Prof. Lineu Prestes, 580, Conj. das Químicas, Bloco 13, Cidade Universitária Butantã, São Paulo, Brazil.
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Sibille FX, de Saint-Hubert M, Henrard S, Aubert CE, Goto NA, Jennings E, Dalleur O, Rodondi N, Knol W, O'Mahony D, Schwenkglenks M, Spinewine A. Benzodiazepine Receptor Agonists Use and Cessation Among Multimorbid Older Adults with Polypharmacy: Secondary Analysis from the OPERAM Trial. Drugs Aging 2023; 40:551-561. [PMID: 37221407 DOI: 10.1007/s40266-023-01029-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND Benzodiazepine receptor agonists (BZRAs) are commonly prescribed in older adults despite an unfavorable risk-benefit ratio. Hospitalizations may provide a unique opportunity to initiate BZRA cessation, yet little is known about cessation during and after hospitalization. We aimed to measure the prevalence of BZRA use before hospitalization and the rate of cessation 6 months later, and to identify factors associated with these outcomes. METHODS We conducted a secondary analysis of a cluster randomized controlled trial (OPtimising thERapy to prevent Avoidable hospital admissions in the Multimorbid elderly [OPERAM]), comparing usual care and in-hospital pharmacotherapy optimization in adults aged 70 years or over with multimorbidity and polypharmacy in four European countries. BZRA cessation was defined as taking one or more BZRA before hospitalization and not taking any BZRA at the 6-month follow-up. Multivariable logistic regression was performed to identify factors associated with BZRA use before hospitalization and with cessation at 6 months. RESULTS Among 1601 participants with complete 6-month follow-up data, 378 (23.6%) were BZRA users before hospitalization. Female sex (odds ratio [OR] 1.52 [95% confidence interval 1.18-1.96]), a higher reported level of depression/anxiety (OR up to 2.45 [1.54-3.89]), a higher number of daily drugs (OR 1.08 [1.05-1.12]), use of an antidepressant (OR 1.74 [1.31-2.31]) or an antiepileptic (OR 1.46 [1.02-2.07]), and trial site were associated with BZRA use. Diabetes mellitus (OR 0.60 [0.44-0.80]) was associated with a lower probability of BZRA use. BZRA cessation occurred in 86 BZRA users (22.8%). Antidepressant use (OR 1.74 [1.06-2.86]) and a history of falling in the previous 12 months (OR 1.75 [1.10-2.78]) were associated with higher BZRA cessation, and chronic obstructive pulmonary disease (COPD) (OR 0.45 [0.20-0.91]) with lower BZRA cessation. CONCLUSION BZRA prevalence was high among included multimorbid older adults, and BZRA cessation occurred in almost a quarter of them within 6 months after hospitalization. Targeted BZRA deprescribing programs could further enhance cessation. Specific attention is needed for females, central nervous system-acting co-medication, and COPD co-morbidity. REGISTRATION ClinicalTrials.gov identifier: NCT02986425. December 8, 2016.
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Affiliation(s)
- François-Xavier Sibille
- Department of Geriatric Medicine, CHU UCL Namur, Avenue Dr Gaston Therasse, 1, 5530, Yvoir, Belgium.
- Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium.
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium.
| | - Marie de Saint-Hubert
- Department of Geriatric Medicine, CHU UCL Namur, Avenue Dr Gaston Therasse, 1, 5530, Yvoir, Belgium
- Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
| | - Séverine Henrard
- Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
| | - Carole Elodie Aubert
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Namiko Anna Goto
- Department of Geriatric Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Emma Jennings
- Department of Medicine, School of Medicine, University College Cork, Cork, Republic of Ireland
| | - Olivia Dalleur
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
- Department of Pharmacy, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Wilma Knol
- Department of Geriatric Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Denis O'Mahony
- Department of Medicine, School of Medicine, University College Cork, Cork, Republic of Ireland
| | | | - Anne Spinewine
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
- Department of Pharmacy, CHU UCL Namur, Yvoir, Belgium
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Keller MS, Carrascoza-Bolanos J, Breda K, Kim LY, Kennelty KA, Leang DW, Murry LT, Nuckols TK, Schnipper JL, Pevnick JM. Identifying barriers and facilitators to deprescribing benzodiazepines and sedative hypnotics in the hospital setting using the Theoretical Domains Framework and the Capability, Opportunity, Motivation and Behaviour (COM-B) Model: a qualitative study. BMJ Open 2023; 13:e066234. [PMID: 36813499 PMCID: PMC9950911 DOI: 10.1136/bmjopen-2022-066234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
OBJECTIVES Geriatric guidelines strongly recommend avoiding benzodiazepines and non-benzodiazepine sedative hypnotics in older adults. Hospitalisation may provide an important opportunity to begin the process of deprescribing these medications, particularly as new contraindications arise. We used implementation science models and qualitative interviews to describe barriers and facilitators to deprescribing benzodiazepines and non-benzodiazepine sedative hypnotics in the hospital and develop potential interventions to address identified barriers. DESIGN We used two implementation science models, the Capability, Opportunity and Behaviour Model (COM-B) and the Theoretical Domains Framework, to code interviews with hospital staff, and an implementation process, the Behaviour Change Wheel (BCW), to codevelop potential interventions with stakeholders from each clinician group. SETTING Interviews took place in a tertiary, 886-bed hospital located in Los Angeles, California. PARTICIPANTS Interview participants included physicians, pharmacists, pharmacist technicians, and nurses. RESULTS We interviewed 14 clinicians. We found barriers and facilitators across all COM-B model domains. Barriers included lack of knowledge about how to engage in complex conversations about deprescribing (capability), competing tasks in the inpatient setting (opportunity), high levels of resistance/anxiety among patients to deprescribe (motivation), concerns about lack of postdischarge follow-up (motivation). Facilitators included high levels of knowledge about the risks of these medications (capability), regular rounds and huddles to identify inappropriate medications (opportunity) and beliefs that patients may be more receptive to deprescribing if the medication is related to the reason for hospitalisation (motivation). Potential modes of delivery included a seminar aimed at addressing capability and motivation barriers in nurses, a pharmacist-led deprescribing initiative using risk stratification to identify and target patients at highest need for deprescribing, and the use of evidence-based deprescribing education materials provided to patients at discharge. CONCLUSIONS While we identified numerous barriers and facilitators to initiating deprescribing conversations in the hospital, nurse- and pharmacist-led interventions may be an appropriate opportunity to initiate deprescribing.
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Affiliation(s)
- Michelle S Keller
- Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Health Policy and Management, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | - Kathleen Breda
- Orthopedics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Linda Y Kim
- Nursing, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Korey A Kennelty
- College of Pharmacy, The University of Iowa, Iowa City, Iowa, USA
| | - Donna W Leang
- Pharmacy, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Logan T Murry
- Department of Pharmacy Practice and Science, University of Iowa, Iowa City, Iowa, USA
| | - Teryl K Nuckols
- Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jeffrey L Schnipper
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Joshua M Pevnick
- Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Niznik JD, Collins BJ, Armistead LT, Larson CK, Kelley CJ, Hughes TD, Sanders KA, Carlson R, Ferreri SP. Pharmacist interventions to deprescribe opioids and benzodiazepines in older adults: A rapid review. Res Social Adm Pharm 2022; 18:2913-2921. [PMID: 34281786 PMCID: PMC8836277 DOI: 10.1016/j.sapharm.2021.07.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Many older adults are prescribed opioids and benzodiazepines (BZDs), despite increased susceptibility to adverse events. Challenges of deprescribing include fragmented care and lack of knowledge or time. Pharmacists are well-positioned to overcome these challenges and facilitate deprescribing of these medications. OBJECTIVES We sought to evaluate interventions utilizing pharmacists to deprescribe opioids and BZDs in older adults. METHODS We conducted a rapid review following a comprehensive literature search to identify interventions with pharmacist involvement for deprescribing opioids and BZDs in older adults. Studies were included based on: (1) inclusion of patients ≥ 65 years old receiving BZDs and/or opioids, (2) evaluation of feasibility or outcomes following deprescribing (3) pharmacists as part of the intervention. We included randomized, observational, cohort, and pilot studies. Studies that did not report specific results for BZD or opioids were excluded. RESULTS We screened 687 abstracts and included 17 studies. Most (n = 13) focused on BZD deprescribing. Few studies focused on opioids (n = 2) or co-prescribing of opioids and BZDs (n = 2). The most common intervention was educational brochures (n = 8), majority being the EMPOWER brochure for deprescribing BZDs. Other interventions included chart review with electronic notes (n = 4), pharmacist-led programs/services (n = 2), and multifactorial interventions (n = 3). Many studies were underpowered or lacked suitable control groups. Generally speaking, interventions utilizing educational materials and those in which pharmacists engaged with patients and providers were more effective. Interventions relying on electronic communication by pharmacists were less successful, due to low acceptance or acknowledgement. CONCLUSIONS We identified a number of feasible interventions to reduce BZD use, but fewer interventions to reduce opioid use in older adults. An optimal approach for deprescribing likely requires pharmacists to engage directly with patients and providers. Larger well-designed studies are needed to evaluate the effectiveness of deprescribing interventions beyond feasibility.
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Affiliation(s)
- Joshua D Niznik
- University of North Carolina School of Medicine, Division of Geriatric Medicine and Center for Aging and Health, Chapel Hill, NC, USA; University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA; VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA.
| | - Brendan J Collins
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Lori T Armistead
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Claire K Larson
- University of North Carolina School of Medicine, Division of Geriatric Medicine and Center for Aging and Health, Chapel Hill, NC, USA
| | - Casey J Kelley
- University of North Carolina School of Medicine, Division of Geriatric Medicine and Center for Aging and Health, Chapel Hill, NC, USA
| | - Tamera D Hughes
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Kimberly A Sanders
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Rebecca Carlson
- University of North Carolina, Health Sciences Library, Chapel Hill, NC, USA
| | - Stefanie P Ferreri
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
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Sibille FX, Spinewine A, Zerah L, Maljean L, Schoevaerdts D, de Saint-Hubert M. Current practice in benzodiazepine receptor agonists deprescribing on acute geriatric wards: a cohort study. BMC Geriatr 2022; 22:88. [PMID: 35100982 PMCID: PMC8805235 DOI: 10.1186/s12877-022-02753-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 12/20/2021] [Indexed: 11/10/2022] Open
Abstract
Background Benzodiazepine receptor agonist (BZRA) use is highly prevalent in hospitalised older people although these drugs are associated with numerous and serious adverse events. Deprescribing can reduce risks associated with chronic BZRA use. The aim of this study was to measure the prevalence of, and factors associated with, BZRA deprescribing in acute geriatric units. Methods During a one-year period, this multicentre retrospective study included patients aged ≥70 years, hospitalised in acute geriatric units, and using ≥1 BZRA on admission. BZRA deprescribing at discharge was defined as: ≥25% decrease in lorazepam-equivalent admission dose; discontinuation of all BZRAs; or cessation of a rescue prescription at discharge. BZRA cessation was defined as discontinuation of all BZRAs at discharge. We identified social, medical, geriatric and medication factors associated with BZRA deprescribing using logistic regression. Results In total, 561 patients were included (mean age: 85.3±5.9 years, 70% of women). BZRA deprescribing occurred in 240 (42.8%), including 85 with BZRA cessation (15.2%). Deprescribing occurred more frequently in patients with a BZRA-related adverse event on admission or during hospital stay (odds ratio (OR) 4.5; 95% confidence interval [2.6; 7.9]), with an antidepressant (1.6 [1.1; 2.4]) and a higher lorazepam-equivalent dosage on admission (OR 1.2 [1; 1.4]), and less frequently in patients with antipsychotic drug (OR 0.5 [0.3; 0.8]). BZRA cessation was more likely in patients with a BZRA-related adverse event (OR 2.2 [1.2; 4.3]) and a lower lorazepam-equivalent dosage on admission (OR 0.5 [0.3; 0.6]). Conclusions During hospitalisation in the acute geriatric units of our hospital, BZRA deprescribing occurred in 42.8% of the patients. Identification of an BZRA-related adverse event by the treating physician appears to be a major factor: this reactive deprescribing accounted for 74% of cases in our study. Further prospective studies are needed to measure long-term persistence of in-hospital deprescribing and encourage proactive management.
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Affiliation(s)
- François-Xavier Sibille
- Department of Geriatric Medicine, CHU Dinant Godinne UCL Namur, Avenue Dr Gaston Therasse, 1, 5530, Yvoir, Belgium. .,Institute of Health and Society, Université Catholique de Louvain, Clos Chapelle aux Champs, 30 Bte B1. 30.13, 1200, Brussels, Belgium. .,Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Avenue Mounier, 72 bte B1.72.02, 1200, Brussels, Belgium.
| | - Anne Spinewine
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Avenue Mounier, 72 bte B1.72.02, 1200, Brussels, Belgium.,Department of Pharmacy, CHU Dinant Godinne UCL Namur, Avenue Dr Gaston Therasse, 1, 5530, Yvoir, Belgium
| | - Lorène Zerah
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Avenue Mounier, 72 bte B1.72.02, 1200, Brussels, Belgium
| | - Laurentine Maljean
- Department of Pharmacy, CHU Dinant Godinne UCL Namur, Avenue Dr Gaston Therasse, 1, 5530, Yvoir, Belgium
| | - Didier Schoevaerdts
- Department of Geriatric Medicine, CHU Dinant Godinne UCL Namur, Avenue Dr Gaston Therasse, 1, 5530, Yvoir, Belgium.,Institute of Health and Society, Université Catholique de Louvain, Clos Chapelle aux Champs, 30 Bte B1. 30.13, 1200, Brussels, Belgium
| | - Marie de Saint-Hubert
- Department of Geriatric Medicine, CHU Dinant Godinne UCL Namur, Avenue Dr Gaston Therasse, 1, 5530, Yvoir, Belgium.,Institute of Health and Society, Université Catholique de Louvain, Clos Chapelle aux Champs, 30 Bte B1. 30.13, 1200, Brussels, Belgium.,NARILIS, Namur, Belgium
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Neville HL, Granter C, Adibi P, Belliveau J, Isenor JE, Bowles SK. Interventions to reduce benzodiazepine and sedative-hypnotic drug use in acute care hospitals: A scoping review. Res Social Adm Pharm 2021; 18:2874-2886. [PMID: 34253470 DOI: 10.1016/j.sapharm.2021.07.004] [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: 11/26/2020] [Revised: 05/17/2021] [Accepted: 07/04/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Benzodiazepines and sedative-hypnotic drugs (BZD/SHD) are commonly utilized in the acute care setting for insomnia and anxiety and are associated with cognitive impairment, falls, and fractures. Interventions to reduce use of BZD/SHD in hospitals are not well characterized. OBJECTIVE The objective was to conduct a scoping review to identify and characterize interventions to reduce the use of BZD/SHD by adults in the acute care setting. METHODS English language studies and abstracts that described an intervention to reduce BZD/SHD in adult hospital patients were included. Six databases (PubMed, EMBASE, CINAHL, PsycINFO, Scopus, and Web of Science) were searched up to July 2018 and updated to February 3, 2021. The grey literature (Opengrey, Grey Matters, Google Advanced) was searched up to July 2018. Titles and abstracts were screened and full-text articles were reviewed and charted by three independent reviewers. Stakeholders were consulted to inform the scoping review and collect perspectives on the findings. RESULTS There were 13,046 records identified and 43 studies included. The most common study designs were uncontrolled before and after (23/43, 53.5%) and randomized controlled trials (7/43, 16.3%). The majority of studies tested a single intervention (32/43, 74.4%) such as education, deprescribing, relaxation training and sleep protocols. Patients were frequently the target of relaxation training and behavior change interventions; while sleep protocols, multifaceted interventions, education and deprescribing were usually directed at healthcare providers, either alone or in combination with patients. Most studies reported positive results in decreasing BZD/SHD use (27/43, 62.8%). CONCLUSIONS The scoping review found a variety of interventions to decrease the utilization of BZD/SHD in hospitals. Multifaceted interventions aimed at patients and healthcare providers that include a combination of education, sleep protocols, and deprescribing may support reductions in BZD/SHD use. Stakeholders also recommended policy and system changes such as computer alerts due to feasibility and workload.
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Affiliation(s)
- Heather L Neville
- Nova Scotia Health, 1276 South Park Street, Halifax, Nova Scotia, B3H 2Y9, Canada.
| | - Courtney Granter
- Nova Scotia Health, 1276 South Park Street, Halifax, Nova Scotia, B3H 2Y9, Canada; IWK Health Centre, 5980 University Ave, Halifax, Nova Scotia, B3H 1V7, Canada.
| | - Pegah Adibi
- Nova Scotia Health, 1276 South Park Street, Halifax, Nova Scotia, B3H 2Y9, Canada.
| | - Julia Belliveau
- Nova Scotia Health, 1276 South Park Street, Halifax, Nova Scotia, B3H 2Y9, Canada.
| | - Jennifer E Isenor
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Susan K Bowles
- Nova Scotia Health, 1276 South Park Street, Halifax, Nova Scotia, B3H 2Y9, Canada; College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada.
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11
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Choi J, Vordenberg SE. Older adults' perceptions of deprescribing chronic benzodiazepines. J Am Pharm Assoc (2003) 2021; 61:533-538.e3. [PMID: 33893059 DOI: 10.1016/j.japh.2021.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/25/2021] [Accepted: 04/05/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The primary objective of our study was to explore older adults' willingness to stop or lower the dose or frequency their chronic benzodiazepine with the long-term goal of developing a patient-centered intervention to support older adults during the deprescribing process. METHODS We conducted semistructured interviews with adults aged 60 years and older who reported taking a benzodiazepine for at least 3 months. We recruited participants using our institutional research recruitment website between September and November 2019. Eligible participants completed an interview which was audio-recorded and subsequently transcribed. We identified themes related to older adults' willingness to consider deprescribing their benzodiazepine, if recommended by their prescriber in a hypothetical scenario. Secondary outcomes focused on their use and perceptions of taking a benzodiazepine as well as their experiences attempting to stop the medication. RESULTS Among the 21 participants, most were female (n = 14, 66.7%), white (n = 20, 95.2%), and reported good or fair health (n = 17, 81.0%). More than three-fourths of participants who reported data (n = 14 of 18, 77.8%) had taken a benzodiazepine for 6 or more years. Participants generally reported that the medication was very effective (n = 16, 76.2%) and adverse effects were infrequent (n = 5, 23.8%). Participants varied widely in their attitudes toward the hypothetical questions about changing their current benzodiazepine. A total of 7 people were open to stopping the medication, 4 were willing to potentially consider it, and 10 were resistant. However, most of the participants were open to the idea of de-escalation (n = 17, 81.0%). CONCLUSION Many older adults were willing to consider deprescribing a long-term benzodiazepine if it were recommended by their prescriber. Older adults were more open to consider lowering the dose or frequency of the chronic benzodiazepine than stopping the medication. Further research is needed to design a patient-centered intervention tool to support prescribers and older adults in deprescribing conversations about benzodiazepines.
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Aubert CE, Kerr EA, Maratt JK, Klamerus ML, Hofer TP. Outcome Measures for Interventions to Reduce Inappropriate Chronic Drugs: A Narrative Review. J Am Geriatr Soc 2020; 68:2390-2398. [DOI: 10.1111/jgs.16697] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 06/05/2020] [Accepted: 06/05/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Carole E. Aubert
- Department of General Internal Medicine, Bern University Hospital University of Bern Bern Switzerland
- Institute of Primary Health Care University of Bern Bern Switzerland
- Veterans Affairs Center for Clinical Management Research Ann Arbor Michigan USA
- Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor Michigan USA
| | - Eve A. Kerr
- Veterans Affairs Center for Clinical Management Research Ann Arbor Michigan USA
- Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor Michigan USA
- Department of Internal Medicine University of Michigan Ann Arbor Michigan USA
| | - Jennifer K. Maratt
- Department of Medicine Indiana University School of Medicine Indianapolis Indiana USA
- Richard L. Roudebush Veterans Affairs Medical Center Indianapolis Indiana USA
| | - Mandi L. Klamerus
- Veterans Affairs Center for Clinical Management Research Ann Arbor Michigan USA
| | - Timothy P. Hofer
- Veterans Affairs Center for Clinical Management Research Ann Arbor Michigan USA
- Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor Michigan USA
- Department of Internal Medicine University of Michigan Ann Arbor Michigan USA
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13
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Oliva EM. Commentary on Park et al. (2020): Buprenorphine and benzodiazepine co-prescribing- key considerations and future directions. Addiction 2020; 115:933-934. [PMID: 32077171 DOI: 10.1111/add.14990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 01/24/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Elizabeth M Oliva
- VA Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
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