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Vicens C, Leiva A, Bejarano F, Sempere-Verdú E, Rodríguez-Rincón RM, Fiol F, Mengual M, Ajenjo-Navarro A, Do Pazo F, Mateu C, Folch S, Alegret S, Coll JM, Martín-Rabadán M, Socias I. Evaluation of a multicomponent intervention consisting of education and feedback to reduce benzodiazepine prescriptions by general practitioners: The BENZORED hybrid type 1 cluster randomized controlled trial. PLoS Med 2022; 19:e1003983. [PMID: 35522626 PMCID: PMC9075619 DOI: 10.1371/journal.pmed.1003983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 04/07/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Current benzodiazepine (BZD) prescription guidelines recommend short-term use to minimize the risk of dependence, cognitive impairment, and falls and fractures. However, many clinicians overprescribe BZDs and chronic use by patients is common. There is limited evidence on the effectiveness of interventions delivered by general practitioners (GPs) on reducing prescriptions and long-term use of BZDs. We aimed to evaluate the effectiveness of a multicomponent intervention for GPs that seeks to reduce BZD prescriptions and the prevalence of long-term users. METHODS AND FINDINGS We conducted a multicenter two-arm, cluster randomized controlled trial in 3 health districts in Spain (primary health centers [PHCs] in Balearic Islands, Catalonia, and Valencian Community) from September 2016 to May 2018. The 81 PHCs were randomly allocated to the intervention group (n = 41; 372 GPs) or the control group (n = 40; 377 GPs). GPs were not blinded to the allocation; however, pharmacists, researchers, and trial statisticians were blinded to the allocation arm. The intervention consisted of a workshop about the appropriate prescribing of BZDs and tapering-off long-term BZD use using a tailored stepped dose reduction with monthly BZD prescription feedback and access to a support web page. The primary outcome, based on 700 GPs (351 in the control group and 349 in the intervention group), compared changes in BZD prescriptions in defined daily doses (DDDs) per 1,000 inhabitants per day after 12 months. The 2 secondary outcomes were the proportion of long-term users (≥6 months) and the proportion of long-term users over age 65 years. Intention-to-treat (ITT) analysis was used to assess all clinical outcomes. Forty-nine GPs (21 intervention group and 28 control group) were lost to follow-up. However, all GPs were included in the ITT analysis. After 12 months, there were a statistically significant decline in total BZD prescription in the intervention group compared to the control group (mean difference: -3.24 DDDs per 1,000 inhabitants per day, 95% confidence interval (CI): -4.96, -1.53, p < 0.001). The intervention group also had a smaller number of long-term users. The adjusted absolute difference overall was -0.36 (95% CI: -0.55, -0.16, p > 0.001), and the adjusted absolute difference in long-term users over age 65 years was -0.87 (95% CI: -1.44, -0.30, p = 0.003). A key limitation of this clustered design clinical trial is the imbalance of some baseline characteristics. The control groups have a higher rate of baseline BZD prescription, and more GPs in the intervention group were women, GPs with a doctorate degree, and trainers of GP residents. CONCLUSIONS A multicomponent intervention that targeted GPs and included educational meeting, feedback about BZD prescriptions, and a support web page led to a statistically significant reduction of BZD prescriptions and fewer long-term users. Although the effect size was small, the high prevalence of BZD use in the general population suggests that large-scale implementation of this intervention could have positive effects on the health of many patients. TRIAL REGISTRATION ISRCTN ISRCTN28272199.
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Affiliation(s)
- Caterina Vicens
- Balearic Health Service IbSalut Son Serra-La Vileta Healthcare Centre, Palma, Illes Balears, Spain
- Research Network on Chronicity, Primary Care, and Health Promotion (RICAPPS)-Balearic Islands Health Research Institute (IdISBa), Mallorca, Spain
| | - Alfonso Leiva
- Research Network on Chronicity, Primary Care, and Health Promotion (RICAPPS)-Balearic Islands Health Research Institute (IdISBa), Mallorca, Spain
- Balearic Health Service IbSalut, Reseach Unit Primary care Mallorca, Palma, Illes Balears, Spain
- * E-mail:
| | - Ferran Bejarano
- Catalan Institute of Health Cat-salut, DAP Camp de Tarragona, Tarragona, Catalunya, Spain
| | - Ermengol Sempere-Verdú
- Conselleria de Sanitat Universal i Salut Pública, Paterna Healthcare Centre, Valencia, Comunitat Valenciana, Spain
| | - Raquel María Rodríguez-Rincón
- Balearic Health Service IbSalut Hospital Universitari Son Espases, Pharmacy Department,Palma de Mallorca, Illes Balears, Spain
| | - Francisca Fiol
- Balearic Health Service IbSalut Son Serra-La Vileta Healthcare Centre, Palma, Illes Balears, Spain
| | - Marta Mengual
- Catalan Institute of Health Cat-salut, DAP Camp de Tarragona, Tarragona, Catalunya, Spain
| | - Asunción Ajenjo-Navarro
- Conselleria de Sanitat Universal i Salut Pública, Paterna Healthcare Centre, Valencia, Comunitat Valenciana, Spain
| | - Fernando Do Pazo
- Balearic Health Service IbSalut Hospital Universitari Son Espases, Pharmacy Department,Palma de Mallorca, Illes Balears, Spain
| | - Catalina Mateu
- Balearic Health Service IbSalut Son Serra-La Vileta Healthcare Centre, Palma, Illes Balears, Spain
| | - Silvia Folch
- Catalan Institute of Health Cat-salut, DAP Camp de Tarragona, Tarragona, Catalunya, Spain
| | - Santiago Alegret
- Balearic Health Service IbSalut Son Serra-La Vileta Healthcare Centre, Palma, Illes Balears, Spain
| | - Jose Maria Coll
- Balearic Health Service IbSalut, Menorca Primary Care Management, Maó, Illes Baleares, Spain
| | - María Martín-Rabadán
- Balearic Health Service IbSalut, Can Misses Healthcare Centre Ibiza, Illes Baleares, Spain
| | - Isabel Socias
- Research Network on Chronicity, Primary Care, and Health Promotion (RICAPPS)-Balearic Islands Health Research Institute (IdISBa), Mallorca, Spain
- Balearic Health Service IbSalut, Manacor Healthcare Centre, Manacor, Illes Baleares, Spain
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Socias I, Leiva A, Pombo-Ramos H, Bejarano F, Sempere-Verdú E, Rodríguez-Rincón RM, Fiol F, Mengual M, Ajenjo-Navarro A, Do Pazo F, Mateu C, Folch S, Alegret S, Coll JM, Martín-Rabadán M, Vicens C. Evaluating the Implementation of a Multicomponent Intervention Consisting of Education and Feedback on Reducing Benzodiazepine Prescriptions by General Practitioners: BENZORED Hybrid Type I Cluster Randomized Controlled Trial. Int J Environ Res Public Health 2021; 18:7964. [PMID: 34360267 PMCID: PMC8345522 DOI: 10.3390/ijerph18157964] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/15/2021] [Accepted: 07/21/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND General practitioners (GPs) in developed countries widely prescribe benzodiazepines (BZDs) for their anxiolytic, hypnotic, and muscle-relaxant effects. Treatment duration, however, is rarely limited, and this results in a significant number of chronic users. Long-term BZD use is associated with cognitive impairment, falls with hip fractures, traffic accidents, and increased mortality. The BENZORED IV trial was a hybrid type-1 trial conducted to evaluate the effectiveness and implementation of an intervention to reduce BZD prescription in primary care. The purpose of this qualitative study was to analyze the facilitators and barriers regarding the implementation of the intervention in primary care settings. METHODS A qualitative interview study with 40 GPs from three Spanish health districts. Focus group meetings with GPs from the intervention arm of the BENZORED IV trial were held at primary healthcare centers in the three districts. For sampling purposes, the GPs were classified as high or low implementers according to the success of the intervention measured at 12 months. The Consolidated Framework for Implementation Research (CFIR) was used to conduct the meetings and to code, rate, and analyze the data. RESULTS Three of the 41 CFIR constructs strongly distinguished between high and low implementers: the complexity of the intervention, the individual Stage of Change, and the key stakeholder's engagement. Seven constructs weakly discriminated between the two groups: adaptability in the intervention, external policy and incentives, implementation climate, relative priority, self-efficacy, compatibility, and engaging a formally appointed implementation leader. Fourteen constructs did not discriminate between the two groups, six had insufficient data for evaluation, and eleven had no data for evaluation. CONCLUSIONS We identified constructs that could explain differences in the efficacy in implementation of the intervention. This information is relevant for the design of successful strategies for implementation of the intervention.
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Affiliation(s)
- Isabel Socias
- Healthcare Centre Manacor, Balearic Health Service IbSalut, 07500 Manacor, Spain;
- Balearic Islands Health Research Institute (IdISBa), 07120 Palma, Spain
| | - Alfonso Leiva
- Balearic Islands Health Research Institute (IdISBa), 07120 Palma, Spain
- Reseach Unit Mallorca, Balearic Health Service IbSalut, 07003 Palma, Spain
| | - Haizea Pombo-Ramos
- Primary Care Research Unit of Biscaia, Basque HealthCare Service Osakidetza, BioCruces Health Research Institute, 48903 Bizkaia, Spain;
| | - Ferran Bejarano
- Catalunya Health Services-CatSalut, DAP Camp de Tarragona, 43002 Tarragona, Spain; (F.B.); (M.M.); (S.F.)
| | - Ermengol Sempere-Verdú
- Paterna Healthcare Centre, Conselleria de Sanitat Universal i Salut Pública, 46980 Valencia, Spain; (E.S.-V.); (A.A.-N.)
| | - Raquel María Rodríguez-Rincón
- Pharmacy Department, Hospital Universitari Son Espases, Balearic Health Service IbSalut, 07120 Palma, Spain; (R.M.R.-R.); (F.D.P.)
| | - Francisca Fiol
- Balearic Islands Health Research Institute (IdISBa), 07120 Palma, Spain
- Son Serra-La Vileta Healthcare Centre, Balearic Health Service IbSalut, 07013 Palma, Spain; (F.F.); (C.M.); (S.A.); (C.V.)
| | - Marta Mengual
- Catalunya Health Services-CatSalut, DAP Camp de Tarragona, 43002 Tarragona, Spain; (F.B.); (M.M.); (S.F.)
| | - Asunción Ajenjo-Navarro
- Paterna Healthcare Centre, Conselleria de Sanitat Universal i Salut Pública, 46980 Valencia, Spain; (E.S.-V.); (A.A.-N.)
| | - Fernando Do Pazo
- Pharmacy Department, Hospital Universitari Son Espases, Balearic Health Service IbSalut, 07120 Palma, Spain; (R.M.R.-R.); (F.D.P.)
| | - Catalina Mateu
- Son Serra-La Vileta Healthcare Centre, Balearic Health Service IbSalut, 07013 Palma, Spain; (F.F.); (C.M.); (S.A.); (C.V.)
| | - Silvia Folch
- Catalunya Health Services-CatSalut, DAP Camp de Tarragona, 43002 Tarragona, Spain; (F.B.); (M.M.); (S.F.)
| | - Santiago Alegret
- Son Serra-La Vileta Healthcare Centre, Balearic Health Service IbSalut, 07013 Palma, Spain; (F.F.); (C.M.); (S.A.); (C.V.)
| | - Jose Maria Coll
- Menorca Primary Care Management, Balearic Health Service IbSalut, 07701 Maó, Spain;
| | - María Martín-Rabadán
- Can Misses Healthcare Centre Ibiza, Balearic Health Service IbSalut, 07800 Ibiza, Spain;
| | - Caterina Vicens
- Balearic Islands Health Research Institute (IdISBa), 07120 Palma, Spain
- Son Serra-La Vileta Healthcare Centre, Balearic Health Service IbSalut, 07013 Palma, Spain; (F.F.); (C.M.); (S.A.); (C.V.)
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Capel M, Ciudin A, Mareque M, Rodríguez-Rincón RM, Simón S, Oyagüez I. Cost-Effectiveness Analysis of Exenatide versus GLP-1 Receptor Agonists in Patients with Type 2 Diabetes Mellitus. Pharmacoecon Open 2020; 4:277-286. [PMID: 31338828 PMCID: PMC7248155 DOI: 10.1007/s41669-019-0171-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE The aim of this study was to assess the efficiency of exenatide 2 mg/week compared with other glucagon-like peptide-1 (GLP-1) receptor agonists (dulaglutide 1.5 mg/week, liraglutide 1.2 mg/day, liraglutide 1.8 mg/day and lixisenatide 20 μg/day) in adult patients with type 2 diabetes mellitus (T2DM) not adequately controlled on metformin alone from the perspective of the Spanish National Health System (NHS). METHODS Quality-adjusted life-years (QALYs) gained and total costs of each assessed drug combined with metformin (2 g/day) were estimated over a 40-year time horizon using the Cardiff Diabetes Model (based on UK Prospective Diabetes Study [UKPDS] 68 equations), which simulates disease progression considering the T2DM-related micro- and macrovascular complications, hypoglycaemia, nausea, body mass index (BMI) changes and treatment discontinuation due to adverse effects (AEs). Drug efficacy derived from an indirect comparison performed in a network meta-analysis. Patient characteristics were obtained from the literature. The baseline utility value (0.80) was derived from the PANORAMA study, applying utility decrements to micro- and macrovascular complications, hypoglycaemia episodes and changes in BMI. Treatment discontinuation due to AEs or poorly controlled diabetes (HbA1c > 7.5%) involved switching to second-line (basal insulin) or third-line (basal-bolus insulin) treatment. Total cost (€, 2018) included the costs of drug acquisition, hypoglycaemia, weight gain, micro- and macrovascular complications, nausea and treatment discontinuation due to AEs. An annual discount rate of 3% was applied to costs and outcomes. Deterministic and probabilistic sensitivity analyses (SA) were performed. RESULTS In base-case, exenatide 2 mg/week resulted in more QALYs (8.26) than dulaglutide 1.5 mg/week (8.19 QALYs), liraglutide 1.2 mg/day (8.10 QALYs), liraglutide 1.8 mg/day (8.20 QALYs) and lixisenatide 20 μg/day (8.13 QALYs). Total cost/patient was €20,423.27 (exenatide 2 mg/week), €22,611.94 (dulaglutide 1.5 mg/week), €21,065.97 (liraglutide 1.2 mg/day), €24,865.69 (liraglutide 1.8 mg/day) and €21,334.58 (lixisenatide 20 μg/day). Deterministic SA confirmed the robustness of the model. In the probabilistic SA, 95-99% of the 1000 Monte Carlo iterations performed were under a hypothetical willingness-to-pay threshold of €20,000/QALY gained. CONCLUSIONS Exenatide 2 mg/week would be a dominant strategy (more effective and less costly) versus the other GLP-1 receptor agonists assessed for the treatment of T2DM patients who are not adequately controlled on metformin alone.
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Affiliation(s)
| | | | - María Mareque
- Pharmacoeconomics and Outcomes Research Iberia (PORIB), Paseo Joaquín Rodrigo 4-I, Pozuelo de Alarcón, 28224, Madrid, Spain.
| | | | | | - Itziar Oyagüez
- Pharmacoeconomics and Outcomes Research Iberia (PORIB), Paseo Joaquín Rodrigo 4-I, Pozuelo de Alarcón, 28224, Madrid, Spain
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Castro-Manzanares M, do Pazo-Oubiña F, Rodríguez-Rincón RM. Prevalence of potential drug-drug interactions in outpatients on treatment with parenteral antineoplastic drugs. Int J Clin Pharm 2019; 41:1429-1433. [PMID: 31538281 DOI: 10.1007/s11096-019-00910-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 09/12/2019] [Indexed: 11/28/2022]
Abstract
Background As live expectancy and cancer incidence growing, polypharmacy in oncology patients is also increasing, raising the risk of developing potential drug-drug interactions.Objective To assess the prevalence of clinically relevant potential drug-drug interactions among cancer patients who receive parenteral treatment at our outpatient clinic. Method Retrospective observational study which included randomly selected patients who had received parenteral treatment from November 1st 2016 to January 31st 2017. Interactions were checked in 3 databases, and classified as clinically relevant or not and in three categories of severity: contraindicated, consider modification or monitor. Results A total of 273 patients were included; of which seventy three (26.7%) had at least one clinically relevant potential drug-drug interaction. Amongst them, 54 (74%) had at least one classified as monitor treatment, 50 (68.5%) as contraindicated and 26 (35.6%) as consider modification. The number of chronic prescriptions was associated with a higher risk of drug interactions. Conclusion Around one in four patients on treatment with parenteral antineoplastic drugs presented a clinically relevant potential drug-drug interaction. A systematic assessment of drug-drug interactions should be implemented to reduce the risk of clinically relevant drug-drug interactions.
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Affiliation(s)
- M Castro-Manzanares
- Pharmacy Department, Hospital Universitari Son Espases, Palma de Mallorca, Spain.
| | - F do Pazo-Oubiña
- Pharmacy Department, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - R M Rodríguez-Rincón
- Pharmacy Department, Hospital Universitari Son Espases, Palma de Mallorca, Spain
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Vicens C, Leiva A, Bejarano F, Sempere E, Rodríguez-Rincón RM, Fiol F, Mengual M, Ajenjo A, Do Pazo F, Mateu C, Folch S, Alegret S, Coll JM, Martín-Rabadán M, Socias I. Intervention to reduce benzodiazepine prescriptions in primary care, study protocol of a hybrid type 1 cluster randomised controlled trial: the BENZORED study. BMJ Open 2019; 9:e022046. [PMID: 30705235 PMCID: PMC6359733 DOI: 10.1136/bmjopen-2018-022046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Benzodiazepines (BZDs) are mainly used to treat anxiety and sleep disorders, and are often prescribed for long durations, even though prescription guidelines recommend short-term use due to the risk of dependence, cognitive impairment, and falls and fractures. Education of general practitioners (GPs) regarding the prescription of BZDs may reduce the overuse and of these drugs.The aims of this study are to analyse the effectiveness of an intervention targeted to GPs to reduce BZD prescription and evaluate the implementation process. METHODS AND ANALYSIS The healthcare centres in three regions of Spain (Balearic Islands, Catalonia and Community of Valencia) will be randomly allocated to receive a multifactorial intervention or usual care (control). GPs in the intervention group will receive a 2-hour workshop about best-practice regarding BZD prescription and BZD deprescribing, monthly feedback about their BZD prescribing practices and access to a support web page. Outcome measures for each GP are the defined daily dosage per 1000 inhabitants per day and the proportion of long-term BZD users at 12 months. Data will be collected from the electronic prescription database of the public health system, and will be subjected to intention-to-treat analysis. Implementation will be evaluated by mixed methods following the five domains of the Consolidated Framework For Implementation Research. ETHICS AND DISSEMINATION This study was approved by the Balearic Islands Ethical Committee of Clinical Research (IB3065/15), l'IDIAP Jordi Gol Ethical Committee of Clinical Research (PI 15/0148) and Valencia Primary Care Ethical Committee of Clinical Research (P16/024). The results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN28272199.
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Affiliation(s)
- Caterina Vicens
- Son Serra-La Vileta Healthcare Centre, Balearic Health Service Ib-Salut, Palma, Spain
- Instituto de Investigación Sanitaria de Baleares (IdISBa), Palma, Spain
| | - Alfonso Leiva
- Instituto de Investigación Sanitaria de Baleares (IdISBa), Palma, Spain
- Primary Care Reseach Unit, Balearic Health Service Ib-Salut, Palma, Spain
| | - Ferran Bejarano
- DAP Camp de Tarragona, Catalunya Health Services-CatSalut, Tarragona, Spain
| | - Ermengol Sempere
- Paterna Healthcare Centre, Conselleria de Sanitat Universal, Agència Valenciana de Salut, Valencia, Spain
| | | | - Francisca Fiol
- Son Serra-La Vileta Healthcare Centre, Balearic Health Service Ib-Salut, Palma, Spain
| | - Marta Mengual
- DAP Camp de Tarragona, Catalunya Health Services-CatSalut, Tarragona, Spain
| | - Asunción Ajenjo
- Paterna Healthcare Centre, Conselleria de Sanitat Universal, Agència Valenciana de Salut, Valencia, Spain
| | - Fernando Do Pazo
- Pharmacy Department, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - Catalina Mateu
- Son Serra-La Vileta Healthcare Centre, Balearic Health Service Ib-Salut, Palma, Spain
- Instituto de Investigación Sanitaria de Baleares (IdISBa), Palma, Spain
| | - Silvia Folch
- DAP Camp de Tarragona, Catalunya Health Services-CatSalut, Tarragona, Spain
| | - Santiago Alegret
- Son Serra-La Vileta Healthcare Centre, Balearic Health Service Ib-Salut, Palma, Spain
| | - Jose Maria Coll
- Menorca Primary Care Management, Balearic Health Service Ib-Salut, Mahón, Spain
| | | | - Isabel Socias
- Instituto de Investigación Sanitaria de Baleares (IdISBa), Palma, Spain
- Manacor Healthcare Centre, Balearic Health Service Ib-Salut, Manacor, Spain
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