Benzodiazepine and hypnotics (BDZ) are meant to be used short-term for anxiety and insomnia.
The legacy prescribing habit had resulted in BDZ being used longer than recommended. In our practice, we aimed to engage with all patients taking long term BDZ to support their reliance on BDZ and to reduce their risk of cognitive impairment and falls as described in NICE Key Therapeutic Topic - Hypnotics. Practice described in this example is also relevant to NICE's guideline for medicines optimisation (NG5).
Example
Aims and objectives
The aim of the project is to reduce the practice prescribing on benzodiazepine/hypnotics (BDZ) and to reduce the risks of cognitive impairment and sleep to patients taking BDZ long term.
Reasons for implementing your project
The practice resides in a county town with a section of its population living in deprivation. From historical prescribing habits, benzodiazepines and hypnotics (BDZ) were used for the management of anxiety and insomnia for longer than the recommended 4-6 weeks period. This had resulted in a group of patients, especially those with long term mental health issues and the elderly receiving long term BDZ exposing them to a higher risk of cognitive impairment and falls.
At the start of the project in October 2017, the quarterly average daily quantity (ADQ) of hypnotics prescribed per 1000 STAR PU for the practice was 123 whilst the average daily quantity (ADQ) for the CCG was 225 per 1000 Specific Therapeutic group Age-sex Related Prescribing Unit (STAR PU). Although we are prescribing less than the CCG average, we still aimed to optimise patient's medication. Thereby, we decided to engage with all patients taking long term BDZ to support them to reduce or to stop their reliance on BDZ and to provide alternative management plans for their condition.
How did you implement the project
A project lead team consisting of a General Practitioner ST3 and a practice pharmacist was formed to prepare a practice policy on benzodiazepine/hypnotics prescribing which was based on NICE key therapeutic topic and the Ashton Manual. This document became the fundament to gain buy-in from the rest of the prescribers in the practice as well as the supporting tool to be used during consultations with patients during the project.
Patients taking long term BDZ were determined (patients with epilepsy and end of life were excluded) and a letter stating the risk of BDZ was sent to the patients inviting to get in touch with the practice to discuss potentially stopping. Patients who did not respond to the initial invitation letter was followed up with a further letter after a month. During the consultation, shared decision making was done with the patient to determine the timing and method of reducing BDZ. Consultations were conducted mainly by the project lead team either face to face or over the telephone depending on the patient's preference.
The main challenges include:
- Getting prescribers in the practice to support the initiatives and to prescribe within national guidance in the future;
- Conducting challenging consultations with patients
- Keeping the momentum of the project going; and
- The General Practitioner ST3 left the practice after completing planned training after three months of project.
To overcome the challenges,
- (1 & 3) the new BDZ prescribing policy was shared with the entire practice team and the impact of the project was shared regularly to keep the entire team informed and engaged.
- (2) Using the principle of shared decision making helped in overcoming the challenges during the consultation. Patients who did not want to make any changes were given more time (1-6 months) before having a follow-up discussion.
- (4) this became a natural end of the active stage of the project and the momentum was kept by incorporating BDZ optimisation into routine medication reviews by the practice pharmacists. Any new patients joining the practice with BDZ will also have a consultation with the practice pharmacists team to review the need for BDZ.
Key findings
The active stage of the project, i.e the initial consultation stage, took three months (October 2017 to December 2017).
Ongoing medication reviews were conducted by practice pharmacists.
At the end of the active stage:
- Initial letters were sent: n=134
- Consultation made: n=103 (76%)
- Follow up letter sent: n=31
- BDZ stopped: n=21 (15%)
- Agreed to reduce: n=21 (15%)
ADQ/1000 Hypnotic STAR PU Oct-Dec 2017: 113 (- 8.13%) Outcome of ongoing medication reviews post active stage of the BDZ deprescribing project (ADQ/1000 Hypnotic STAR PU) : Jan-Mar 2018: 83 (-32.52% ) May -July 2018: 80 (-34.96%) Jan-Mar 2019: 54 ( -56.10%)* * During the same period, CCG ADQ/100 Hypnotic STAR PU had reduced by 12%.
Key learning points
- Engagement - every person in the practice needs to be on board even if not actively involved in the project.
- Cultural change - DO NOT prescribe or - prescribe with an END GAME.
- Every contact counts, first contact counts even more - any new patient joining the practice with BDZ will have a medication review - any new clinician joining the practice will be briefed on the practice BDZ initiative.