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Evaluation of a benzodiazepine deprescribing quality improvement initiative for older adults in primary care

Chae S, Lee E, Lindenberg J, Shen K, Anderson TS. Evaluation of a benzodiazepine deprescribing quality improvement initiative for older adults in primary care. J Am Geriatr Soc. 2023 Dec 26. doi: 10.1111/jgs.18728. Epub ahead of print. PMID: 38147454.

This study, conducted at a large US academic medical center, aimed to evaluate the impact of a low-intensity benzodiazepine deprescribing initiative in primary care involving individuals aged 65 or older. The primary objective was to evaluate patient and clinician engagement challenges within this initiative, highlighting the importance of understanding these challenges for future interventions aimed at encouraging proactive deprescribing conversations.

The low-intensity benzodiazepine deprescribing quality improvement program was implemented in a large academic primary care clinic in Massachusetts between February and April 2022. The target population comprised adults aged 65 and older with at least one prescription for benzodiazepines from primary care physicians (PCPs) in the previous year, excluding those with short-term prescriptions. The program consisted of two phases: outreach to PCPs, providing opt-out opportunities and optional educational sessions, and subsequent outreach to eligible patients via customized letters. These letters conveyed information on benzodiazepine risks and encouraged discussions with PCPs or the clinic’s “Safe Prescribing Team.” The study also assessed 12-month outcomes for patients initiating a taper, including complete discontinuation, maintaining a reduced dose, or returning to the original dose.

The analysis involved 371 participants aged 65 and older, with a mean age of 72 years, 57% female, and 84% White. Within 90 days of outreach, 53% (174 patients) had a clinical encounter or pharmacist conversation, and 26% (97) had documented discussions about benzodiazepines, with 36% (35) specifically discussing deprescribing. Among the 35 who had a deprescribing conversation, 71% (25) initiated a taper, and by 12 months, 64% (16) maintained a lower benzodiazepine dose or had stopped the drug entirely, while 36% (9) returned to the original dose. The study highlighted challenges in PCP engagement, with only one participating in deprescribing training. Strengths include a combined patient- and clinician-outreach method and 12-month outcome assessment. However, limitations include the single-center setting’s potential lack of generalizability and the absence of a control group. The study emphasizes the need for more intensive efforts to overcome barriers to benzodiazepine deprescribing in primary care.

Author Timothy Anderson reflects on how they envision the findings from this study contributing to broader efforts in shaping policy or clinical guidelines related to benzodiazepine use in older adults, with the increasing focus on benzodiazepine deprescribing in national quality metrics;

“Quality measurement comes with the potential to increase attention to the risks of benzodiazepines use for older adults and to increase adoption of deprescribing, however it also comes with risks of unintended consequences. If clinics do not have real-world models for how to engage patients in conversations about deprescribing or how to safely deprescribe, there is a risk that an uninformed push to deprescribe could undermine patient trust or result in overly rapid tapering and risk benzodiazepine withdrawal. Our findings suggest that a simple one-time mailing about deprescribing may engage motivated patients but is not sufficient to engage a substantial portion of patients. Hopefully, this helps inform conversations between payors and health systems about what resources they will need to provide clinicians and practices to safely encourage deprescribing more broadly.”

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