Effectiveness of a Joint General Practitioner-Pharmacist Intervention on Benzodiazepine Deprescribing in the Elderly (BESTOPH-MG)

Evaluation of the Effectiveness of a Joint General Practitioner-Pharmacist Intervention on the Implementation of Benzodiazepine Deprescribing in the Elderly (BESTOPH-MG Trial): Protocol for a Cluster-randomized Controlled Trial

Benzodiazepines or related drug (BZDR) are consumed for hypnotic or anxiolytic purposes in most cases. The consequences of BZDR are multiple with an increased risk of daytime sedation, balance disorders leading to falls and fractures, cognitive disorders, road accidents and dementia. Given their comorbidities, physiological changes, and multiple medications, the elderly are more at risk of suffering from BZDR adverse events.

Interprofessional collaboration has shown efficacy in improving prescribing appropriateness and may affect patients outcomes positively. Morever, motivational interviews (MI) may reduce the extent of substance abuse compared to no intervention.

Study Overview

• Status: Not yet recruiting
• Conditions: Anxiety; Deprescribing; Elderly; Benzodiazepine Dependence; Primary Care; Health Plan Implementation
• Intervention / Treatment: Behavioral: GP - pharmacist collaboration and pharmacist motivational interviewing

Detailed Description

According to a 2017 report from the French National Agency for the Safety of Medicines and Health Products (ANSM), 13.4% of the French population used a benzodiazepine or related drug (BZDR) at least once in 2015. These drugs are consumed for hypnotic or anxiolytic purposes in most cases. As per the recommendations, BZDR should not be prescribed for more than 28 days when for hypnotic use and for 8 to 12 weeks, including withdrawal, when for anxiolytic purpose. Indeed, these drugs have shown a real, but mediocre, short-term efficacy on anxiety and sleep disorders. Moreover, their long-term effectiveness is almost nil. However, the literature shows that nearly one patient out of six taking a BZDR is a long-term user and that the proportion of patients for whom the indication is questionable can reach 2/3. The consequences of BZDR are multiple with an increased risk of daytime sedation, balance disorders leading to falls and fractures, cognitive disorders, road accidents and dementia. Also, given their comorbidities, physiological changes, and multiple medications, the elderly are more at risk of suffering from BZDR adverse events, like falls, driving accidents, dementia or even death. The majority of patients are unaware of these potential risks and continue to use these medications over the long term. They overestimate the benefits of BZDR and underestimate their harmful effects. The consequences are substantial, both from a health and financial perspective.

At the national level, numerous actions have been taken by the health authorities to reduce the use of BZDR: information for health professionals, pictograms on drug boxes, recommendations by health authorities, incentive measures by the Health Insurance services, or else health surveillance and regulatory measures to control prescribing. However, despite these numerous initiatives, the consumption of BZDR remains too high, even emphasized by the pandemic, and their deprescribing is struggling to be implemented in real life. Literature showed that many levers can facilitate the implementation of actions for the proper use of drugs. Interprofessional collaboration has shown efficacy in improving prescribing appropriateness and may affect patients outcomes positively, as shown by many recent systematic reviews and meta-analysis. General practitioners (GPs) who do not feel fully capable of implementing actions to deprescribe BZDR if they have to rely solely on guidelines, and because of the lack of time to re-evaluate these treatments. Yet, current international deprescribing studies remain based on actions only directed at the prescriber. Collaboration between two primary care professionals therefore appears to be a solution for implementing a medical decision to stop treatment. In addition, GPs are faced with a population which is very often reluctant to stop for fear of a return of anxiety or insomnia. In this context, another lever usable to achieve the implementation of deprescribing is the use of techniques that allow the patient to accept the physician's intervention. As such, motivational interviews (MI) may reduce the extent of substance abuse compared to no intervention. Developing and promoting training for healthcare professionals in MI may be a simple and pragmatic implementation strategy to reduce BZDR use.

• Study Type: Interventional
• Enrollment (Anticipated): 400
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Jean-François HUON, Pharm.D PhD; Phone Number: 332 0244768074; Email: jeanfrancois.huon@chu-nantes.fr
• Study Contact Backup: Name: Jean-Pascal Fournier, Professor; Email: jean-pascal.fournier@univ-nantes.fr

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 65 years and older (Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• outpatients aged 65 and over
• followed by the general practitioner and the pharmacist of the GP-PO pair
• having a prescription for an anxiolytic or hypnotic BZDR prescribed at least 4 times in the past year
• the last prescription being less than 3 months old
• having been dispensed monthly during the last 3 months
• affiliated to a social security scheme
• and having given consent to participate in the research.

Exclusion Criteria:

• patients living in an institution
• participating in a clinical trial
• with epilepsy
• active depression
• uncontrolled mental disorders
• unable to participate in an interview or answer a questionnaire (demented, non-French speaking, illiterate, deaf, ...)
• under guardianship
• with a dystonic syndrome
• and patients who are not sufficiently autonomous to carry out the steps inherent in the study

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: GP - pharmacist collaboration and pharmacist motivational interviewing; Once randomized, the patient will have three motivational interviews with their pharmacist. Each time, a report will be sent to the GP.	Behavioral: GP - pharmacist collaboration and pharmacist motivational interviewing; Patients in the GP-CP clusters randomized to the intervention arm will be offered a joint GP-CP deprescribing intervention by their GP.; After the encounter, the patients will go to the pharmacy to get their medication dispensed. They will be given education materials. The pharmacist will plan with the patients 3 Motivational Interviews which will address the risks of using BZDR, and the benefits and modalities of stopping them. The pharmacists will receive a 2-day training course in MI. They will be given guidelines on BZDR deprescribing. If required, the pharmacists will be supported in their first MI.; Following each interview, the pharmacist will inform the GP by means of a formalized report of the points discussed. The pharmacist will inform the GP of the patient's choice or not to get involved in a deprescribing process and of the protocol followed. The objective of this exchange is to formalize the joint GP-CP intervention and to secure the deprescribing of BZDR.
No Intervention: Usual Care; The patient is handled by his GP and the pharmacist as usual (medical encounter plus medication dispensation)

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Appropriateness measured by sociological interviews of patients, general practicioners and pharmacists and pharmacists observations	Four days of observations will be conducted with pharmacists who have just been trained in MI to study, in action, how they conduct their first interviews with the elderly. These same pharmacists will be observed a second time at the end of the study, to see how their approach to MI has evolved. A first wave of ten semi-structured interviews will be conducted with elderly patients who have already been seen by their pharmacist, to see what effects the pharmacist has had on their representations of BZDR and on their consumption. Finally, three focus groups will be carried out, one with CPs, one with GPs and one with pairs.	3 to 6 months after the beginning of the enrollment period and 12 months after the end of the enrollment period

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Acceptability 1	Number of clusters included / Number of clusters planned measured by logbooks	3 months after last inclusion
Acceptability 2	Reason for pharmacists and general practitioners' refusal assesed by individual interviews	within 6 months after refusal
Acceptability 3	Number of patients included / Number of patients eligible measured by logbooks	3 months after last inclusion
Cost-Utility analysis assessed following the Haute Autorité de Santé 2020 recommendations	A Cost-Utility Analysis (CUA) expressed as a cost per Quality Adjusted Life Year (QALY) will be performed from a collective perspective and with a time horizon of 12 months	12 months after the last inclusion
Fidelity 1	Proportion of pairs completing the study measured through a logbook	12 months after the last inclusion
Fidelity 2	Proportion of patients who actually made appointments with the pharmacist measured through a logbook.	12 months after the last inclusion
Fidelity 3	Number of motivational interviews measured through a logbook.	6 months after the last inclusion
Fidelity 4	Number of reporting made by the pharmacist to the GP will be measured through a logbook.	6 months after the last inclusion
BZDR consumption	Cessation or reduction of BZDR use at 12 months from inclusion measured using the National Health Data System. Proportion of patients no longer being dispensed BZDR at 10 months after enrollment, with the last two months (10 to 12 months)	10 to 12 months after enrollment in the study
Anxiety	Anxiety measured by General Anxiety Disorder (GAD-7)	6 and 12 months after enrollment
Insomnia	Quality of sleep measured by Insomnia Severity Index (ISI)	6 and 12 months after enrollment
Attachment to BZDR	Attachment to BZDR measured by Benzodiazepine Cognitive Attachment Scale (ECAB) scale at 6 and 12 months. Score ranges from 0 to 10. A score ≥ 6 allows	6 and 12 months after enrollment
Reported Quality of life of patients	Quality of life measured by EQ-5D-5L questionnaire at 6 and 12 months. A total of 3125 possible health states is defined. Each state is referred to by a 5-digit code.	6 and 12 months after enrollment
Autonomy	Autonomy measured by Instrumental Activities of Daily Living (IADL) at 6 and 12 months. The scale ranges from 0 to 8, with 0 indicating complete dysautonomia and 8 indicating complete autonomy.	6 and 12 months after enrollment

Collaborators and Investigators

• Sponsor: Nantes University Hospital
• Collaborators: Université de Nantes
• Investigators: Principal Investigator: Jean-François HUON, Pharm.D PhD, CHU Nantes

Study record dates

Study Major Dates

• Study Start (Anticipated): March 15, 2023
• Primary Completion (Anticipated): September 15, 2025
• Study Completion (Anticipated): September 15, 2025

Study Registration Dates

• First Submitted: February 10, 2023
• First Submitted That Met QC Criteria: March 9, 2023
• First Posted (Actual): March 13, 2023

Study Record Updates

• Last Update Posted (Actual): March 13, 2023
• Last Update Submitted That Met QC Criteria: March 9, 2023
• Last Verified: February 1, 2023

More Information

Terms related to this study

• Keywords: Primary care; elderly; deprescribing; benzodiazepine; collaborative practice; health plan implementation
• Other Study ID Numbers: RC21_0357

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No