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Reducing Benzodiazepine Prescribing in Older Veterans: A Direct-to-Consumer Educational Brochure

This quality improvement project used an educational brochure to help older veterans reduce their benzodiazepine use.
Federal Practitioner. 2018 September;35(9)a:36-43
September 4, 2018|Federal Practitioner
Margaret A. Mendes, PharmD;Jason P. Smith, PharmD;Jennifer Kryskalla Marin, PharmD;Mark Bounthavong, PharmD, MPH;Marcos K. Lau, PharmD;Juan l. Miranda, MHS;David Gray, PharmD;Maria Brown, PharmD;Peter Hauser, MD
Author and Disclosure Information

Dr. Mendes is a Pharmacist at the VA San Diego Healthcare System in California and Program Director of VISN 22 Academic Detailing Program at the Veterans Integrated Systems Network (VISN) 22 Network Office in Long Beach, California. Dr. Smith is Program Director of VISN 19 Academic Detailing Program in Glendale, Colorado. Dr. Marin is a VISN Pharmacy Benefits Management Data and Program Manager at the VISN 21 Network Office on Mare Island, California. Dr. Bounthavong and Dr. Lau are National Program Managers at the VHA Pharmacy Benefits Management Academic Detailing Service in Washington, DC. Mr. Miranda is a Research Assistant in the Division of Mental Health at the Long Beach VAMC in California. Dr. Gray was the VISN 22 Pharmacy Lead at the Veterans Integrated Systems Network (VISN) 22 Network Office in Long Beach, California. Dr. Brown is a Program Manager for the VISN 22 Academic Detailing Program. Dr. Hauser is the Director of the National VA Telemental Health Hub Long Beach and Psychiatrist in the Division of Mental Health at the Long Beach VAMC; Clinical Professor in the Department of Psychiatry and Human Behavior at the University of California in Irvine; and Clinical Professor in the Department of Psychiatry at the University of California in San Diego.
Correspondence: Dr. Hauser (peter.hauser2@va.gov).

Disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.

Quality Improvement Project 2

Of all the VISN 22 and VISN 21 veterans, 24,420 met the inclusion and exclusion criteria. Of these 24,420 veterans, 2,020 (8.3%) were in VISN 22 and received the EB between December 2014 and August 2015 (QIP-1), and 22,400 (91.7%) were in VISN 21 and did not receive the EB.

Naïve Results Before PS Matching. In the naïve analyses, a larger proportion of EB-exposed vs unexposed veterans discontinued BZD; in addition, reductions were 6.6%, 7.4%, and 9.5% larger for 6 to 9 months, 6 to 12 months, and 1 to 12 months after the index date, respectively (P < .0001 for all comparisons; Table 2).

After controlling for potential confounders, the naïve logistic regression analyses found EB exposure was significantly associated with 44%, 32%, and 42% increases in the odds of BZD discontinuation for 6 to 9 months, 6 to 12 months, and 1 to 12 months after the index date, respectively (Table 3).

Propensity Score Matching. Before matching, there were significant differences in baseline characteristics of veterans who met the inclusion and exclusion criteria, with few exceptions (eAppendices 2 and 3, ).

   After PSM, mean bias was reduced from 6.5% to 1.8%. A total of 2,632 veterans (1,316 in each group) matched according to PSM criteria.
  After matching, there were no significant differences in baseline characteristics of EB-exposed and EB-unexposed veterans (eAppendix 4). 

Propensity Score Matching Results. Inspection of PSs revealed good coverage across treatment groups on a histogram plot and a kernel density plot (eAppendices 5 and 6).

  Table 4 lists the results of the PSM approaches. Risk differences in discontinuing BZD ranged from 6.6% to 6.9% for 6 to 9 months and from 6.5% to 7.1% for 6 to 12 months, in both cases benefiting EB-exposed veterans. 
Regarding the secondary outcome, a higher proportion of EB-exposed versus -unexposed veterans (7.35%-8.92%) discontinued BZD between 1 and 12 months. All risk differences in the sensitivity analyses were significant at α = 0.05 (2-tailed).

Discussion

This QIP was the first to evaluate the impact of an EMPOWER-modeled DTC EB in a large, integrated health care system in the U.S. It was also the first to demonstrate potential benefits of a DTC EB designed for older veterans who are long-term BZD users. In this QIP, which mailed the EB to 3,896 veterans, 1,847 (47.4%) decreased their BZD dose, 458 (11.7%) tapered and then discontinued BZD, and 455 (11.7%) immediately discontinued BZD. The total percentage of veterans who discontinued BZD (23.4%; 913/3,896) was similar to the 27% reported in the EMPOWER trial.17 However, the risk difference between the 1,316 EB-exposed VISN 22 veterans (QIP-1) and the 1,316 EB-unexposed VISN 21 veterans in this QIP was significantly lower than the 23% risk difference in EMPOWER (though it still demonstrated a significantly larger reduction for EB-exposed veterans).17

Given this inclusion of all qualifying veterans from the catchment area studied in this QIP, and given the ethical and practical concerns, an RCT was not possible. Therefore, PSM methods were used to balance the covariates across treatment groups and thereby simulate an RCT.21,22,27 With use of the PSM approach, findings from the descriptive analysis were confirmed and potential selection bias reduced.

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