Original Research

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

Fed Pract. 2018 September;35(9):36-43

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Methods

Two QIPs were undertaken to determine the impact of DTC EB on BZD use in older veterans in the VHA.

Quality Improvement Project 1

Design. A retrospective cohort analysis was performed. The VISN 22 catchment area, which encompasses VA facilities and clinics in southern California and southern Nevada, serves about 500,000 veterans, a substantial proportion of whom are aged ≥ 65 years. Among these older veterans are active long-term BZD users, who were defined as having ≥ 60-day supply of BZD prescriptions dispensed within the past year. Each active long-term user with a BZD prescription released within 200 days before the index date (the date the user was to meet with the prescribing physician) was mailed an EB 2 to 8 weeks in advance of the visit. Excluded from analysis were veterans with a schizophrenia, spinal cord injury, or seizure disorder diagnosis recorded in both their inpatient and outpatient medical records; veterans seen by Palliative Care within the past year; and veterans who died before analysis was completed.

Education Brochure. The EB for VISN 22 (Figure 1, see

eappendix_1.pdf

) was almost identical to the EB used in the EMPOWER trial.¹⁷ The language of the EMPOWER brochure was retained, but veteran-related images were added, and the BZD taper schedule was removed. Tannenbaum and colleagues incorporated constructivist learning into the Test Your Knowledge section of the EB.

Users interact with this section, acquire new knowledge, and reflect on what they already know. Also incorporated is cognitive dissonance, which motivates users to change by confronting inconsistencies in what they know about BZD safety and efficacy. The EB mailed to veterans included a peer champion’s story of successful discontinuation of BZDs. Reading this story is thought to lead to self-identification with the champion’s success, self-efficacy, and confidence in discontinuing BZDs.

Patients. The sample consisted of all veterans identified as meeting the inclusion criteria and being enrolled in VISN 22. The EB was mailed once to veterans on a rolling basis from December 2014 to February 2016. Change in BZD use was analyzed only after 9 to 24 months had passed since the index appointment with the prescribing physician. This period included 12 weeks for BZD taper and then 6 months after taper.

Analysis. For each veteran, monthly mean lorazepam equivalent (LE) was calculated using as many as 12 fills before the index date. Average daily dose of LE was calculated by dividing the sum of LE from all included prescriptions by total number of days between the first fill and the index date. The BZD prescription fills were evaluated after the index date. Veterans who received at least 1 prescription after the index date but then had no BZD prescription activity in VA clinics for 3 consecutive months during the 9-month observation period were recorded as having tapered and then discontinued BZD. Veterans who had no BZD prescription activity in VA clinics after the index date and during the 9-month observation period were recorded as having discontinued BZD without tapering. For veterans who had BZD prescription activity in VA clinics after the index date and during the 9-month observation period, mean LE was calculated by dividing the total LE for BZD prescriptions after the index date by number of days from the first fill after the index date to the date of analysis.