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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Study Limitations

The less robust risk difference found in this QIP has several possible explanations. The authors’ use of a DTC EB coincided with a national VA effort to reduce older veterans’ use of BZDs and other inappropriate medications. For instance, during the study period, academic detailing was being implemented to reduce use of BZDs, particularly in combination with opioids, across VHA facilities and clinics. (Academic detailing is a pharmacy educational outreach program that uses unbiased clinical guidelines to promote physicians’ safety initiatives and align prescribing behavior with best practices.^18-20) However, QIP-2 results and PS analysis of a subgroup of the original sample suggest that EB-exposed veterans were significantly more likely than were their unexposed counterparts were to discontinue BZD. To an extent, this analysis controlled for these other efforts to reduce BZD use in VHA clinics and can be considered a study strength.

Another limitation is the study design, which lacked a control group and did not consider the possibility that some facility or clinic physicians might influence others. Although the region variable was controlled for in PSM, the authors did not capture facility characteristics, including frequency of prescribing BZD and use of a protocol for enforcing the Beers criteria. Such confounders might have influenced outcomes. Unlike the EMPOWER trial,¹⁷ this QIP did not assess or exclude cognitively impaired veterans. It is reasonable to assume that these veterans might not understand some EB messages and consequently might fail to engage their physicians. Failure to initiate discussion with a physician would attenuate the impact of the EB.

Study Strengths

A strength of this QIP was its use of a DTC EB in a large, regional sample of older veterans in a real-world clinical setting. In addition, the study group (EB-exposed veterans) and the comparator group (EB-unexposed veterans) were from similar geographic areas (primarily California and Nevada).

Conclusion

Results of this study suggest that a DTC EB, designed to reduce BZD use among older veterans, was effective in helping patients lower their BZD dose and discontinue BZD. The likelihood of discontinuing BZD 9 and 12 months after the index date was significantly higher for veterans who received an EB modeled on the EMPOWER educational brochure than for a comparator group of veterans who did not receive the EB and were receiving care during the same observation period. In the future, it would be beneficial to use a design that controls for physician exposure to academic detailing focused on BZD reduction and that accounts for the cluster effects of facility practice. Despite these limitations, this QIP is the first real-world empirical example of using an EMPOWER-modeled DTC EB to decrease BZD use among older veterans. Furthermore, these results suggest that a DTC EB can be used to target other high-risk prescription drugs, such as opioids, particularly if alternative treatment options can be provided.

Acknowledgments
Dr. Hauser thanks Cathy, Anika, Katia, and Max Hauser, and Alba and Kevin Quinlan, for their support. In memory of Jirina Hauser, who died on Mother’s Day, May 14, 2017, at the age of 100.