General practitioners prescribing of benzodiazepines in Western Primary Care: metasynthesis of qualitative studies

Introduction: Benzodiazepines are widely prescribed in primary care to treat conditions such as insomnia, anxiety and chronic back pain. Despite guidance stating that they should only be used short-term in the UK and elsewhere, numerous studies have shown that these drugs are being prescribed for extended periods. This has led patients, policymakers and researchers to question why this is the case, what influences a clinician’s decision whether or not to initiate, continue or withdraw a benzodiazepine prescription and how inappropriate prescribing might be addressed. We aimed to explore GPs’ experiences and perceptions of benzodiazepine prescribing by conducting a meta-synthesis of qualitative studies to develop an explanatory framework of processes underlying benzodiazepine prescribing. Methods: A systematic review of the literature was conducted to identify studies using qualitative methods which examined GPs’ experiences of prescribing benzodiazepines in a primary care setting. We included studies published in Western settings in a European language, between January 1990 and August 2011. Studies were critically appraised using the Critical Appraisal Skills Programme Checklist (CASP). A thematic synthesis approach was used to synthesise findings. Results: A total of eight studies were included in the meta-synthesis. Analysis produced an explanatory framework detailing factors underlying benzodiazepine prescribing. This revealed that benzodiazepine prescribing is viewed as a complex task, and prescribing decisions are influenced by interaction between the following: the context within which benzodiazepine prescribing is taking place, the changing role and responsibility of GPs, variation in GPs’ attitudes towards benzodiazepines, a perceived lack of alternative treatment options, GPs’ perception of patient expectations, and the relationship between GPs and patients. Conclusion: Our findings help to explain reasons for prescribing and define key recommendations for improving adherence to clinical guidelines advocating short-term use of benzodiazepines including: education and training of professionals on benzodiazepine prescribing and withdrawal, improved communication with patients, and an increase in the availability of alternative treatment options

Clinicians’ experiences and perceptions of benzodiazepine prescribing in Western primary care settings: systematic review and meta-synthesis

The problem: Benzodiazepines are known to have limited long-term therapeutic benefits, and to have adverse effects including addiction. Consequently, clinical guidelines advocate strictly short-term use. However, benzodiazepines continue to be prescribed for extended periods for conditions such as insomnia, anxiety and chronic back pain. Whilst research suggests that this may be due to factors such as patient demographics, GP attributes and general practice structures, clinicians’ experiences, beliefs and attitudes have also been shown to impact on their prescribing practices. Qualitative studies have the potential to better understand this clinical area by revealing the processes underlying prescribing practices. The approach: We conducted a systematic review and meta-synthesis of qualitative research exploring GPs’ experiences and perceptions of benzodiazepine prescribing. Included studies needed to use both qualitative data and analysis, contain GP or nurse generated data on their experiences of prescribing benzodiazepines in Western primary care settings, and have been published between January 1990 and August 2011 in a European language. Findings from included studies were synthesised using the thematic synthesis approach in order to build an explanatory model of processes underlying prescribing practice. Findings: Eight studies were included in the review. Prescribing decisions were complex, uncomfortable and demanding, particularly within the constraints of daily practice. Overall, GPs showed ambivalent attitudes towards benzodiazepine prescribing, and inconsistently applied management strategies for their use. Variation in prescribing practice was attributed to: the changing context within which GPs work; the role and responsibility of the GP; their attitudes towards benzodiazepines and other interventions; the perceived lack of alternative treatments; and GPs’ relationships with their patients and perceptions of their patients’ expectations. Different challenges are faced in managing initiation, continuation and withdrawal of benzodiazepines. Consequences: The explanatory model produced from the themes identified within the metasynthesis can be used to propose ways to improve adherence to clinical guidelines which recommend short-term use of benzodiazepines only. Recommendations include: increasing education and training to change clinicians’ understanding and perceptions of both benzodiazepines and alternative treatments; increasing the availability of alternative treatments; encouraging clinicians to directly explore patients’ expectations with them to meet their expectations for clinical improvements

A meta-synthesis of clinicians’ experiences and perceptions of benzodiazepine prescribing: implications for the integration of health services

Purpose: To investigate clinicians’ experiences and perceptions of benzodiazepine prescribing. Theory: To develop a theory for improving benzodiazepine prescribing practice, exploring implications for an integrated health services approach. Methods: A multidisciplinary team conducted a systematic review and metasynthesis of qualitative studies published in Western settings between January 1990 and August 2011 using ‘thematic synthesis’. Study quality was assessed using the Critical Appraisal Skills Programme (CASP) checklist. Findings: We included eight studies. Prescribing was complex and demanding within the constraints of daily practice, leading to variable prescribing by individual practitioners and between GPs. Decisions were influenced by the changing context of GPs’ work, their views of their own role and responsibilities, and their perceptions of benzodiazepines and alternative treatment options. Clinical practice was also influenced by GPs’ perception of patient expectations, the relationship with their patient, and whether they were initiating, continuing or withdrawing benzodiazepines. Discussion: Benzodiazepine prescribing could be improved in line with current guidance through improved communication with patients, ensuring GPs accept responsibility for deciding whether or not to continue prescribing for patients who were previously managed in secondary care, education and training of primary and secondary care clinicians on other treatments and greater provision of alternatives to drugs

A tailored e-learning gives long-term changes in determinants of GPs’ benzodiazepines prescribing: a pretest-posttest study with self report assessments

Objective: Despite guidelines and campaigns, general practitioners (GPs) continue to overprescribe benzodiazepines (BZDs). New approaches to improve prescribing are needed. Using behavior change techniques and tailoring interventions to user characteristics are vital to promote behavior change. This study evaluated the impact of a tailored e-learning module on factors known to determine BZD prescribing within GPs. Design: A pretest-posttest study design with three self-report assessments concerning determinants of BZD prescribing: at baseline, immediately after the module (short term) and six months after completion (long term). Setting: Flanders (Belgium) Intervention: A tailored e-module that focuses on avoiding initial BZD prescriptions and using psychological interventions as an alternative. Subjects: 244 GPs Main outcome measures: Assessed determinants include GPs’ attitudes concerning treatment options, perceptions of the patient and self-efficacy beliefs. Readiness to adhere to prescribing guidelines was evaluated through assessing motivation, self-efficacy and implementability of non-pharmacological interventions. Results: A significant and durable impact on determinants of BZD prescribing was observed. GPs underwent desirable changes in attitudes, perceptions and self-efficacy beliefs and these changes remained significant six months later. Conclusion: Tailoring an e-intervention to target group characteristics appears to be successful in promoting behavioral change in experienced GPs. Significant and lasting changes were observed in determinants of prescribing BZDs

Stakeholders’ views and experiences on implementing new diagnostics in primary care to support management of community-acquired acute respiratory tract infections:a qualitative study

Background: The majority of antibiotics are prescribed in primary care for respiratory tract infections. Point-of-care tests (POCTs) for the management of community-acquired acute respiratory tract infections (CA-ARTI) have been developed to help optimize antibiotic prescribing. While some countries in Europe have adopted these tests in primary care settings, most have not. Stakeholders, such as policy-makers, regulators, the diagnostic industry, and scientific associations, have roles in the implementation of new diagnostics in primary care. The aim of this study is to explore these stakeholders’ views and experiences, and identify areas of unmet need relating to POCT implementation.Methods: Stakeholders were recruited using purposive sampling and snowballing. Between March 2021 and May 2022, semi-structured interviews were conducted online with stakeholders in Belgium, the UK and from European Union (EU) -level organizations. Interviews were audio recorded and transcribed verbatim. Transcripts were analysed inductively and deductively using thematic analysis.Results: Twenty-six stakeholders participated: eleven from EU-level organizations, seven from Belgium, and eight from the UK. Five themes were identified. Stakeholders felt a balance of top-down and bottom-up approaches were an optimal strategy to the implementation of POCTs. Stakeholders stressed the need to engage with clinicians to act as champions for tests to help raise awareness and generate new evidence on how tests are used. While acknowledging the potential of POCTs for improving patient outcomes and impacting antibiotic prescribing behavior, some raised concerns on how tests would be used in practice and wished to see national data on effectiveness. COVID-19 catalyzed the use of tests, but stakeholders were pessimistic that processes for approving diagnostics during the pandemic would be replicated in the future.Conclusion: Stakeholders provided recommendations for research and practice. Robust reimbursement policies could alleviate financial burden from clinicians and patients, encouraging practices to adopt POCTs. Industry is likely to benefit from engaging as early on as possible with other stakeholders. Due to uncertainty among stakeholders on the impact of POCTs on antibiotic prescribing, further evidence is needed to understand how practices adopt POCTs and the implications for stewardship. Monitoring how POCTs are used can inform future guidelines on successful diagnostic implementation.</p

Stakeholders’ views and experiences on implementing new diagnostics in primary care to support management of community-acquired acute respiratory tract infections:a qualitative study

Background: The majority of antibiotics are prescribed in primary care for respiratory tract infections. Point-of-care tests (POCTs) for the management of community-acquired acute respiratory tract infections (CA-ARTI) have been developed to help optimize antibiotic prescribing. While some countries in Europe have adopted these tests in primary care settings, most have not. Stakeholders, such as policy-makers, regulators, the diagnostic industry, and scientific associations, have roles in the implementation of new diagnostics in primary care. The aim of this study is to explore these stakeholders’ views and experiences, and identify areas of unmet need relating to POCT implementation.Methods: Stakeholders were recruited using purposive sampling and snowballing. Between March 2021 and May 2022, semi-structured interviews were conducted online with stakeholders in Belgium, the UK and from European Union (EU) -level organizations. Interviews were audio recorded and transcribed verbatim. Transcripts were analysed inductively and deductively using thematic analysis.Results: Twenty-six stakeholders participated: eleven from EU-level organizations, seven from Belgium, and eight from the UK. Five themes were identified. Stakeholders felt a balance of top-down and bottom-up approaches were an optimal strategy to the implementation of POCTs. Stakeholders stressed the need to engage with clinicians to act as champions for tests to help raise awareness and generate new evidence on how tests are used. While acknowledging the potential of POCTs for improving patient outcomes and impacting antibiotic prescribing behavior, some raised concerns on how tests would be used in practice and wished to see national data on effectiveness. COVID-19 catalyzed the use of tests, but stakeholders were pessimistic that processes for approving diagnostics during the pandemic would be replicated in the future.Conclusion: Stakeholders provided recommendations for research and practice. Robust reimbursement policies could alleviate financial burden from clinicians and patients, encouraging practices to adopt POCTs. Industry is likely to benefit from engaging as early on as possible with other stakeholders. Due to uncertainty among stakeholders on the impact of POCTs on antibiotic prescribing, further evidence is needed to understand how practices adopt POCTs and the implications for stewardship. Monitoring how POCTs are used can inform future guidelines on successful diagnostic implementation.</p

Stakeholders’ views and experiences on implementing new diagnostics in primary care to support management of community-acquired acute respiratory tract infections:a qualitative study

Background: The majority of antibiotics are prescribed in primary care for respiratory tract infections. Point-of-care tests (POCTs) for the management of community-acquired acute respiratory tract infections (CA-ARTI) have been developed to help optimize antibiotic prescribing. While some countries in Europe have adopted these tests in primary care settings, most have not. Stakeholders, such as policy-makers, regulators, the diagnostic industry, and scientific associations, have roles in the implementation of new diagnostics in primary care. The aim of this study is to explore these stakeholders’ views and experiences, and identify areas of unmet need relating to POCT implementation.Methods: Stakeholders were recruited using purposive sampling and snowballing. Between March 2021 and May 2022, semi-structured interviews were conducted online with stakeholders in Belgium, the UK and from European Union (EU) -level organizations. Interviews were audio recorded and transcribed verbatim. Transcripts were analysed inductively and deductively using thematic analysis.Results: Twenty-six stakeholders participated: eleven from EU-level organizations, seven from Belgium, and eight from the UK. Five themes were identified. Stakeholders felt a balance of top-down and bottom-up approaches were an optimal strategy to the implementation of POCTs. Stakeholders stressed the need to engage with clinicians to act as champions for tests to help raise awareness and generate new evidence on how tests are used. While acknowledging the potential of POCTs for improving patient outcomes and impacting antibiotic prescribing behavior, some raised concerns on how tests would be used in practice and wished to see national data on effectiveness. COVID-19 catalyzed the use of tests, but stakeholders were pessimistic that processes for approving diagnostics during the pandemic would be replicated in the future.Conclusion: Stakeholders provided recommendations for research and practice. Robust reimbursement policies could alleviate financial burden from clinicians and patients, encouraging practices to adopt POCTs. Industry is likely to benefit from engaging as early on as possible with other stakeholders. Due to uncertainty among stakeholders on the impact of POCTs on antibiotic prescribing, further evidence is needed to understand how practices adopt POCTs and the implications for stewardship. Monitoring how POCTs are used can inform future guidelines on successful diagnostic implementation.</p