Engaging Clinicians and Veterans in Efforts to Decrease Benzodiazepines in Posttraumatic Stress Disorder (PTSD): De-Implementing through Academic Detailing Nancy C. Bernardy, Macgregor Monta ñ o, Kathleen Sherrieb, and Craig Rosen December 15, 2016
Objectives: • Review recommendations regarding use of benzodiazepines in PTSD • Describe our strategies to decrease the use of benzodiazepines • Share findings from our work to de-implement benzodiazepine use in PTSD in the Department of Veterans Affairs VETERANS HEALTH ADMINISTRATION 1
PTSD Pharmacotherapy Recommendations • SSRI (Selective Serotonin Reuptake Inhibitor) – Sertraline – Paroxetine – Fluoxetine • SNRI (Serotonin Norepinephrine Reuptake Inhibitor) – Venlafaxine • Other – Benzodiazepines (harm) – Mirtazapine – Nefazodone* (Caution: liver injury) – Tricyclic Antidepressants (TCAs) • Amitriptyline, imipramine (VA/DoD Clinical Practice Guideline for the treatment of PTSD 2010) VETERANS HEALTH ADMINISTRATION
BZDs PTSD • Benzodiazepines are ineffective for PTSD treatment or prevention • Risk >>>>> short term relief • Two old RCTs did not show benefit • BZDs – Worsen overall PTSD severity National Center for PTSD White – Increased risk of developing Paper PTSD if used immediately “… OIG also found that facility leadership after trauma and primary care providers needed to – Worse psychotherapy improve adherence to required benzodiazepine appropriateness outcomes, aggression, evaluations for patients on chronic depression, substance use opioid therapy who have post-traumatic stress disorder.” (Guina 2015) VETERANS HEALTH ADMINISTRATION 3
4 Benzodiazepines – No Benefit in PTSD • VA/DoD PTSD Clinical Practice Guideline recommend against the use of benzodiazepines (BZDs) in the treatment of PTSD (2010) • Especially important to avoid in vulnerable subgroups: – History of TBI or Substance Use Disorder – 65 years and older – Concurrent sedatives such as opioids – Pulmonary disease and sleep apnea – Women of child-bearing age Bottom line: Avoid new starts and in those patients taking benzodiazepines, educate about risk and discuss slow taper VETERANS HEALTH ADMINISTRATION
5 PTSD and Prescribing Trends in PTSD (1999- 2009) • SSRI or SNRI Benzodiazepines VA clinicians continue Atypical Antipsychotics Quetiapine, low dose to prescribe Zolpidem Prazosin benzodiazepines 70% • Special challenges in SSRI or SNRI 60% rural settings – Mental health 50% Frequency of use service and Benzodiazepines 40% provider shortages – Higher rates of 30% Atypical Antipsychotics benzodiazepine and 20% concurrent opioid use in rural VA 10% patients with PTSD 0% 99 00 01 02 03 04 05 06 07 08 09 Fiscal Year (Bernardy 2012) VETERANS HEALTH ADMINISTRATION
Existing Dissemination Materials • Increased education, training, and consultation to both clinicians and Veterans can potentially help de- implement the use and harm of benzodiazepines. VETERANS HEALTH ADMINISTRATION 6
Academic Detailing to Improve PTSD Care in Two Sites • Research projects funded by the VA Mental Health QUERI and the Office of Rural Health • Multicomponent model to improve PTSD care • Key clinical messages include: – Decrease benzodiazepine use in PTSD – Increase referral for trauma-focused psychotherapy – Increase use of prazosin for nightmares VETERANS HEALTH ADMINISTRATION
Comprehensive Approach to Change Clinician Behavior & Improve Outcomes • Proven strategy to improve care (Cochrane Scholarly approach to Review 2007) balanced evidence based information • Key messages individualized to provider and patient population and delivered in an Academic interactive way Detailing • Visits focus on key actions and specific Direct one-on-one patients Service-oriented social marketing • outreach for healthcare Delivered where the techniques (e.g. professionals by pharmaceutical clinician practices healthcare professionals industry ) VETERANS HEALTH ADMINISTRATION
Adaptable to any Gap in Clinical Quality VETERANS HEALTH ADMINISTRATION 9
Academic Detailing Model Components • Detailer pharmacists meets quarterly with prescribers – Dashboard to show clinician prescribing patterns with their own patients – Educates and makes suggestions • General education meetings with larger team • Provide additional resources to solve problems • Direct mail campaign to patients on benzodiazepines – Only underway now… VETERANS HEALTH ADMINISTRATION 10
11 Additional Implementation Supports Developed Based on Clinician Feedback(Site 1) Part of original model • Dashboard identifies providers with greatest caseload of patients with need for change • Direct-to-consumer mailing patient brochures to identified subgroups of Veterans and asking them to discuss content with their provider at upcoming visit Added during project • PTSD Pharmacotherapy E-consult to access specialists • Prazosin titration (up) quick orders • BDZ titration (down) tool – Clinicians preferred this to referral to a BDZ titration clinic VETERANS HEALTH ADMINISTRATION
12 Design of individual patient taper schedules online • BZD Taper Tool • Easy-to-use, unique • Developed by VA Academic Detailing Service • Clinician Inputs: – Total daily dose of BZD(s) – Number of months to display for patient • Tool Generates: – Slow taper schedule and Rx writing guidance • Varies between 3-7 months depending on starting dose – Patient-friendly taper schedule and directions – Electronic record chart-friendly version to copy and paste to a progress note VETERANS HEALTH ADMINISTRATION
Educational Materials Promoting Shared Decision Making for patients and providers VETERANS HEALTH ADMINISTRATION 13
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Direct Mail Marketing to Patients • Seemed simple, easy to implement – Dashboard identifies PTSD patients on BDZ – Clerk sends out letter to patient, asks patients to bring letter to discuss during next visit – NO effort for clinician to initiate • But actually took 18 months to get approval – Clinicians concerned about not being in control – Clinicians concerned about scaring patients • Only NOW Being implemented… VETERANS HEALTH ADMINISTRATION 15
What VA Clinicians Have to Say • Inherit large caseloads of Veterans on chronic benzodiazepines and opioids • Want tangible facility and administrator resources to support practice change – Easy to use, available at point of care – Flexibility in the electronic health record • Have ceased/decreased initiation of new prescriptions and are attempting tapers • Frustrated that patients go to other providers (particularly in primary care) and get started on harmful meds again • Top question during PTSD detailing: How do I order naloxone? VETERANS HEALTH ADMINISTRATION 16
Site 1: Promising Changes Prescribing Trends in Site 1 VA Veterans with PTSD 16 Prescription prevalence (per 100 patients) 14 12 10 8 Chronic benzodiazepine EDUCATIONAL INTERVENTION (Q1 FY2014-Q4 FY2016) 6 Off-label atypical antipsychotic 4 Prazosin 2 0 2013 2014 2015 2016 Fiscal Year VETERANS HEALTH ADMINISTRATION 17
Site 2: Low Implementation Fidelity • Across the country from project lead (less oversight) • Assigned pharmacist less comfortable being detailer – Younger, less gravitas – Less comfortable giving clinicians feedback • Meet 1-2 times rather than quarterly • Did not implement dashboard audit and feedback – But did hand out informational brochures VETERANS HEALTH ADMINISTRATION 18
Site 2 study - PTSD Patients (%) with BZD Prescriptions by Provider Over 8 Months Pre Post 60 Percent Patients with PTSD and BZD Prescriptions 50 40 30 20 10 0 Clinician 1 Clinician 2 Clinician 3 Clinician 4 Clinician 5 Clinician 6 Clinician 7 Clinician 8 Clinician 9 Clinician 10Clinician 11Clinician 12Clinician 13Clinician 14 Pts. had data at all 3 timepoints Prescribing Clinicians 19
Findings • Not all pharmacists are strong Academic Detailers: – Requires a comfort level to engage MDs in discussions regarding their prescribing patterns and time to set up appointments, develop a plan for the visit, and travel to meet with the provider. – We are testing telehealth now. • Clinical providers too busy to use performance dashboards; appointment time with the detailer is limited. – Detailer must show key data, offer brief messages, suggest clinical shortcuts, and provide resources to engage clinicians in a working dialogue. VETERANS HEALTH ADMINISTRATION 20
Positive Response to Academic Detailing • Providers have been welcoming and have shared barriers to providing quality PTSD care • Providers show a hunger to learn and be heard – Requests for traditional learning opportunities • TBI and PTSD • PTSD and pregnancy • PTSD symptom management • Integration of Cognitive Behavioral Therapy strategies in Primary Care – Request for help on benzodiazepine tapering quality improvement project – Process improvements for safer, more efficient care VETERANS HEALTH ADMINISTRATION 21
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