Engaging Clinicians and Veterans in Efforts to Decrease - - PowerPoint PPT Presentation

Engaging Clinicians and Veterans in Efforts to Decrease Benzodiazepines in Posttraumatic Stress Disorder (PTSD): De-Implementing through Academic Detailing

December 15, 2016

Nancy C. Bernardy, Macgregor Montaño, Kathleen Sherrieb, and Craig Rosen

VETERANS HEALTH ADMINISTRATION

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

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VETERANS HEALTH ADMINISTRATION

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

• Benzodiazepines are ineffective

for PTSD treatment or prevention

• Risk >>>>> short term relief
• Two old RCTs did not show benefit
• BZDs

– Worsen overall PTSD severity – Increased risk of developing PTSD if used immediately after trauma – Worse psychotherapy

• utcomes, aggression,

depression, substance use

PTSD BZDs

National Center for PTSD White Paper “… OIG also found that facility leadership and primary care providers needed to improve adherence to required benzodiazepine appropriateness evaluations for patients on chronic

• pioid therapy who have post-traumatic

stress disorder.”

(Guina 2015)

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VETERANS HEALTH ADMINISTRATION

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

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VETERANS HEALTH ADMINISTRATION

PTSD and Prescribing Trends in PTSD (1999-

2009)

• VA clinicians continue

to prescribe benzodiazepines

• Special challenges in

rural settings

– Mental health service and provider shortages – Higher rates of benzodiazepine and concurrent opioid use in rural VA patients with PTSD

0% 10% 20% 30% 40% 50% 60% 70% 99 00 01 02 03 04 05 06 07 08 09

Frequency of use Fiscal Year

SSRI or SNRI

Benzodiazepines

Atypical Antipsychotics Quetiapine, low dose Zolpidem Prazosin

(Bernardy 2012)

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SSRI or SNRI Benzodiazepines Atypical Antipsychotics

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.

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VETERANS HEALTH ADMINISTRATION

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 Review 2007)

• Key messages

individualized to provider and patient population and delivered in an interactive way

• Visits focus on key

actions and specific patients

• Delivered where the

clinician practices Academic Detailing

Scholarly approach to balanced evidence based information

Service-oriented

• utreach for healthcare

professionals by healthcare professionals Direct one-on-one social marketing techniques (e.g. pharmaceutical industry)

VETERANS HEALTH ADMINISTRATION

Adaptable to any Gap in Clinical Quality

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VETERANS HEALTH ADMINISTRATION

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…

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VETERANS HEALTH ADMINISTRATION

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

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VETERANS HEALTH ADMINISTRATION

Design of individual patient taper schedules

• nline
• 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

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VETERANS HEALTH ADMINISTRATION

Educational Materials Promoting Shared Decision Making for patients and providers

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VETERANS HEALTH ADMINISTRATION

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…

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VETERANS HEALTH ADMINISTRATION

What VA Clinicians Have to Say

• Inherit large caseloads of Veterans on chronic benzodiazepines and
• pioids
• 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?

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VETERANS HEALTH ADMINISTRATION

Site 1: Promising Changes

2 4 6 8 10 12 14 16 2013 2014 2015 2016 Prescription prevalence (per 100 patients) Fiscal Year

Prescribing Trends in Site 1 VA Veterans with PTSD

Chronic benzodiazepine Off-label atypical antipsychotic Prazosin

EDUCATIONAL INTERVENTION (Q1 FY2014-Q4 FY2016)

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VETERANS HEALTH ADMINISTRATION

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

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19 10 20 30 40 50 60 Clinician 1 Clinician 2 Clinician 3 Clinician 4 Clinician 5 Clinician 6 Clinician 7 Clinician 8 Clinician 9 Clinician 10Clinician 11Clinician 12Clinician 13Clinician 14 Percent Patients with PTSD and BZD Prescriptions

Prescribing Clinicians

Site 2 study - PTSD Patients (%) with BZD Prescriptions by Provider Over 8 Months

Pre Post

• Pts. had data at all 3 timepoints

VETERANS HEALTH ADMINISTRATION

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.

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VETERANS HEALTH ADMINISTRATION

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

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VETERANS HEALTH ADMINISTRATION

Health Care is a Team Sport

• Academic detailing requires the

detailer to anticipate and practice dealing with resistance from providers

• Detailer must assess values,

strengths, barriers, weaknesses

• Embrace team strength and

thinking – PharmD, PT, OT, PsyD, health psychologist, SW, RN, LPN, MSA, PSA, etc.

• Practice “at the speed of evidence”

and adapt to new knowledge and patient needs

• Spread what works and share

success stories

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VETERANS HEALTH ADMINISTRATION

Summary – AD is Partnering for Solutions

• Academic detailing is a powerful tool to improve care –
• ne provider at a time
• Important to maintain fidelity to the proven academic

detailing model if we want to see clinical change

• Academic Detailing takes a comprehensive approach to

clearing the path to evidence-based care

• The use of academic detailing and developed resources

should be disseminated to enhance shared-decision- making processes, leading to prescribing of safer treatment options in PTSD and improved access to quality care.

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