Strategies Associated With Reducing Benzodiazepine Prescribing to Older Adults: A Mixed Methods Study

Donovan T. Maust; Linda Takamine; Ilse R. Wiechers; Frederic C. Blow; Amy S. B. Bohnert; Julie Strominger; Lillian Min; Sarah L. Krein

doi:10.1370/afm.2825

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Figure 1.
Expected yearly change in facility-level average daily BZD dose among a cohort of long-term BZD users.^a,b
BZD = benzodiazepine.
^a Priority and nonpriority refer to whether, as part of Psychotropic Drug Safety Initiative phase 2, facility chose to focus on BZD deprescribing to older veterans.
^b High-performing facilities achieved a greater change in average daily dose of BZD prescribing; low-performing facilities, lesser.

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Table 1.

Demographic and Clinical Characteristics of Chronic BZD Users at the Start of PDSI Phase 2

Characteristic^a	No. (%) (N = 24,512)
Age, y
75-79	9,385 (38.3)
80-84	8,438 (34.4)
85-89	4,463 (18.2)
≥90	2,226 (9.1)
Male	23,952 (97.7)
Race
White	22,939 (93.6)
Black	1,008 (4.1)
Other	452 (1.8)
Missing	113 (0.5)
Rurality
Urban	14,881 (60.7)
Rural	9,188 (37.5)
Highly rural	413 (1.7)
Missing	30 (0.1)
Depression	2,317 (9.5)
Anxiety	8,946 (36.5)
PTSD	2,875 (11.7)
Alcohol-related disorder	541 (2.2)
Non-alcohol substance-related disorder	239 (1.0)
Dementia	1,296 (5.3)
Insomnia	4,666 (19.0)
Chronic pain	15,470 (63.1)

BZD = benzodiazepine; PDSI = Psychotropic Drug Safety Initiative; PTSD = posttraumatic stress disorder; VA = Veterans Affairs.
↵a Race, rurality, and clinical conditions derived per Stroupe et al,¹⁶ the VA Information Resource Center,¹⁷ and Maust et al,⁵ respectively.

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Table 2.

Facility-Level Average BZD Use at the Start of PDSI Phase 2 and Expected Quarterly Change Among a Cohort of Long-Term BZD Users, Overall and By Facility Priority Status

	Overall (N = 140)	Priority (n = 47)	Nonpriority (n = 93)
Facility-level daily dose of benzodiazepines, mean (SD)^a,^b
At the start of PDSI Phase 2	1.34 (0.17)	1.35 (0.14)	1.34 (0.19)
Average yearly change	–0.27 (0.09)	–0.29 (0.09)	–0.26 (0.09)

BZD = benzodiazepine; PDSI = Psychotropic Drug Safety Initiative.
↵a From a model in which the outcome was facility-level average daily dose of BZDs and included terms for PDSI phase 2 status (0 or 1), time (quarter, 0-6), their interaction, facility-level average age, and facility-level random intercepts and slopes. Fixed and random effects were used to estimate the expected facility-level starting dose and change over time (slope) for each facility, with average age set to the mean.
↵b In oral lorazepam-equivalent mg.

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Table 3.

Average Annual Change in Facility BZD Prescribing and Facility Strategies to Reduce Prescribing

	Facilities						Facilities
	Low Performing						High Performing
	A	B	C	D	E	F	Q	R	S	T	U	V	W	X	Y	Z
Facility-level annual change (mg/d)	–0.19	–0.21	–0.23	–0.23	–0.24	–0.26	–0.38	–0.39	–0.39	–0.40	–0.40	–0.41	–0.42	–0.46	–0.58	–0.59
Facility size^a	med	small	med	large	small	large	large	large^b	med^b	small^b	small	med^b	large	small	large^b	med
Census region	south	NE	west	NE	south	MW	south	west	west	MW	MW	south	south	west	south	west
Strategies
Passive
Identify hot spots	X		X		X		X	X		X	X	X	X		X	X
Patient- and provider-facing education	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X
Provide services and tools			X	X			X	X	X	X		X	X	X	X	X
Active
Provide guidance			X	X	X		X	X		X		X	X	X	X	X
Barriers to prescribing			X		X		X	X	X	X			X		X	X
Performance measures					X		X	X				X			X
Personal authority								X				X		X	X

BZD = benzodiazepine; MW = Midwest; NE = Northeast.
↵a Facilities were placed into size tertiles based on the number of unique individuals aged ≥55 years with health care encounters during the first quarter of phase 2 (small facilities served 7,175-21,228 patients; medium, 21,734-31,296; large, 31,545-84,981).
↵b Nonpriority sites.