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Original article

Vol. 148 No. 0506 (2018)

The influence of hospitalisation on the initiation, continuation and discontinuation of benzodiazepines and Z-drugs – an observational study

  • Thomas Grimmsmann
  • Markus Harden
  • Thomas Fiß
  • Wolfgang Himmel
DOI
https://doi.org/10.4414/smw.2018.14590
Cite this as:
Swiss Med Wkly. 2018;148:w14590
Published
07.02.2018

Summary

BACKGROUND AND OBJECTIVES

Hospitalisation influences drug therapy in ambulatory care and this influence is generally negatively perceived. The few studies that have explored changes in benzodiazepine or sleep medication use as a function of hospitalisation failed to precisely determine the hospital’s role in initiating, continuing and discontinuing these drugs on a valid basis. The aim of the study was to ascertain the overall influence of hospitalisation on the prescription of benzodiazepines and Z-drugs in outpatient care with a special focus on the role of different hospital departments and drug classes.

METHODS

In a secondary data analysis, we used prescription data for 181 037 patients who visited 127 hospitals and compared the numbers of patients with prescriptions of benzodiazepines and Z-drugs 50 days before and 50 or 100 days after hospitalisation.

RESULTS

The proportion of patients who received benzodiazepines or Z-drugs increased from 3.1% before admission to 3.6% at 50 days after discharge and fell to the former level after an additional 50 days. A multivariable logistic regression showed that gender and department had an additional impact on these results. Of those patients without a prescription for a benzodiazepine or Z-drug before admission, 0.6% received a prescription in both time-windows after discharge. Of those patients who were prescribed a benzodiazepine, 38.0% received short-acting substances and 40.3% received long-acting substances before hospitalisation. After hospitalisation, these rates changed to favour short-acting substances (44.4% and 34.4%, respectively).

CONCLUSIONS

The hospital effect on initiating and increasing hypnotic or sedative drug use seems to be only moderate and temporary. A change in favour of short-acting substances is even welcome. In less than 1% of patients, the hospital initiated the continuous use of benzodiazepines and Z-drugs, which may put pressure on primary care physicians. However, the widespread use of these drugs in hospitals does not seem to be continued on a large scale in primary care.

References

  1. Olfson M, King M, Schoenbaum M. Benzodiazepine use in the United States. JAMA Psychiatry. 2015;72(2):136–42.https://doi.org/10.1001/jamapsychiatry.2014.1763
  2. Janhsen K, Roser P, Hoffmann K. The problems of long-term treatment with benzodiazepines and related substances. Dtsch Arztebl Int. 2015;112(1-2):1–7. doi:.https://doi.org/10.3238/arztebl.2015.0001
  3. Lader M. Benzodiazepines revisited--will we ever learn? Addiction. 2011;106(12):2086–109..https://doi.org/10.1111/j.1360-0443.2011.03563.x
  4. Holt S, Schmiedl S, Thürmann PA. Potentially inappropriate medications in the elderly: the PRISCUS list. Dtsch Arztebl Int. 2010;107(31-32):543–51..https://doi.org/10.3238/arztebl.2010.0543
  5. Pasina L, Djade CD, Tettamanti M, Franchi C, Salerno F, Corrao S, et al.; REPOSI Investigators. Prevalence of potentially inappropriate medications and risk of adverse clinical outcome in a cohort of hospitalized elderly patients: results from the REPOSI Study. J Clin Pharm Ther. 2014;39(5):511–5.https://doi.org/10.1111/jcpt.12178
  6. Antai-Otong D. The art of prescribing. Risks and benefits of non-benzodiazepine receptor agonists in the treatment of acute primary insomnia in older adults. Perspect Psychiatr Care. 2006;42(3):196–200.https://doi.org/10.1111/j.1744-6163.2006.00070.x
  7. Gunja N. In the Zzz zone: the effects of Z-drugs on human performance and driving. J Med Toxicol. 2013;9(2):163–71.https://doi.org/10.1007/s13181-013-0294-y
  8. Anthierens S, Grypdonck M, De Pauw L, Christiaens T. Perceptions of nurses in nursing homes on the usage of benzodiazepines. J Clin Nurs. 2009;18(22):3098–106.https://doi.org/10.1111/j.1365-2702.2008.02758.x
  9. Weiß V, Heinemann S, Himmel W, Nau R, Hummers-Pradier E. Benzodiazepine und Z-Substanzen als Schlaf- und Beruhigungsmittel in einem Krankenhaus [The use of benzodiazepines and Z-drugs for patients with sleeping problems - A survey among hospital doctors and nurses] [in German]. Dtsch Med Wochenschr. 2016;141(13):e121–6. https://www.thieme-connect.de/DOI/DOI?10.1055/s-0042-102618.
  10. Ramesh M, Roberts G. Use of night-time benzodiazepines in an elderly inpatient population. J Clin Pharm Ther. 2002;27(2):93–7.https://doi.org/10.1046/j.1365-2710.2002.00400.x
  11. Schumacher L, Dobrinas M, Tagan D, Sautebin A, Blanc AL, Widmer N. Prescription of sedative drugs during hospital stay: a Swiss prospective study. Drugs Real World Outcomes. 2017;4(4):225–34.https://doi.org/10.1007/s40801-017-0117-6
  12. Riemann D, Baum E, Cohrs S, Crönlein T, Hajak G, Hertenstein E, et al. S3-Leitlinie Nicht erholsamer Schlaf/Schlafstörungen [S3 Guidelines on non-restorative sleep/sleep disorders]. [in German]. Somnologie (Berl). 2017;21:2–44. doi:https://doi.org/10.1007/s11818-016-0097-x
  13. Riemann D, Baglioni C, Bassetti C, Bjorvatn B, Dolenc Groselj L, Ellis JG, et al. European guideline for the diagnosis and treatment of insomnia. J Sleep Res. 2017;26(6):675–700.https://doi.org/10.1111/jsr.12594
  14. Bell CM, Fischer HD, Gill SS, Zagorski B, Sykora K, Wodchis WP, et al. Initiation of benzodiazepines in the elderly after hospitalization. J Gen Intern Med. 2007;22(7):1024–9.https://doi.org/10.1007/s11606-007-0194-4
  15. Scales DC, Fischer HD, Li P, Bierman AS, Fernandes O, Mamdani M, et al. Unintentional continuation of medications intended for acute illness after hospital discharge: a population-based cohort study. J Gen Intern Med. 2016;31(2):196–202.https://doi.org/10.1007/s11606-015-3501-5
  16. Zisberg A, Shadmi E, Sinoff G, Gur-Yaish N, Srulovici E, Shochat T. Hospitalization as a turning point for sleep medication use in older adults: prospective cohort study. Drugs Aging. 2012;29(7):565–76.https://doi.org/10.1007/BF03262274
  17. Heinemann S, Weiß V, Straube K, Nau R, Grimmsmann T, Himmel W, et al. Understanding and reducing the prescription of hypnotics and sedatives at the interface of hospital care and general practice: a protocol for a mixed-methods study. BMJ Open. 2016;6(8):e011908.https://doi.org/10.1136/bmjopen-2016-011908
  18. Marcus R, Peritz E, Gabriel KR. On closed testing procedures with special reference to ordered analysis of variance. Biometrika. 1976;63(3):655–60. doi:.https://doi.org/10.1093/biomet/63.3.655
  19. Viktil KK, Blix HS, Eek AK, Davies MN, Moger TA, Reikvam A. How are drug regimen changes during hospitalisation handled after discharge: a cohort study. BMJ Open. 2012;2(6):e001461.https://doi.org/10.1136/bmjopen-2012-001461
  20. Grimmsmann T, Schwabe U, Himmel W. The influence of hospitalisation on drug prescription in primary care--a large-scale follow-up study. Eur J Clin Pharmacol. 2007;63(8):783–90.https://doi.org/10.1007/s00228-007-0325-1
  21. Ahrens D, Chenot JF, Behrens G, Grimmsmann T, Kochen MM. Appropriateness of treatment recommendations for PPI in hospital discharge letters. Eur J Clin Pharmacol. 2010;66(12):1265–71.https://doi.org/10.1007/s00228-010-0871-9
  22. Wermeling M, Himmel W, Behrens G, Ahrens D. Why do GPs continue inappropriate hospital prescriptions of proton pump inhibitors? A qualitative study. Eur J Gen Pract. 2014;20(3):174–80.https://doi.org/10.3109/13814788.2013.844787
  23. Somers A, Robays H, Audenaert K, Van Maele G, Bogaert M, Petrovic M. The use of hypnosedative drugs in a university hospital: has anything changed in 10 years? Eur J Clin Pharmacol. 2011;67(7):723–9.https://doi.org/10.1007/s00228-010-0983-2
  24. Arnold I, Straube K, Himmel W, Heinemann S, Weiss V, Heyden L, et al. High prevalence of prescription of psychotropic drugs for older patients in a general hospital. BMC Pharmacol Toxicol. 2017;18(1):76.https://doi.org/10.1186/s40360-017-0183-0
  25. Glaeske G, Gerdau-Heitmann C, Höfel F, Schicktanz C. Gender-specific drug prescription in Germany. Results from prescriptions analyses. In: Regitz-Zagrosek V (ed.) Sex and Gender Differences in Pharmacology (Handbook of Experimental Pharmacology; vol. 214, pp 149–167). https://doi.org/10.1007/978-3-642-30726-3
  26. Johnell K, Fastbom J. Gender and use of hypnotics or sedatives in old age: a nationwide register-based study. Int J Clin Pharm. 2011;33(5):788–93.https://doi.org/10.1007/s11096-011-9536-8
  27. Halfens RJ, Lendfers ML, Cox K. Sleep medication in Dutch hospitals. J Adv Nurs. 1991;16(12):1422–7.https://doi.org/10.1111/j.1365-2648.1991.tb01589.x
  28. Nakao M, Takeuchi T, Yano E. Prescription of benzodiazepines and antidepressants to outpatients attending a Japanese university hospital. Int J Clin Pharmacol Ther. 2007;45(1):30–5.https://doi.org/10.5414/CPP45030
  29. Warie H, Petrovic M, Somers A, Mariman A, Robays H, Pevernagie D. The use of hypnosedative drugs in a university hospital setting. Acta Clin Belg. 2003;58(4):225–32.https://doi.org/10.1179/acb.2003.58.4.003
  30. Egger SS, Bachmann A, Hubmann N, Schlienger RG, Krähenbühl S. Prevalence of potentially inappropriate medication use in elderly patients: comparison between general medical and geriatric wards. Drugs Aging. 2006;23(10):823–37.https://doi.org/10.2165/00002512-200623100-00005
  31. Millar HL, Clunie FS, McGilchrist MM, McMahon AD, MacDonald TM. The impact on community benzodiazepine prescribing of hospitalization. J Psychosom Res. 1997;42(1):61–9.https://doi.org/10.1016/S0022-3999(96)00232-2
  32. Kroll DS, Nieva HR, Barsky AJ, Linder JA. Benzodiazepines are prescribed more frequently to patients already at risk for benzodiazepine-related adverse events in primary care. J Gen Intern Med. 2016;31(9):1027–34.https://doi.org/10.1007/s11606-016-3740-0
  33. Nicholson AN. The use of short- and long-acting hypnotics in clinical medicine. Br J Clin Pharmacol. 1981;11(S1, Suppl 1):61S–9S.https://doi.org/10.1111/j.1365-2125.1981.tb01841.x
  34. Gallagher P, Ryan C, Byrne S, Kennedy J, O’Mahony D. STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther. 2008;46(2):72–83.https://doi.org/10.5414/CPP46072
  35. de Vries OJ, Peeters G, Elders P, Sonnenberg C, Muller M, Deeg DJ, et al. The elimination half-life of benzodiazepines and fall risk: two prospective observational studies. Age Ageing. 2013;42(6):764–70.https://doi.org/10.1093/ageing/aft089
  36. Chen L, Bell JS, Visvanathan R, Hilmer SN, Emery T, Robson L, et al. The association between benzodiazepine use and sleep quality in residential aged care facilities: a cross-sectional study. BMC Geriatr. 2016;16(1):196.https://doi.org/10.1186/s12877-016-0363-6
  37. Skinner BW, Johnston EV, Saum LM. Benzodiazepine initiation and dose escalation. Ann Pharmacother. 2017;51(4):281–5.https://doi.org/10.1177/1060028016682530

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