Choosing Wisely Canada recommendations

VOL 63: NOVEMBER • NOVEMBRE 2017

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Choosing Wisely Canada Web exclusive

Choosing Wisely Canada recommendations

Interview with Drs Stephanie Klein and Dana Mayer

Hospital medicine recommendation 3 Geriatric medicine recommendation 2 Psychiatry recommendation 13

Do not use benzodiazepines or other sedative-hypnotics in older adults as frst-choice treatment for insomnia, agi- tation, or delirium.

Psychiatry recommendation 9

Do not routinely continue benzodiazepines initiated dur- ing an acute-care hospital admission without a careful review and plan for tapering and discontinuing, ideally before hospital discharge.

How have you implemented these recommendations in your practice?

We did our resident quality improvement project on depre- scribing chronic benzodiazepines in the elderly. This coincided with the development of a sleep program at our family health team (FHT), where pharmacists helped patients taper sedative-hypnotic drugs, and social workers ran a cognitive-behavioural therapy group for insomnia.

We identified patients using an electronic medical record search for benzodiazepines prescribed within the past year for those older than age 65. Chart reviews were used to identify the reason for the prescription and the length of use. We focused on patients who took the medi- cation for 3 months or longer for insomnia or mild anxiety, or for whom the prescription was not evidence based.

We then contacted eligible patients by telephone or at their next appointment to discuss the harms of chronic benzodiazepine use and invite them to taper their doses.

If interested, they were provided with the deprescribing tool for benzodiazepines created by Dr Cara Tannenbaum and colleagues.¹

For some patients, the tool was enough for them to start tapering. If more support was needed, we referred them to the FHT sleep program. We would periodically follow up to see if they needed additional support.

To date, 62% of the patients we engaged in the pilot study have reduced their dose or tapered off completely.

How have you brought the Choosing Wisely principles to your relationship with patients?

Several Choosing Wisely Canada recommendations address overprescribing. These conversations are not always easy, but there are opportunities that lend them- selves to a medication review. For example, if a patient who is dependent on benzodiazepines has a fall, he or she might be open to discussing the possibility of taper- ing. Or, during a periodic health review, if the patient still

feels he or she is not getting restful sleep, he or she might be open to a risk-beneft discussion. Most patients do not know that benzodiazepines only add an average of 23 extra minutes of sleep per night.² Most also do not know the risks of taking them, such as daytime sedation, falls, hip fractures, impaired cognition, and car accidents.

In our project, we recognized we were not here to tell patients what to do, or to push their limits. One of the most important parts of family medicine is building a trust- ing, long-standing relationship with patients. We want to empower our patients and know that they are con- sidering deprescribing based on their own decisions. We used motivational interviewing to understand why people believed they needed the medication. We also addressed sleep myths (eg, how many hours people need to function).

What does Choosing Wisely mean to you as family physicians in training?

In medical school, you are expected to learn all tests and treatments relevant to managing your patients’ care. Over time, you home in on what is appropriate—this is an art. In our residency, the Choosing Wisely principles are central to the way we practise. We always ask ourselves, What will I get from these test results? Will it change the treatment and potentially the outcome? Choosing Wisely provides support to challenge the notion that “more is better,” to be intro- spective about the care we provide, and to think critically.

To us, Choosing Wisely also means working collab- oratively with our interprofessional team. We would not be able to implement quality improvement initiatives if it were not for the members of the North York FHT coming together to provide integrated, patient-centred care.

Dr Klein is Co-Chief Resident and Dr Mayer is a resident at North York General Hospital in Toronto, Ont.

References

1. Tannenbaum C, Ahmed S, Benedetti A, Tamblyn R. EMPOWER trial—empowering older adults to reduce benzodiazepine use. Ottawa, ON: Bruyère Research Institute.

Available from: https://goo.gl/upxnna. Accessed 2017 Sep 25.

2. Glass J, Lanctôt KL, Herrmann N, Sproule BA, Busto UE. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefts. BMJ 2005;331(7526):1169.

Choosing Wisely Canada is a campaign to help clinicians and patients engage in conversations about unnecessary tests, treatments, and procedures, and to help physicians and patients make smart and effective choices to ensure high-quality care. To date there have been 11 family medicine recommendations, but many of the recommendations from other specialties are relevant to family medicine. In each installment of the Choosing Wisely Canada series in Canadian Family Physician, a family physician is interviewed about how he or she has implemented one of the recommendations in his or her own practice. The interviews are prepared by Dr Kimberly Wintemute, Primary Care Co-Lead, and Hayley Thompson, Project Coordinator, for Choosing Wisely Canada.