Table 2.

Studies Evaluating Prescriber-Focused Interventions to Overcome Prescriber Barriers to Reduce SH Use in Community-Dwelling Adults.

Study description	Intervention	Results	NNT
Subcategory: education
Smith and Tett (2010) 41 • Design: controlled pre-post • Duration: 6-month intervention • Setting: Australian general practice • Target: BZD	Education components: • GPs, pharmacists, and nurses in aged care facilities received 3 emails with educational facts related to BZDs (side effects, indications, nonpharmacological sleep management) • Consumers filling prescriptions for BZDs received a bookmark containing facts on BZDs and a website address with further information	• No difference in BZD use between before or after education (P > 0.05)	N/A
Avdagic et al (2018) 42 • Design: retrospective cohort study • Duration: 12-month, 24-month assessment periods • Setting: Community Behavioral Health Services, San Francisco • Target: BZD, nonbenzodiazepine hypnotics (Z-drugs)	Multimodal intervention: • Psychiatrists, therapists, pharmacists, case managers, other health care providers provided education, coordination of care, guideline development, safe prescribing of SHs in 3 time periods: 1. Preintervention period: October 2013 to December 2013 2. 12-month assessment period: October 2014 to December 2014 3. 24-month assessment period: October 2015 to December 2015	• Number of chronic SH prescriptions decreased from preintervention period (1764 [15.3%]) to 12-month assessment period (1634 [14.9%]) to 24-month assessment period (1018 [9.8%]) • Difference not statistically significant between preintervention and 12-month assessment period (absolute decrease 0.4%, P = 0.32) • Significant decrease between preintervention and 24-month assessment period (absolute decrease 5.5%, P < 0.0001) and between 12-month and 24-month assessment period (absolute decrease 5.1%, P < 0.0001)	N/A
Subcategory: audit and feedback
Zwar et al (2000) 43 • Design: RCT (randomization at the practitioner level) • Duration: 2 follow-up surveys • Setting: GP practices in New South Wales, Australia, n = 157 primary care physicians • Target: BZD	• Intervention group: ° 20-Minute education on BZD prescribing ° Academic detailing by trained GP ° Management guidelines detailed to GP suggested reassessing need for SH followed by gradual withdrawal ° Provided information on anxiety, insomnia, exercise and a patient aid to managing BZD withdrawal • Control group: educational session on unrelated topic	• Overall BZD prescriptions decreased from 2.3 to 1.7/100 encounters in the intervention group vs 2.2 to 1.6/100 encounters in controls • A statistically significant change was observed over time (P = 0.042); however, there was no difference between intervention and control groups (P = 0.99)	N/A
Pimlott et al (2003) 44 • Design: RCT • Duration: 6 months • Setting: community setting of primary care GPs in Ontario, Canada. Identified primary care physician who wrote at least 10 prescriptions for target drugs in 2-month period • Targeted: BZD	• Intervention group: physician-level feedback on prescribing patterns and educational bulletins about BZD prescribing among older adults • Control group: physician-level feedback on prescribing patterns and education on antihypertensive treatment among older adults • Intervention was mailed to providers every 2 months for 6 months. Feedback presented as bar graphs comparing the prescriber with peers and with a hypothetical best practice	• No significant differences between experimental and control group physicians or baseline BZD prescribing patterns • Small reduction in the proportion of long-acting BZDs prescribed by intervention group (19.6 vs 20.9; P = 0.036) • No significant impact on the proportion of seniors who received long-term BZD therapy or the proportion who were prescribed BZDs in combination with other psychoactive medications	N/A
Subcategory: electronic prescriber alerts (ie, pop-ups)
Smith et al (2006) 45 • Design: interrupted time series • Duration: 39 months • Setting: group model HMO in US Pacific Northwest • Target: potentially inappropriate drugs for the elderly	• Decision support alerted clinicians to preferred alternative medications when they ordered certain nonpreferred medications (including long-acting BZDs) for all patients	• 22% Relative decrease in prescribing of target medication compared to baseline (21.9% vs 16.8%; P < 0.01) • No change observed in monthly initial prescribing of nonpreferred BZDs • Decrease in target medications was only observed in elderly patients, primarily driven by tertiary tricyclic agents	N/A
Simon et al (2006) 46 • Design: cluster RCT (randomization at the clinic level) • Duration: 42 months, n = 239 clinicians; 50 924 patients • Setting: 15 clinics of a HMO in Oregon and Washington, USA • Target: tertiary tricyclic amine antidepressants, long-acting BZD, propoxyphene This is a continuation of Smith et al, 2006 above	• Intervention group: 7 practices (113 clinicians, 24 119 patients) were randomly assigned to receive age-specific alerts for target medications plus academic detailing intervention (interactive educational program delivering evidence-based information) • Control group: 8 practices (126 clinicians, 26 805 patients) received age-specific alerts for target medications alone • Two alert types were studied with a time series analysis: 1. computerized drug-specific alerts (preintervention) based on ordering of a target medication (eg, tertiary tricyclic amine antidepressants, long-acting BZD, propoxyphene) and 2. age-specific alerts (postintervention) occurred when a targeted medication was newly prescribed for patients 65 years and older • Both alerts suggested an alternative medication	• Age-specific alerts sustained, but did not change, the effect of non–age-specific alerts observed by Smith et al 46 • There was no additional effect resulting from academic detailing (P = 0.52 for level change) • Age-specific alerts led to fewer false-positive alerts for clinicians	N/A
Fortuna et al (2009) 47 • Design: Cluster RCT (randomized at the practice level) • Duration: 12-month baseline and 12-month follow-up • Setting: 14 outpatient, internal medicine practice sites within Harvard Vanguard Medical Associates, USA • Target: new SH prescriptions on the market	Practice sites randomized to: 1. Computerized prescription alerts: a new prescription for a study SH (Ambien CR, Lunesta, Sonata, and Rozerem) triggered an alert that recommended an alternative medication and prompted the prescriber to continue to an order set with decision support: • alternate drug, co-payment information, patient educational materials about insomnia and sleep hygiene 2. Alert and education • 45-minute sessions led by experienced internist • incorporated principles of academic detailing • emphasized nonpharmacological therapies • informational packet distributed to those who did not attend session 3. Usual care Alert stating co-payment tier of the medication (1, 2, 3 corresponding to the out-of-pocket cost of the medication)	• 89 Providers received at least 1 alert; 245 alerts activated during the study period • 23.3% of prescriptions for study SH that activated an alert were changed to a generic equivalent • Computerized alert groups experienced preintervention levels of study SH prescribing in both the alert-only (adjusted RR = 0.97; 95% CI = 0.82-1.14) and alert plus education groups (RR = 0.98; 95% CI = 0.83-1.17) • Usual care group experienced an increase in prescribing (RR = 1.31; 95% CI = 1.08-1.60) • Compared to usual care, both the alert groups had lower RR of prescribing study SH (RRR = 0.74; 95% CI = 0.58-0.97) • The prescribing of study SH was similar in the alert group and alert plus education group (RRR = 1.02; 95% CI = 0.80-1.29)	N/A

Abbreviations: BZD, benzodiazepine; GP, general practitioner; HMO, health maintenance organization; N/A, not applicable; NNT, number needed to treat; RCT, randomized controlled trial; RR, risk ratio; RRR, relative risk ratio; SH, sedative-hypnotic.