Use of Benzodiazepines by Older Primary Care Patients

描述(申请人提供)：此R21申请是一个探索性/发展性项目，旨在解决老年初级保健(PC)患者使用苯二氮卓类药物的高流行率，以及初级保健提供者(PCP)继续开出他们的处方。尽管有明确证据表明，这些药物具有潜在的重大健康风险，尽管有更安全、更合适的药物和心理疗法可用，但这种处方和使用模式仍然存在。已经有许多随机临床试验评估促进停用苯二氮卓类药物的策略。然而，这些策略的传播很少，而且这些试验的外部和内部有效性都可能受到质疑，因为低摄取率、有偏见的抽样和患者的选择性保留。老年人不适当地使用苯二氮卓类药物被视为一个公共卫生问题，而PCP的处方被视为一个护理质量问题，但我们缺乏有效的临床工具来促进减少使用。我们提出了一种混合方法的三角设计来解释老年患者和PCP对苯二氮卓类药物使用的看法。第一个具体目标是得出PCP对苯二氮类药物处方的一般隐含模型，包括对有关其使用建议的反应。第二个具体目标是引出患者的说明性模型，包括他们有助于使用的相关经验以及他们对有关使用的决策场所的理解。第三个具体目标是了解PCP和患者观点之间的一致和差异。该项目包括三个阶段的顺序评估：1)就老年患者对苯二氮卓类药物处方的一般信念和态度对30名PCP进行定性访谈；2)从每个PCP中抽取5名患者进行定性访谈和定量评估，了解他们的症状状态和苯二氮卓类药物的继续使用情况；3)对这些特定患者的PCP进行跟踪评估，以及PCP对我们初步发现的反应(成员检查)。该项目的关键目标是了解老年患者对苯二氮卓类药物使用的可接受性以及减少这种使用的策略，以便设计干预研究，产生强有力的可接受和有效的停用策略。

DESCRIPTION (provided by applicant): This R21 application is for an Exploratory/Developmental Project addressing the high prevalence of use of benzodiazepines by older primary care (PC) patients and their continued prescription by primary care providers (PCPs). This pattern of prescription and use persists despite clear evidence that these medications pose potentially significant health risks and despite the availability of medications and psychotherapies that are safer and more appropriate. There are already numerous randomized clinical trials evaluating strategies for facilitating discontinuation of benzodiazepines. However, there has been little dissemination of these strategies, and both the external and internal validity of these trials can be questioned because of low uptake, biased sampling, and selective retention of patients. Inappropriate use of benzodiazepines by the elderly is seen as a public health problem and prescriptions by PCP's is seen as a quality of care issue, yet we lack effective clinical tools to facilitate reduction in use. We propose a mixed method triangulation design to explicate older patients' and PCPs' perspectives on use of benzodiazepines. The first specific aim is to elicit PCPs' general implicit model of benzodiazepine prescription, including reactions to recommendations about their use. The second specific aim is to elicit patients' explanatory model, including their relevant experiences contributing to their use as well as their understanding of the locus of decision-making concerning their use. The third specific aim is to understand agreements and discrepancies between PCP and patient perspectives. The project involves a three phase sequential assessment: 1) qualitative interviews of 30 PCPs concerning general beliefs and attitudes about benzodiazepine prescription to older patients; 2) qualitative interviews and quantitative assessment of 5 patients drawn from each PCP concerning their symptomatic status and continued use of benzodiapezines; 3) follow-up assessment of PCP's concerning these specific patients and the PCPs response to our preliminary findings (member-checking). The key goal of this project is to understand the acceptability of both benzodiazepines usage by older patients and of strategies to reduce this use in order to design intervention studies yielding robustly acceptable and effective strategies for discontinuation.