The interplay of context factors in hypnotic and sedative prescription in primary and secondary care—a qualitative study

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Abstract

Purpose

Non-medical or contextual factors strongly influence physicians’ prescribing behavior and may explain why drugs, such as benzodiazepines and Z-drugs, are still frequently prescribed in spite of well-known adverse effects. This study aimed to explore which contextual factors influence the prescription of hypnotics and sedatives and to compare their role in primary and secondary care.

Methods

Understanding medical practices as games with specific rules and strategies and performed in a largely habitual, not fully conscious manner, we asked a maximum variation sample of 12 hospital doctors and 12 general practitioners (GPs) about their use of hypnotics and sedatives. The interviews were analyzed by qualitative content analysis.

Results

Hospital doctors’ and GPs’ use of hypnotics and sedatives was influenced by a variety of contextual factors, such as the demand of different patient groups, aims of management, time resources, or the role of nurses and peers. Negotiating patient demands, complying with administrative regulations, and finding acceptable solutions for patients were the main challenges, which characterized the game of drug use in primary care. Maintaining the workflow in the hospital and finding a way to satisfy both nurses and patients were the main challenges in secondary care.

Conclusions

Even if doctors try to act rationally, they cannot escape the interplay of contextual factors such as handling patient needs, complying with administrative regulations, and managing time resources. Doctors should balance these factors as if they were challenges in a complex game and reflect upon their own practices.

Electronic supplementary material

The online version of this article (10.1007/s00228-018-2555-9) contains supplementary material, which is available to authorized users.

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Most cited references 45

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European guideline for the diagnosis and treatment of insomnia

Elisabeth Hertenstein, Colin Espie, Jason Ellis … (2017)

This European guideline for the diagnosis and treatment of insomnia was developed by a task force of the European Sleep Research Society, with the aim of providing clinical recommendations for the management of adult patients with insomnia. The guideline is based on a systematic review of relevant meta-analyses published till June 2016. The target audience for this guideline includes all clinicians involved in the management of insomnia, and the target patient population includes adults with chronic insomnia disorder. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to grade the evidence and guide recommendations. The diagnostic procedure for insomnia, and its co-morbidities, should include a clinical interview consisting of a sleep history (sleep habits, sleep environment, work schedules, circadian factors), the use of sleep questionnaires and sleep diaries, questions about somatic and mental health, a physical examination and additional measures if indicated (i.e. blood tests, electrocardiogram, electroencephalogram; strong recommendation, moderate- to high-quality evidence). Polysomnography can be used to evaluate other sleep disorders if suspected (i.e. periodic limb movement disorder, sleep-related breathing disorders), in treatment-resistant insomnia, for professional at-risk populations and when substantial sleep state misperception is suspected (strong recommendation, high-quality evidence). Cognitive behavioural therapy for insomnia is recommended as the first-line treatment for chronic insomnia in adults of any age (strong recommendation, high-quality evidence). A pharmacological intervention can be offered if cognitive behavioural therapy for insomnia is not sufficiently effective or not available. Benzodiazepines, benzodiazepine receptor agonists and some antidepressants are effective in the short-term treatment of insomnia (≤4 weeks; weak recommendation, moderate-quality evidence). Antihistamines, antipsychotics, melatonin and phytotherapeutics are not recommended for insomnia treatment (strong to weak recommendations, low- to very-low-quality evidence). Light therapy and exercise need to be further evaluated to judge their usefulness in the treatment of insomnia (weak recommendation, low-quality evidence). Complementary and alternative treatments (e.g. homeopathy, acupuncture) are not recommended for insomnia treatment (weak recommendation, very-low-quality evidence).

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Gaps between knowing and doing: understanding and assessing the barriers to optimal health care.

Martin Dupuis, Tricia R. Tooman, Anthea L Cochrane … (2006)

A significant gap exists between science and clinical practice guidelines, on the one hand, and actual clinical practice, on the other. An in-depth understanding of the barriers and incentives contributing to the gap can lead to interventions that effect change toward optimal practice and thus to better care. A systematic review of English language studies involving human subjects and published from January 1998 to March 2007 yielded 256 articles that fulfilled established criteria. The analysis was guided by two research questions: How are barriers are assessed? and What types of barriers are identified? The studies abstracted were coded according to 33 emerging themes; placed into seven categories that typified the barriers; grouped as to whether they involved the health care professional, the guideline, the scientific evidence, the patient, or the health system; and organized according to relationship pattern between barriers. The results expand our understanding of how multiple factors pose barriers to optimal clinical practice. The review reveals increasing numbers of behavioral and system barriers. Quantitative survey type assessments continue to dominate barrier research; however, an increasing number of qualitative and mixed-method study designs have emerged recently. The findings establish the evolution of research methodologies and emerging barriers to the translation of knowing to doing. While many studies are methodologically weak, there are indications that designs are becoming more aligned with the complexity of the health care environment. The review provides support for the need to examine multiple factors within the knowledge-to-action process.

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Benzodiazepines revisited--will we ever learn?

Malcolm Lader (2011)

To re-examine various aspects of the benzodiazepines (BZDs), widely prescribed for 50 years, mainly to treat anxiety and insomnia. It is a descriptive review based on the Okey Lecture delivered at the Institute of Psychiatry, King's College London, in November 2010. A search of the literature was carried out in the Medline, Embase and Cochrane Collaboration databases, using the codeword 'benzodiazepine(s)', alone and in conjunction with various terms such as 'dependence', 'abuse', etc. Further hand-searches were made based on the reference lists of key papers. As 60,000 references were found, this review is not exhaustive. It concentrates on the adverse effects, dependence and abuse. Almost from their introduction the BZDs have been controversial, with polarized opinions, advocates pointing out their efficacy, tolerability and patient acceptability, opponents deprecating their adverse effects, dependence and abuse liability. More recently, the advent of alternative and usually safer medications has opened up the debate. The review noted a series of adverse effects that continued to cause concern, such as cognitive and psychomotor impairment. In addition, dependence and abuse remain as serious problems. Despite warnings and guidelines, usage of these drugs remains at a high level. The limitations in their use both as choice of therapy and with respect to conservative dosage and duration of use are highlighted. The distinction between low-dose 'iatrogenic' dependence and high-dose abuse/misuse is emphasized. The practical problems with the benzodiazepines have persisted for 50 years, but have been ignored by many practitioners and almost all official bodies. The risk-benefit ratio of the benzodiazepines remains positive in most patients in the short term (2-4 weeks) but is unestablished beyond that time, due mainly to the difficulty in preventing short-term use from extending indefinitely with the risk of dependence. Other research issues include the possibility of long-term brain changes and evaluating the role of the benzodiazepine antagonist, flumazenil, in aiding withdrawal. © 2011 The Author, Addiction © 2011 Society for the Study of Addiction.

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Author and article information

Contributors

Vivien Weiß:

ORCID: http://orcid.org/0000-0001-5958-6243

+49(0)551/39-14227 , vivien.weiss@med.uni-goettingen.de

Journal

Journal ID (nlm-ta): Eur J Clin Pharmacol

Journal ID (iso-abbrev): Eur. J. Clin. Pharmacol

Title: European Journal of Clinical Pharmacology

Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )

ISSN (Print): 0031-6970

ISSN (Electronic): 1432-1041

Publication date (Electronic): 13 September 2018

Publication date PMC-release: 13 September 2018

Publication date (Print): 2019

Volume: 75

Issue: 1

Pages: 87-97

Affiliations

[1 ]ISNI 0000 0001 0482 5331, GRID grid.411984.1, Department of General Practice, , University Medical Center, Göttingen, ; Humboldtallee 38, 37073 Göttingen, Germany

[2 ]ISNI 0000 0004 4683 4190, GRID grid.491719.3, Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, ; An der Lutter 24, 37075 Göttingen, Germany

[3 ]ISNI 0000 0001 2297 4381, GRID grid.7704.4, SOCIUM Research Center on Inequality and Social Policy, , University of Bremen, ; Mary-Somerville-Straße 3, 28359 Bremen, Germany

Author information

Vivien Weiß http://orcid.org/0000-0001-5958-6243

Article

Publisher ID: 2555

DOI: 10.1007/s00228-018-2555-9

PMC ID: 6326988

PubMed ID: 30215101

SO-VID: 2c424ca5-2f97-4d7d-affe-4f50bcdf3485

License:

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

History

Date received : 8 March 2018

Date accepted : 3 September 2018

Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100003107, Bundesministerium für Gesundheit;

Award ID: FKZ-IIA5-2513DSM228

Award Recipient : Eva Hummers

Custom metadata

ScienceOpen disciplines: Pharmacology & Pharmaceutical medicine

Keywords: drug utilization, hypnotics and sedatives,hospital medical staff,family physicians,attitudes of health personnel,qualitative research

Data availability:

ScienceOpen disciplines: Pharmacology & Pharmaceutical medicine

Keywords: drug utilization, hypnotics and sedatives, hospital medical staff, family physicians, attitudes of health personnel, qualitative research

The interplay of context factors in hypnotic and sedative prescription in primary and secondary care—a qualitative study

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iDR24 Conference - Poster Abstracts

Most cited references 45

European guideline for the diagnosis and treatment of insomnia

Gaps between knowing and doing: understanding and assessing the barriers to optimal health care.

Benzodiazepines revisited--will we ever learn?

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