Abstract

Context
This improvement project was set in a single general practice in rural Lincolnshire, East Midlands, UK. All doctors and practice staff were actively engaged in reducing inappropriate long term prescribing of hypnotic drugs in the practice population as part of a Quality Improvement Collaborative (QIC).

Problem
Hypnotic drugs are only licensed for short term use but inappropriate long-term prescribing of hypnotics is common. Evidence from previous studies shows that hypnotics have limited therapeutic value and potential for significant adverse cognitive and psychiatric effects. Although there is evidence for hypnotic drug withdrawal programmes there have been few improvement projects showing whether and how this might work in practice.

Assessment of problem and analysis of its causes
Baseline rates of hypnotic prescribing were analysed and charted using statistical process control (SPC) methods. Patients on repeat prescriptions of hypnotic drugs were identified from the practice database. Causes, solutions and barriers were determined using surveys and focus groups of patients and staff. A withdrawal programme was implemented for all patients on long term hypnotics by writing to patients, arranging a consultation, making a detailed assessment and using techniques such as tapering doses of drugs and using cognitive behavioural therapy for insomnia (CBTi) during general practice consultations. The improvement was supported by a QIC called REST (Resources for Effective Sleep Treatment) which supported the practice team to implement sleep assessment and management tools using plan-do-study-act cycles, process mapping and new protocols.

Strategy for change
The change was coordinated in the practice over six months, with each practitioner maintaining an agreed and consistent approach for managing sleep problems. All staff including doctors, nurses, administrative staff and practice manager took part. Patients were informed of the planned alteration to their treatment for their sleeping problem via a letter detailing exactly how the new regime would be implemented alongside the reasons for this. Patients were offered an appointment to discuss the proposed changes with their GP and all did so.

Measurement of improvement
We measured improvement by analysing prescribing rates using statistical process control charts. We also surveyed patients and conducted a focus group to explore the patients’ personal experiences of the new service the support they received during the withdrawal programme and how they manage their sleep now.

Effects of changes
There was a significant reduction in hypnotic prescribing of benzodiazepines (664.9 to 62.0 ADQ per 1000-STAR-PU) and Z drugs (2156.7 to 120.1A ADQ per STAR-PU) in the practice over the six months of the project and this improvement has been sustained since the initiative. Some patients were initially unhappy about being taken off sleeping tablets but with the approach described were successfully withdrawn. No patients are now prescribed long term benzodiazepines or Z drugs for sleep difficulties in the practice. Psychological treatments for the management of sleep problems are used first-line instead of hypnotics. The transition from hypnotics to psychological treatments is evidence of improvement in patient care.

Lessons learnt
It is possible to implement a hypnotic withdrawal programme over a relatively short period of time in general practice using a carefully constructed programme applied consistently by staff comprising a letter to patients, tapering of drugs and CBTi supported through education of practitioners in sleep management and quality improvement methods.

Message for others
Key factors for success in this improvement project were a motivated practice team, a range of solutions which could be adapted locally, expert support on sleep management and quality improvement methods and feedback of results. We will present further data on the experience of patients in this improvement project.