Non-Guideline-Compliant Prescriptions of Benzodiazepines and Z Drugs: Effects of Social Norm Feedback. A Randomized Controlled Trial.

Abstract

BACKGROUND: In Germany, long-term prescribing of benzodiazepines and Z drugs remains common even though their use for no more than 30 days is recommended in the guidelines because of risks including dependence, cognitive impairment, and falling. In this randomized controlled trial, we studied whether social norm feedback can reduce non-guideline-compliant prescribing in outpatient practices. METHODS: Using routine prescribing data that we obtained from the Rhineland-Palatinate Association of Statutory Health Insurance Physicians (KV RLP) for the third and fourth quarters of 2022, we identified 1258 outpatient primary care practices that had issued non-guideline-compliant benzodiazepine or Z-drug prescriptions (≥30 days). These practices were randomized (1:1) to receive either social norm feedback or no feedback (629 practices in each group). The practices in the intervention group were sent a letter in June 2023 containing their prescribing percentile rank relative to other practices in the same specialty, as well as guideline recommendations; those in the control group were not contacted. The primary outcome was the change in defined daily doses (DDD) of non-guideline-compliant prescriptions per 1000 patients from Q3/Q4 2022 to Q3/Q4 2023. The data were analyzed by the intention-to-treat principle. 108 practices were lost to follow-up. RESULTS: The intervention group displayed a larger reduction in DDD of non-guideline-compliant prescriptions per 1000 patients (-6.5%, from 408.97 to 382.40) than the control group (-3.0%, from 401.38 to 389.30; p = 0.006), as well as in the percentage of patients receiving inappropriate prescriptions (-20.2% vs -6.6%; p < 0.001). The strongest effect was seen among practices that had been below the 65th percentile of non-compliant prescribing at baseline. CONCLUSION: This first randomized controlled trial on social norm feedback in Germany demonstrates that a simple, low-cost social norm intervention can reduce inappropriate benzodiazepine and Z-drug prescribing and help address an ongoing public health concern.