Main findings
The proportion of patients who continued their benzodiazepine prescriptions beyond the recommended duration did not decrease between 2011 and 2012, despite recommendations and financial incentives. On the contrary, this database study shows a slight but significant increase in the number of patients who did not interrupt benzodiazepine consumption. One in five patients who initiated a benzodiazepine regimen continued drug intake beyond the recommended 12-week duration, which increased to more than one in four patients over the age of 65. The proportion of long half-life benzodiazepine prescriptions decreased in the latter population, which could be attributed to a 20% increase from 2011 to 2012 in the overall prescription of short half-life benzodiazepines, compared with no change in long half-life benzodiazepine prescription. This study shows that substituting long half-life benzodiazepines with short half-life benzodiazepines might be counterproductive because the prescription of short half-life benzodiazepines was significantly associated with treatment continuation beyond the recommended duration.
Strengths and weaknesses
The pay-for-performance intervention that was evaluated in this study was implemented as a nationwide strategy in a country in which these drugs are extensively prescribed. Policy makers and GPs organisations selected the objectives and the related outcomes of their own initiatives. Our study was designed to be consistent with the objectives and evaluations put forth by policy makers, and the research findings should be relevant to GPs in clinical practice.
The study has several limitations because policy makers primarily designed the implemented intervention without researchers’ opinions. This pay-for-performance study was an uncontrolled before-and-after study, which did not allow the assertion of a causal link between the intervention and the observed changes [
22,
23]. An optional pay-for-performance system had been piloted in France previously; consequently, the effective novelty of the pay-for-performance scheme probably concerned only two-thirds of the GPs who participated to the study. Information in this study was extracted from large databases derived from healthcare insurance systems, which is similar to previous studies [
24‐
26]. A limitation reported in other studies of inappropriate prescribing was that information about disease and indications could not be considered. Drug intake could be assessed using only proxy measures because data collection was based on reimbursement.
Findings relative to other studies
The positive impact of financial incentives on benzodiazepine prescribing practices is difficult to assess. Our results are consistent with previous evaluations of the effectiveness of pay-for-performance strategies. Evidence of improvement in patient health is lacking [
22,
23]. Flodgren et al. reported that financial incentives for physicians were generally ineffective for improving compliance with guideline outcomes [
23]. In contrast, two recent Dutch studies demonstrated a link between payment facilities and benzodiazepine use [
27,
28], although the interventions in these studies most likely had a greater impact on patient behaviour than on GPs’ prescribing practices. In particular, these studies evaluated the impact of benzodiazepine delisting by health insurance. The first study focused on indications for “anxiety” and “sleep disorders” and demonstrated a moderate impact of delisting on the number of benzodiazepine treatment initiations [
27]. The second study compared the number of days that each patient underwent benzodiazepine treatment during the 2 years before and 2 years after delisting. The number of days of treatment decreased, especially in patients with initial low intake [
28].
Financial incentives for GPs did not favour the discontinuation of benzodiazepine prescribing. Two interpretations of this result must be considered. First, the inappropriate practices of GPs are likely not due to a lack of motivation. Previous studies have also shown that GPs are aware of their actions [
29]. Thus, further interventions should focus on other solutions. For instance, cognitive behavioural therapies are recommended [
30], but no reimbursement is provided to the patient for such therapies, even if he or she consults a psychologist [
31]. Second, patients with psychological disorders are likely to face difficulties that require sustained long-term care. Karanikolos reported that the prevalence of mental health disorders in people undergoing primary care increased significantly in European countries in association with the current economic crisis and austerity policies [
32]. Many anxiety and depressive symptoms can be attributed to either individual or family unemployment or difficulties with payments [
33]. Many recent publications have also reported increasing suicide rates in European countries [
34‐
36], so the study periods were unfavourable for expectations of a decrease in benzodiazepine consumption. In further studies, clinical assessment of indications and distinctions among anxiety, sleep disorders and other indications would facilitate an improved focus on inappropriate long-term use of benzodiazepines. GPs should reconsider treatment indications to shift towards non-pharmacological treatments or other drugs, such as serotonin reuptake inhibitors, to resolve this issue regarding benzodiazepine prescriptions. These alternative treatments could help to avoid the side effects of benzodiazepines.
The reduced proportion of long half-life benzodiazepine prescriptions was consistent with the key message of policy makers to GPs. Previous authors suggested that reducing the use of long half-life benzodiazepines in individuals older than 65 years could reduce the risk of sedation, falls, hip fractures, memory disorders and accidents [
37,
38]. However, other publications did not find the same associations [
39,
40]. The use of short-acting benzodiazepines has also been associated with fall-related injuries [
41]. Therefore, the changes in physician practice that were observed in this study might not be relevant. Prescribers should evaluate the indication, dose and duration of benzodiazepine treatment according to the clinical characteristics of patients. Half-life duration is an important consideration but should not be the main reason for choosing a benzodiazepine. Indeed, half-life benzodiazepine classifications differ between different authors. The French pay-for-performance intervention refers to an international classification published by Laroche in 2007 [
42], but other studies distinguish three types of benzodiazepines: short, intermediate and long half-life benzodiazepines [
43]. Last but not least, this study suggests that the use of short half-life drugs might increase the risk of addiction, which is consistent with their pharmacology [
44].