Teaching Health Profession Students the Skills Needed to Maintain Wellbeing

by Anna Carroll Harris, PharmD, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

Numerous studies have been published exploring burnout among healthcare workers. Health profession students are also prone to burnout due to the vigorous course load required to obtain their degrees. The WHO defines burnout as a syndrome that is directly correlated with an environment that exposes workers or students to chronic stress and where the stressors are not successfully handled. It is characterized by feelings of emotional exhaustion, amplified feelings of negativism towards one’s job, and decreased professional worth.

The occurrence of burnout not only affects those working and learning in the healthcare industry, but also the patients to whom they provide care. For example, pharmacists who are experiencing increased levels of stress and emotional exhaustion may feel a sense of depersonalization towards patients they are caring for. This in turn can lead to medication errors and harmful events for patients.¹ It is imperative that schools and colleges of pharmacy, and other health professional degree programs, help students develop the skillset and positive behavior practices that needed to maintain their wellbeing and prevent burnout throughout their careers.²

Many professional organizations have noted the need to provide health profession students and healthcare practitioners with resources to encourage a state of well-being and prevent burnout. The American Association of Colleges of Pharmacy has published two policies, a 2017 and 2018 statement, in response to the increasing realization that burnout is prevalent. Both statements encourage and hold schools and colleges of pharmacies accountable for effectively promoting wellness and implementing management methods directed to students, faculty, preceptors, and staff.³ In reaction to these statements, schools and colleges of pharmacy across the country are putting programs into place that foster an environment for creating and maintaining well-being. For example, the Ohio State University College of Pharmacy has a “Wellness Corner” dedicated to providing faculty, staff, and students an environment that promotes and protects well-being. They have been recognized across their campus as having a strong culture of wellness by implementing evidence-based wellness strategies and providing tools to achieve a sense of wellbeing.⁴

The University of Kentucky College of Pharmacy completed a study where they “nudged” pharmacy students to adopt well-being behaviors. Over a span of 4 months, a series of optional well-being challenges were embedded in their pharmacy management course. These challenges included limiting smartphone use, emphasizing feelings of gratitude, good sleep hygiene, and engaging in regular exercise. Participants completed a reflection at the end of the course that explored reasons for participation, prior behaviors, and if participants planned to continue to implement the new behaviors after completion of the challenges. The majority of participants indicated that they planned on maintaining the positive behaviors moving forward.⁵

The specific stressors that lead to burnout have been identified in many studies. A study that included pharmacy students in an urban Midwestern region identified strategies that pharmacy students utilized to protect their wellbeing and prevent burnout. Students participating in a social and administrative science course were to write a reflection on factors that they believed had the greatest impact, either positively, negatively or mixed, on their wellbeing during pharmacy school. Four specific themes emerged as strategies that students use to cope with stressors during pharmacy school:⁶

1. Availability and accessibility of institutional resources
2. Personal time management and organizational strategies
3. Personal, mental, and physical health strategies
4. Activities that maintain social relationships

These results provide schools and colleges of pharmacy specific ways they can augment their campuses' attempts to foster wellbeing. Ensuring that institutional resources, such as the medical library and faculty, are readily available to students can help reduce stress and maintain wellbeing. Offering counseling and health services to those who needed them is supportive of students’ wellbeing. A few of the wellness activities mentioned in the Ohio State University College of Pharmacy “Wellness Corner” were a take five-station, a mental timeout area where students could play a game or create a craft, as well as monthly wellness walks. Ensuring that students maintain a healthy balance between schoolwork and leisure activities can reduce stress. Emphasizing the need for students to take time for themselves to socialize with friends and family and maintain hobbies is important.

In the unprecedented times of a pandemic, providing students with resources and teaching them skills to protect their well-being is more essential than ever. With COVID-19 disrupting the lives and wellbeing of so many, health profession students are dealing with the added stressors of helping take care of family members and serving on the frontlines of healthcare, in addition to their demanding coursework.⁷ The loss of person-to-person contact and being isolated away from one’s family has taken a toll on many students. What once provided a means for students to reset and take a break from the rigors of academic coursework is now discouraged.  Schools and colleges need to find creative ways to provide ongoing support to their students, faculty, and staff.  See Table 1.

Table 1: Examples of support during a pandemic

Virtual group exercise	Email check-ins	Virtual mentorships programs
Virtual game nights	Virtual group meditations	PPE drives/mask-making
Virtual book clubs	Virtual dinner dates	Virtual tutoring

As health profession students graduate, they will continue to experience stressful times and emotional exhaustion that can lead down the path of burnout. Health profession programs should work to implement programming and strategies early in their curricula that can provide students with a skillset to prevent burnout. General professional development courses, which are often part of the curriculum, would be a great place to embed lectures about managing stress and including periodic wellbeing challenges for students. These longitudinal courses should be pass/fail due to the nature of the content and should encourage students to adopt and execute tactics that best fit their personal circumstances and needs. Learning about and implementing these healthy habits while in school can help students cope with the stressors they will face throughout their careers.

References

1. World Health Organization. Burn-out an "occupational phenomenon": International Classification of Diseases. Accessed November 18, 2020.
2. Hagemann TM, Reed BN, Bradley BA, et al. Burnout among clinical pharmacists: Causes, interventions, and a call to action. J Am Coll Clin Pharm 2020; 3:832–842.
3. American Association of Colleges of Pharmacy. AACP Statement on Commitment to Clinician Well-being and Resilience. Accessed November 18, 2020. https://accpjournals.onlinelibrary.wiley.com/doi/full/10.1002/jac5.1256
4. The Ohio State University College of Pharmacy. Wellness Corner. https://pharmacy.osu.edu/wellness-corner. Access November 18, 2020.
5. Cain J. Effectiveness of Issuing Well-being Challenges to Nudge Pharmacy Students to Adopt Well-being Protective Behaviors. Am J Pharm Educ 2020; 84(8) Article 7875.
6. Abraham O, Babal, JC, Brasel KV, Gay S. Strategies first year doctor of pharmacy students use to promote well-being. Currents in Pharmacy Teaching and Learning. 2021; 13:29–35.
7. Schlesselman LS, Cain J, DiVall M. THE COVID-19 PANDEMIC ACROSS THE ACADEMY: Improving and Restoring the Well-being and Resilience of Pharmacy Students during a Pandemic. Am J Pharm Educ 2020; 84 (6) Article 8144.

Community Baby Showers: An Innovative Approach to Teaching New Mothers Sleep Safety

by Megan Carter, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Ahlers-Schmidt C R, Schunn C, Hervey A M, et al. Redesigned community baby showers to promote infant safe sleep. Health Education Journal 2020; 79(8): 888-900.

When looking through the Health Education Journal, this article piqued my interest because I was aware of the importance of safe sleeping habits for infants.  My mom works for the Alabama Department of Public Health and has been reviewing infant death cases for about 15 years.  Although she doesn't reveal details about the cases she reviews, she has shared a couple of particularly heart-wrenching stories regarding babies who died.  Unfortunately, these stories are not rare, as nearly 3500 infant deaths in the USA are due to sleep-related causes. Unfortunately, although we know much more about sleep safety during infancy, this number has not declined in recent years.¹ These kinds of deaths are preventable if parents are properly educated about how to create a safe sleeping environment.  This study aimed to provide sleep safety education to mothers, specifically mothers from low-income communities, in a relaxed environment. The authors assessed a novel approach that could increase knowledge and health-promoting behaviors.

The authors of this study designed their educational intervention — including recruitment, lesson plans, materials, and assessments — around constructs from the Health Beliefs Model.  The intervention was delivered at community "baby showers" conducted in Sedgwick County, Kansas, and targeted women who were pregnant or who had recently delivered.  Upon arrival at the shower, participants were asked to complete a pre-assessment and information card.  Organizers divided the women into tour groups of 3-5 participants with a volunteer guide who led the women around the various vendor and educational booths for brief presentations.  The last stop for each tour group was the Safe Sleep Crib Demonstration.  Certified nurses or safe sleep instructors used a demonstration crib with safety-approved items to demonstrate their effectiveness as well as examples of unsafe items that are a hazard to infants.  Instructors provided tips for removing hazardous items from the infant's sleep environment.  The sessions were not time-constrained, allowing time for participants to ask questions.  After the shower, participants took home a safety-approved portable crib, blanket, and educational handouts/materials.

These events were held twice yearly (March and October) from Spring 2015 to Spring 2019 and recruited women using a variety of means including fliers at churches and clinics, maternal and child health programs, social media posts, and through partner organizations.  The program specifically targeted locations that served low-income communities, as this was the population that was most at-risk for sleep-related infant deaths.  During the study period, nine “community baby shower” events were conducted. The participants came from a range of racial and ethnic backgrounds: Non-Hispanic Black (30.4%), Non-Hispanic White (30.4%), and Hispanics (25.1%).  Greater than 70% of participants had only a high school education or less and greater than 70% were on Medicaid or uninsured.  It is also notable that less than half of participants received prenatal care from a private provider and about 20% received care from a county health department, community center, or received no routine care. The pre-assessment consisted of true/false statements developed around the Health Belief Model constructs on infant sleep safety and were compared to the responses to the same questions given as a post-assessment.  McNemar's test for paired dichotomous variables was used to analyze differences in pre- and post-assessment responses along with the McNemar odds ratio statistic.  The following true/false questions were included on the pre- and post-assessments:

• My baby is at risk of dying of SIDS
• Loose blankets in the crib can cause infant death
• Sleeping with my baby can cause infant death
• Putting my baby alone, on the back in a crib will help protect her
• My baby will choke on his back
• People tell me different things about how my baby should sleep and I don't know what to do.
• I can't keep my baby warm without blankets.
• I don't have room for a crib in my room.

The results of the study demonstrated statistically significance (p<0.001) improvements in the participants' responses in all but two of the assessment questions.  Responses to questions about knowledge and intentions showed changes in sleep positions, sleep locations, crib items, and plans to discuss safe sleep with others.  Overall, these results appear promising and events such as the community baby shower provide an excellent opportunity to teach sleep safety to mothers.

The results look promising, but as with any study, statistically significant results don't always equate to an improvement in outcomes.  This study did have several strengths, as the participants are representative of the target population and the assessment questions were based on the Health Belief Model and evaluated by the Medical Society of Sedgwick County's Safe Sleep Taskforce.  On the flip side, this study was conducted in one community, so may not be generalizable to other communities.  The study also targeted individuals from low-income areas with lower education, so the results may not apply to mothers in higher-income neighborhoods with greater levels of education.  The recruiting methods did yield a diverse participant population but relatively few dates that the event was held likely limited many women from attending.  Another potential issue was the true/false statements included in the assessment.  Several of the statements are subjective and others are potentially confusing, which may have contributed to some of the nonsignificant results.  Improving the clarity of these statements could improve the accuracy and validity of this study.  While the results were promising, I would be interested to see if the participants put their new knowledge into practice.  Are mothers able to identify hazardous materials in their home? Do they remove or replace these items?  Have the rates of infant death or hospital visits due to unsafe sleeping habits improved in this county as a result of the educational intervention?  Additionally, the results could have been biased as the group who developed the program assessed the results.  Moreover, there was no control group who received instruction in a more “traditional” manner.

Overall, this study proves that educational programs that structure their lesson plans around the Health Belief Model and offered in non-traditional environments can lead to changes in behavioral intentions.  It is important to recognize that instructional programs can be implemented outside of the traditional classroom settings and that informal community events can a venue where patients can learn about important health topics in a fun and engaging way.

References

1. About 3,500 babies in the US are lost to sleep-related deaths each year. (2018, January 09). Retrieved November 30, 2020, from https://www.cdc.gov/media/releases/2018/p0109-sleep-related-deaths.html
2. Ahlers-Schmidt C R, Schunn C, Hervey A M, et al. Redesigned community baby showers to promote infant safe sleep. Health Education Journal 2020; 79(8): 888-900.

The Importance of Post-Exam Quality Assurance

by Karmen Garey, PharmD, PGY-1 Baptist Memorial Hospital – North Mississippi Pharmacy Resident, University of Mississippi School of Pharmacy

From the students’ perspective, once they hit “submit” after completing an exam they think “Thank goodness that’s done!” However, for teachers, there is still some critical work to do. Now it’s time to review the performance data to ensure the examination was fair and measured what was intended. Here are a few tips and strategies to assess the quality of an exam.

Make certain the exam (as a whole) is a “good” one 

Before the exam is administered to students, a good exam should be written with the following goals in mind:^1,2

• An exam should address multiple levels of Bloom’s taxonomy — from knowledge recall to application and analysis.
• The exam should include a variety of questions that test a range of concepts that map back to the learning objectives.
• The consistency of the exam's performance over time is important. An exam should routinely perform the same from year to year despite some changes to the questions.
• An exam should measure the learning outcomes and course material it was designed to test.

Make certain the questions included on the exam are “good” ones

There are two types of questions that should be included on exams: mastery questions and discriminating questions.  Mastery questions are those questions that students are expected to excel on.³ This type of question is typically a “knowledge level” question in Bloom’s Taxonomy. The questions often test factual recall and the recognition of fundamental material.²  These questions might be called “gimmie questions” by the students; however, teachers include these questions to ensure that students have a firm understanding of the basic but super important concepts or facts.  Discrimination questions, on the other hand, are intended to identify students who have a deeper knowledge of the material and separate students into different performance levels (e.g. identify "A", "B", and "C" students).  Higher-performing students are expected to answer these questions correctly more often than lower-performing students.  This type of question often targets the comprehension, application, analysis, synthesis, or evaluation cognitive level in Bloom’s taxonomy. These questions require an in-depth knowledge of the subject matter.²

Next, let’s look at the distractors.  Does each question include appropriate distractors?³ A distractor is an answer choice that, while wrong, sounds and appears like it could be plausible. A good distractor should be clear and concise and should be similar in structure and content to the correct response. Savvy test-takers have learned to spot answers that seem different in some way, so even small variations in the style, subject matter, and length of the answer choices can provide clues. 

Next, is the question stem clearly written.  Is it clear what the learner is being asked?  Or is the question open to interpretation?  When writing questions, it is important to ensure that the question is not misconstrued.  Sometimes students will overthink a question and try to find the hidden meaning when there is none. To avoid this problem, use words that are unambiguous.  Avoid phrasing that could be cryptic.

Finally, is the answer to the question correctly keyed.  If a lot of students selected the “wrong” answer, it's possible that the question was miskeyed.  While this is not something that happens often, it does happen! So it is always a good idea to double-check that the correct answer was selected on the answer key. 

Some other things to consider as you look at the post-exam performance data.  How did the exam scores look last year? While a group of students performing much better or much worse than previous year’s students is not always an indication that the exam is invalid, it should prompt additional questions.

• Was the material taught in a manner that was different from previous years?
• Was the exam formatted or delivered differently?
• Could the students this year have been less (or better) prepared in some way to comprehend the material?
• Is cheating suspected?
• If there are multiple instructors, did students received different messages about the content?

The answers to these questions may not be obvious or even relevant, but it is something to keep in mind.

Use the post-exam statistical analysis to identify problem questions³

As technology becomes a more integral part of exam delivery, it enables a wealth of data that can be used for post-exam quality assurance. Most post-exam statistical analysis tools report similar elements; however, the names may be slightly different. ExamSoft is among the most common exam delivery tools available today and routinely reports these statistics:

• Item Difficulty represents the difficulty of a question. It reports the percentage of students who correctly answered the question. The lower the percentage the more difficult the question. There is not a set number that the item difficulty should be but the number should be used to ensure the intent behind the question matches the number. For example, if the teacher wants the item to be a mastery question, the difficulty should be 0.90 to 1.00 with very few students getting the question wrong.  If the question is meant to separate those who have a firm grasp on the material vs. those who don’t, lower levels are acceptable. An instructor may have a difficulty “cutoff” number in mind where anything below 0.6 (for example) prompts additional analysis of the question.

• Upper/Lower 27%, Discrimination Index, and Point Biserial are each calculated differently but they report a similar concept. Stated simply, they all determine whether the top performers on the exam achieved better results on a question compared to those who did not perform well. If the top performers don’t out-perform the poor performers, the question should be assessed to determine why.
  • Upper 27% / Lower 27% - what percentage of the top 27%  vs. the bottom 27% of performers got the question correct.
  • Discrimination Index – this represents the difference in performance between the best performers vs. the lowest performers.
  • Point Biserial – indicates whether those who answered correctly on a specific item correlates with doing well on the exam overall.  In other words, does performance on this question predict whether a student did well (or not so well) on the exam? 

 

Correlation with Overall Exam was	Point Biserial
Very good	>0.3
Good	0.2-0.29
Moderate	0.09-0.19
Poor	<0.09

So, let’s look at the statistical analysis from two example questions. 

• This was a mastery question — students are expected to do well on this question. It’s a fundamental concept that all students should know.
• The Discrimination index = 0.04 which indicates almost no discrimination between the top and bottom performers. In this case, because it’s a mastery question and we expected all students to perform well on this question.  Thus, we don’t expect this question to discriminate between the best and worse performers.
• The Point Biserial = 0.10 indicating this question only moderately correlate with doing well on the exam overall. Again, the top and bottom performers performed quite similarly on this question, so there won’t be a strong correlation between the performance on this question and the overall exam.
• If this question was not intended to be a mastery question, perhaps the material was taught particularly well … or maybe there was cheating involved

Now let’s take a look at a question where only 66% of the students selected the correct response.

• Item difficulty = 0.66 so 66% of the students selected the correct response. This is not a bad thing but it is important to make sure the students who understood the material were more likely to get this question right.
• This is intended to be a discriminating question, so let’s make certain it’s actually discriminating between the best and worse performers.
• Look at the Upper vs. Lower 27%: 82% of the top performers got this question correct. Only 46% of those who performed the poorest on this exam got this question correct.
• Discrimination Index: 0.36. This question did a good job discriminating between the best and worst performers on this exam.
• Point Biserial = 0.28 Performance on this question has a good correlation with the student’s overall exam performance.

While there are no hard rules for how to analyze an examination, the strategies I’ve outlined in this blog post are some of the best practices every teacher should follow. It is important to follow a systematic process and establish “cut-offs” in advance. The key is to be clear and consistent from exam to exam.

References

1. Brame C. Writing Good Multiple Choice Test Questions. 2013. Accessed December 3, 2020.
2. Omar N, Haris SS, Hassan R, Arshad H, Rahmat M, Zainal NFA, et al. Automated Analysis of Exam Questions According to Bloom's Taxonomy. Procedia - Social and Behavioral Sciences. 2012;59:297–303. Accessed December 1, 2020.
3. Ermie E. Psychometrics 101: Know What Your Assessment Data Is Telling You. Examsoft. 2015. Accessed November 18, 2020.

A Hopeful Pharmacist-Led Educational Program to Reduce Prescription Errors

by Spencer Harris, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of:  Gursanscky J, Young J, Griffett K, Liew D, Smallwood D. Benefit of targeted, pharmacist-led education for junior doctors in reducing prescription writing errors - a controlled trial. Journal of Pharmacy Practice and Research. 2018;48(1):26–35.

Writing a safe and properly-formatted prescription is no easy task. Not only does the prescriber need to include the patient’s name, date of birth or address, the date of the writing, the name of the drug, the dose, the dosage form, the instructions on how to take it, the quantity, the number of refills, and the signature of the authorizing provider but the prescriber must write a prescription that is safe for the patient. Factor in the multitude of patients a physician sees, the innumerable questions that she receives, the monotony of writing dozens of prescriptions every day, and many other variables that add stress on her shoulders, it's understandable there will be an error here and there. While understandable, it is not something that can be accepted or overlooked. Each year, according to the FDA’s Wedwatch website, more than one hundred thousand reports about medication errors are documented. A subset of these reports are related to errors in prescribing errors, both in the sense of missing information and prescribing inappropriate therapy.  These errors affect patient health outcomes; this is inexcusable. I have witnessed these errors firsthand, as I am sure nearly every person who has worked in a pharmacy has.

Educational programs might be one way to address this problem. But an educational program must be efficient and compatible with the constant bustle of healthcare, where there is no time to waste. It is for this reason that I read the study by Gursanscky and his colleagues from Monash University in Australia with high hopes.

The investigators implemented a pharmacist-led approach to teaching junior physicians (who write a notably large proportion of prescriptions in teaching hospitals) about prescription writing.  They compared this approach to an online education program (based on the National Inpatient Medication Chart Training course) and to a control group that did not receive any additional instruction. The study was a cluster-randomized trial that enrolled all junior doctors in the general medical units at an Australian tertiary hospital (twelve interns and four registrars). The junior physicians were divided equally into four person-groups who were randomly assigned to either the pharmacist-led intervention (one group), the e-learning intervention (one group), or the control arm (two groups).

The pharmacist-led intervention consisted of three very brief (10-minute) sessions per week for four weeks.  During these sessions, a clinical pharmacist discussed types of errors, their frequency, and severity. Over the four weeks, the pharmacist discussed each error type, why it was unsafe, its consequences, and how to avoid it. Following each tutorial, the pharmacist addressed participant questions. A full report on the intervention can be found in the original study.

Data was collected for three weeks before the intervention and for four weeks during the intervention. The data collected was the prescription error rate among all groups. An error was defined as a prescription that had incomplete patient or prescriber details or which was “illegible, incomplete, or incorrect.” The error rates were then compared using a Chi-square analysis for the pre- and post-intervention periods.

The results (n= 9,657 prescriptions analyzed) showed that the pharmacist-led group had a significantly lower rate of errors in the post-intervention period. Interestingly, the error rates in both the control group and the e-learning group increased significantly in the post-intervention period.

Table 1: Rate of Errors per Total Orders Before and After the Intervention Period

	Control	E-learning	Pharmacist-led
Pre-intervention	0.49	0.58	0.58
Post-intervention	0.59	0.63	0.37
p-value	<0.001	0.025	<0.001

This study addresses a real-world problem that negatively impacts patients and places a substantial burden on the healthcare system. Additionally, the study clearly describes the design of the educational intervention and outcome measures (e.g. the prescription writing error and its methods of data collection).  The number of prescriptions that were analyzed over the course of the study is very large (n=9,657). With that large of a sample, it is likely that the measured error rate is small but there is always the possibility of bias in the selection process. This study also has some flaws that can leave it weak in the eyes of reasonable readers. Specifically, the sample size of providers is small with only sixteen physicians, four per group.  The study duration was relatively short — approximately two months. These shortcomings may have led to the odd and significant increase in the error rate among the e-learning group and control group. Why would a course designed by professionals to instruct providers on how to write prescriptions result in a higher prescription error rate? Of course, the e-learning course could be poorly designed in some way, but I believe that the more likely reason is there was a small number of participants in the group.  Thus the changes in error rates observed in the control and pharmacist-led intervention groups might be due to chance as well.

Personally, I believe a pharmacist-led approach can and should result in a lower error rate, but I believe that this study must be replicated on a larger scale before any conclusions can be made about the effectiveness of this approach. None-the-less, the study is still relevant. The reason is simple; there are preventable medication errors being made all over the world and they lead to problems that directly affect patients. Until this problem is solved, we should be looking for answers and taking action to find good practices for reducing the errors. While this study is not of the highest quality, the intervention is simple and practical to implement.

Therefore, I urge those who are involved in the training of prescribers to use this study as a template to provide pharmacist-led instruction on prescription-writing. A successful program should include frequent but brief tutorials with an opportunity to ask questions. We must actively make efforts to provide our patients with the high-quality healthcare that they deserve.

References

1. Gursanscky J, Young J, Griffett K, Liew D, Smallwood D. Benefit of targeted, pharmacist-led education for junior doctors in reducing prescription writing errors - a controlled trial. Journal of Pharmacy Practice and Research. 2018; 48(1):26–35.
2. Working to Reduce Medication Errors [Internet]. U.S. Food and Drug Administration. FDA; 2019.  Accessed October 23, 2020.

Educating Older Adults Reduces Inappropriate Benzodiazepine Use

by Hallie Butler, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Review and Analysis of: Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S. Reduction of Inappropriate Benzodiazepine Prescriptions Among Older Adults Through Direct Patient Education: The EMPOWER Cluster Randomized Trial. JAMA Intern Med. 2014;174(6):890–898.

Shared decision making has been encouraged because it not only uses evidence but also considers the patient’s preferences and values to help choose the most effective therapy. The American Board of Internal Medicine initiated the Choosing Wisely campaign to assist providers and patients when deciding which therapies should be discontinued. The idea is that we need to de-escalate or discontinue therapies in older adults, those older than 65 years of age, that are unnecessary or may cause harm. The American Geriatrics Society took part in this campaign and they recommend against the use of benzodiazepines as a treatment for insomnia in older adults. The reason: benzodiazepines cause cognitive impairment and drastically increase the risk of falls and fractures. Unfortunately, benzodiazepines are commonly prescribed.  While research has consistently shown that the risks of benzodiazepines in the elderly far outweigh their benefits, older adults are more likely to be prescribed medications from this class than younger adults.² Even though physicians are aware of the risks of benzodiazepines, more than 50% of them continue to prescribe them to their older patients. The objective of the EMPOWER trial was to implement and measure the effectiveness of a direct-to-patient education program for older adults receiving long-term benzodiazepine therapy. In this study, they assessed rates of dose reduction and cessation of benzodiazepine use.¹ 

This study was a 2-arm, parallel-group, pragmatic cluster randomized control trial. Thirty community pharmacies participated. These pharmacies had at least 20% or more of their patients age 65 or older. There were 303 participants in this study ranging in age from 65 to 95 years old. The pharmacies were randomly assigned to either the intervention or control groups. All of the participants including the pharmacists, patients, evaluators, and prescribers were all blinded to the outcome assessment. To be eligible for this study, the patient had to have at least 5 active prescriptions with at least one being a benzodiazepine. They also had to receive a refill of a benzodiazepine for three consecutive months prior to study enrollment. Patients that had a diagnosis of severe mental illness or dementia, had a current prescription for an antipsychotic and/or cholinesterase inhibitor or memantine in the previous three months, or who were a resident of a long term care facility, were excluded. ¹

The educational intervention included a booklet on self-efficacy and social learning theory. Each of the participants completed a self-assessment about their opinions on benzodiazepine use and then received information on the harms associated with their use. Knowledge statements were presented with the purpose of creating a cognitive dissonance regarding the safety of benzodiazepine use. The participants were also educated on certain drug interactions and listened to peer champion stories to promote self-efficacy. The study team discussed with the patients about treatment options that were equally or more effective substitutions and educated them on how to taper off their benzodiazepine. The taper schedule was based on a 21-week protocol. The protocol was picture-based and showed the diminishing dose from a full pill to half pill, and finally a quarter pill. The participants were encouraged to speak with their providers and/or pharmacist about deprescribing. All of the reading material was written at a sixth-grade level and in 14 point font.¹ This should make it accessible to nearly all participants.  The control group received usual care and there was no active effort to educate these participants about the risks of benzodiazepine use.

The complete cessation of benzodiazepine use in six months was the primary outcome. In order to be classified as complete cessation, the patient must have had no benzodiazepine prescriptions or renewals at the time of the six-month follow-up and sustained for at least three consecutive months. The investigators verified this using pharmacy profiles. The study team defined a dose reduction as at least 25% or more reduction in dose compared to baseline for at least three consecutive months. Every participant had a complete follow-up at their pharmacy in six months. One research nurse and one investigator, who was blinded to group allocation, used a protocol to independently assess the outcomes.¹

Complete cessation was achieved in 27% of participants vs 5% in controls. There was an 8-fold higher probability of participants who received the intervention to discontinue benzodiazepine therapy. In addition, 11% of the intervention group reduced their benzodiazepine dose. This study suggests that teaching adults with an evidence-based approach, in a way that makes them question the safety and necessity of benzodiazepine use, is a safe and effective method to address over-prescribing. In previous studies that did not include a direct patient educational program, efforts to have physicians deprescribe benzodiazepine had a smaller impact. 

Systematically recruiting participants through community pharmacies is just one of the many strengths of this study.¹ Some other strengths would be the blinding of all participants and how they objectively assessment of drug discontinuation rates. I believe one weakness of this study was the six-month time frame for patient follow-up. With a longer follow-up period, the intervention could have proven to be more or less effective — there might have been a higher discontinuation rate or, perhaps, there might have been a high relapse rate.

Educators should pay attention to this particular study for several reasons. The patient education techniques these researchers used had a significant impact on patient behavior. This is a major accomplishment as many older adults are very reluctant to stop benzodiazepine use.² The educational intervention was well designed. It included different forms of instruction and promoted self-efficacy.  Promoting self-efficacy can help patients improve other chronic illnesses as well such as hypertension and diabetes. Patients must believe that they can make a difference in their health outcomes. A picture-based drug-tapering protocol is a great instructional tool because it is friendly to all ages, languages, and health literacy levels. A larger font should also be used when distributing materials to older adults as many of them have visual impairments. The strategies employed in this study can be used in a wide array of disease states and can be used as a model to get patients more involved in their care.

References

1. Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S. Reduction of Inappropriate Benzodiazepine Prescriptions Among Older Adults Through Direct Patient Education: The EMPOWER Cluster Randomized Trial. JAMA Intern Med.2014;174(6):890–898.
2. Pereto A. Data: Seniors prescribed benzodiazepines most often. Athena Health. Accessed November 25, 2020.