Protected: Qi14 – Hypnotics and sedatives

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Operationalisation

Denominator

The 18–79-year-old population ( / 1,000) alive at the end of the year.

Numerator

  • All defined in the denominator who were dispensed at least 180 DDDs of the following medications within 365 days of their first dispensation in a year
    • Anxiolytics, BZD derivates (N05BA)
    • Hypnotics, BZD derivates (N05CD)
    • Hypnotics, BZD-related medications, Z-drugs (N05CF)

Exclusions (Numerator, denominator)

  • Individuals aged under 18 or over 79 years at the end of the year.
  • Individuals who die or emigrate during the examined year.

Notes

  • Amount dispensed is examined in Defined daily doses (DDDs). DDD is the assumed average maintenance dose per day for a medication used for its main indication in adults (1).
  • The threshold of cumulative ≥180 DDDs per year is used commonly in literature and Nordic register-based research (2,3). Swedish national indicators define high use based on at least 0.5 DDDs per day for a year, which yields 182,5 DDD annually (4,5).
  • Finnish previous studies have included clonazepam (N03AE01) when used for non-epilepsy indications (2). However, indication details are not as comprehensively available in the prescription registers of other Nordic countries.

Sources of Data

  • Population register
  • Outpatient medication dispensations register

Information about the indicator set

Purpose

  • The quality indicator set is intended for comparison of effectiveness and/or safety aspects of prescribing across Nordic countries and subnational regions.
  • Further comparisons across population subgroups (e.g., socioeconomic position, immigration background) can inform equity considerations.
  • Further comparisons in relation to expenditures can inform efficiency considerations

Limitations

  • The indicators in the set use medication dispensings and/or sales data as a proxy for appropriate prescribing and medication use. This is to allow comparisons using register data, which have the advantage of being readily available and comprehensive in terms of population coverage and over time (5–7).
  • Register data are not without limitations. Medications may have been prescribed, but not collected from the pharmacy by the user. Collected medications may not have been (appropriately) used by the patient. Sales data may not be fully comparable across countries.
  • Register data are collected primarily for other purposes than quality assessment. Thus, discontinuities over time due to, e.g., legislative changes and administrative reforms need to be acknowledged in the interpretation of the results.
  • Indicators need to be updated regularly because clinical guidelines and the range of available medications change over time.
  • ATC-codes are based on WHO Collaborating Centre for Drug Statistics Methodology ATC/DDD Index version 2024

Background and literature related to the proposed indicator

Similar or related indicators in Nordic or European quality assessment guidelines or databases

OECD Health Care Quality Indicators (15)

  • Chronic Benzodiazepine Use: Number of patients per 1,000, aged 65 years and over who have prescriptions for benzodiazepines for more than 365 days

 Swedish Association of Local Authorities and Regions quality indicators (Vården i siffror/Primärvårdskvalitet)

  • Individuals (20–79 years) with regular use of benzodiazepines (at least 0,5 DDD per day for a year) per 1,000 inhabitants (4)
  • Individuals (20–79 years) with regular use BZD-related medications (at least 0,5 DDD per day for a year) per 1,000 inhabitants (5)
  • The share of patients initiating BZD who were prescribed ≤ 30 tablets (16)
  • The share of patients initiating BZD-related medications who were prescribed ≤ 30 tablets (17)

 The Finnish Institute for Health and Welfare (Kuva-mittaristo) (18)

  • Consumption of benzodiazepines DDD (defined daily dose) per 1,000 inhabitants per day

Similar or related indicators in international scientific literature

  • Number of prescriptions of anxiolytics, sedatives or hypnotics per quarter year / Number of insured persons with at least 1 medication prescription per quarter year. The measure was applied to Swiss insurance claim data environment without information on DDDs. The number or prescriptions was assessed crude but informative measure. The original indicator measured the proportion of persons receiving more than 30 DDD of persons receiving anxiolytics, sedatives, or hypnotics. (19)
  • DDDs benzodiazepines/benzodiazepine STAR-PU (including zopiclone and zolpidem) (20)
  • The percentage of patients aged over 65 years prescribed benzodiazepines for more than 6 months (21)
  • Percentage of patients in the practice who were prescribed a benzodiazepine more than six times per year (22)
  • Children (< 18 years): Dispensing of N05BA for anxiolytics, or N05CD/N05CF for hypnotics greater than 28 DDD over two consecutive months (23)
  • Children (< 18 years): Single dispensing of N05BA for anxiolytics, or N05CD/N05CF for hypnotics greater than 7 DDD (23)
  • A low rate of benzodiazepine prescribing for prolonged periods (>2–4 weeks) (24)
  • The percentage of patients (age > 65) dispensed benzodiazepines or one of the Z-drugs (including zopiclone, zolpidem and zaleplon) for more than 4 weeks (25)
  • Children and young adults (0–24 years): Benzodiazepine (BZD) prescribing patterns: individual treatment period (sequence defined as subsequent BZD dispensations with max 6 months between dispensings) and average daily dose (DDD dispensed / treatment period). Classified into period (3 mo, >3 mo to ≤6 mo, >6 mo ) and dose (<0.5 DDD/day , ≥0.5 to <1.5 DDD/day, ≥1.5 DDD/day). Controls/stratifiers: Concurrent psychotropic medication, psychiatric diagnoses and epilepsy, type of healthcare provider (26)
  • Benzodiazepine or Z-drug for ≥21 days in a patient aged >65 years who is not receiving benzodiazepines or Z-drugs on a long-term basis (27)
  • Percentage of patients prescribed benzodiazepines where continuous usage exceeds 4 weeks (28)
  • Treatment duration error, Central nervous system: Benzodiazepines prescribed long term (i.e. more than 2–4 weeks)(risk of dependence and withdrawal reactions) (29)
  • Duration error, Central nervous system: Benzodiazepine-like drugs (e.g. zopiclone) prescribed long term (i.e. more than 2–4 weeks) (risk of dependence reactions) (29)
  • Benzodiazepines (e.g. nitrazepam, temazepam) should not be used long-term (greater than four weeks) (30)
  • Non-benzodiazepine hypnotics (zolpidem, zaleplon, zopiclone) should not be used long-term (greater than 4 weeks) (30)
  • Benzodiazepine, Z-drug or sedating antihistamine for more than 1 month (risk of prolonged sedation, confusion, impaired balance, falls) (risk of tolerance and dependence with benzodiazepines and Z-drugs) (31)

References

  1. ATCDDD – Definition and general considerations [Internet]. [cited 2024 May 2]. Available from: https://atcddd.fhi.no/ddd/definition_and_general_considera/
  2. Kurko T, Saastamoinen LK, Tuulio-Henriksson A, Taiminen T, Tiihonen J, Airaksinen M, et al. Trends in the long-term use of benzodiazepine anxiolytics and hypnotics: A national register study for 2006 to 2014. Pharmacoepidemiol Drug Saf. 2018;27(6):674–82.
  3. Kurko TAT, Saastamoinen LK, Tähkäpää S, Tuulio-Henriksson A, Taiminen T, Tiihonen J, et al. Long-term use of benzodiazepines: Definitions, prevalence and usage patterns – a systematic review of register-based studies. Eur Psychiatry. 2015 Nov 1;30(8):1037–47.
  4. PVQ Läkemedel Lm07: Andel bensodiazepinbehandlade patienter med stor förbrukning [Internet]. [cited 2024 Aug 19]. Available from: https://vardenisiffror.se/indikator/544ca731-a0f1-4296-9972-56750ed25f5a?datefrom=2023-06-01&dateto=2023-11-30&gender&relatedmeasuresbyentry=keyword&relatedmeasuresbyid=lakemedelsbehandling&showtarget=false&sort=desc&units=se&units=17&units=08&units=25&units=09&units=14&units=06&units=20&units=13&units=01&units=23&units=03&units=24&units=05&units=12&units=07&units=04&units=19&units=22&units=18&units=21&units=10
  5. PVQ Läkemedel Lm04: Andel patienter med bensodiazepinliknande sömnläkemedel med stor förbrukning [Internet]. [cited 2024 Aug 19]. Available from: https://vardenisiffror.se/indikator/0fedda93-ba0c-43d9-9014-a3c5b9f10e7d?datefrom=2023-06-01&dateto=2023-11-30&gender&relatedmeasuresbyentry=keyword&relatedmeasuresbyid=lakemedelsbehandling&showtarget=false&units=se&units=17&units=08&units=25&units=09&units=14&units=06&units=20&units=13&units=01&units=23&units=03&units=24&units=05&units=12&units=07&units=04&units=19&units=22&units=18&units=21&units=10
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  7. Carmona Araújo A, Casal RJ, Goulão J, Martins AP. Misuse of psychoactive medicines and its consequences in the European Union – a scoping review. J Subst Use. 2023;0(0):1–12.
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  9. Taipale H, Tanskanen A, Kurko T, Taiminen T, Särkilä H, Tiihonen J, et al. Long-term benzodiazepine use and risk of labor market marginalization in Finland: A cohort study with 5-year follow-up. Eur Psychiatry. 2024 Apr 4;67(1):e34.
  10. Haukka J, Kriikku P, Mariottini C, Partonen T, Ojanperä I. Non-medical use of psychoactive prescription drugs is associated with fatal poisoning. Addiction. 2018;113(3):464–72.
  11. Simonsen KW, Kriikku P, Thelander G, Edvardsen HME, Thordardottir S, Andersen CU, et al. Fatal poisoning in drug addicts in the Nordic countries in 2017. Forensic Sci Int. 2020 Aug 1;313:110343.
  12. Laugesen K, Ludvigsson JF, Schmidt M, Gissler M, Valdimarsdottir UA, Lunde A, et al. Nordic Health Registry-Based Research: A Review of Health Care Systems and Key Registries. Clin Epidemiol. 2021 Dec 31;13:533–54.
  13. Furu K, Wettermark B, Andersen M, Martikainen JE, Almarsdottir AB, Sørensen HT. The Nordic countries as a cohort for pharmacoepidemiological research. Basic Clin Pharmacol Toxicol. 2010 Feb;106(2):86–94.
  14. Rasmussen L, Wettermark B, Steinke D, Pottegård A. Core concepts in pharmacoepidemiology: Measures of drug utilization based on individual-level drug dispensing data. Pharmacoepidemiol Drug Saf. 2022;31(10):1015–26.
  15. Healthcare Quality and Outcomes Indicators – OECD [Internet]. [cited 2024 Feb 29]. Available from: https://www.oecd.org/health/health-care-quality-outcomes-indicators.htm
  16. PVQ Läkemedel Lm08: Andel bensodiazepinbehandlade patienter som vid nyförskrivning fått ≤ 30 tabletter – KIK [Internet]. [cited 2024 Aug 19]. Available from: https://kvalitetsindikatorkatalog.se/#/measure/446db5dd-a0c7-46a3-aa0c-f62705ee794c
  17. PVQ Läkemedel Lm05: Andel patienter som vid nyförskrivning av bensodiazepinliknande sömnläkemedel förskrivits ≤ 30 tabletter – KIK [Internet]. [cited 2024 Aug 19]. Available from: https://kvalitetsindikatorkatalog.se/#/measure/3606906c-a968-4fa3-9ed3-ebc1ac89e7e2
  18. Sotekuva [Internet]. [cited 2024 May 2]. Available from: https://sotekuva.fi/en/#/chart?regionCategory=HYVINVOINTIALUE&freeze=false&sortByYear=false&absValue=false&munSortOrder=0&showMinAndMaxValues=false&showLowAndHighValues=false&showChartValues=true&previousView=chart
  19. Blozik E, Reich O, Rapold R, Scherer M, Djalali S, Huber F, et al. Evidence-based indicators for the measurement of quality of primary care using health insurance claims data in Switzerland: results of a pragmatic consensus process. BMC Health Serv Res. 2018 Sep 27;18(1):743.
  20. Campbell SM, Cantrill JA, Roberts D. Prescribing indicators for UK general practice: Delphi consultation study. BMJ. 2000 Aug 12;321(7258):425–8.
  21. Fernández Urrusuno R, Montero Balosa MC, Pérez Pérez P, Pascual de la Pisa B. Compliance with quality prescribing indicators in terms of their relationship to financial incentives. Eur J Clin Pharmacol. 2013 Oct;69(10):1845–53.
  22. Muijrers PEM, Janknegt R, Sijbrandij J, Grol RPTM, Knottnerus JA. Prescribing indicators. Eur J Clin Pharmacol. 2004 Dec 1;60(10):739–46.
  23. Murphy KD, Sahm LJ, McCarthy S, Byrne S. Benzodiazepine prescribing guideline adherence and misuse potential in Irish minors. Int J Clin Pharm. 2015 Oct;37(5):749–52.
  24. Okechukwu I, Bennett K, Feely J. General practitioners’ ranking of evidence-based prescribing quality indicators: a comparative study with a prescription database. Br J Clin Pharmacol. 2006;62(2):218–24.
  25. Spackman E, Clement F, Allan GM, Bell CM, Bjerre LM, Blackburn DF, et al. Developing key performance indicators for prescription medication systems. PloS One. 2019;14(1):e0210794.
  26. Sidorchuk A, Isomura K, Molero Y, Hellner C, Lichtenstein P, Chang Z, et al. Benzodiazepine prescribing for children, adolescents, and young adults from 2006 through 2013: A total population register-linkage study. PLOS Med. 2018 Aug 7;15(8):e1002635.
  27. Avery AJ, Dex GM, Mulvaney C, Serumaga B, Spencer R, Lester HE, et al. Development of prescribing-safety indicators for GPs using the RAND Appropriateness Method. Br J Gen Pract J R Coll Gen Pract. 2011 Aug;61(589):e526-536.
  28. Dang CPL, Toh LS, Cooling N, Jackson S, Curtain C, Thompson A, et al. Updating and validating quality prescribing indicators for use in Australian general practice. Aust J Prim Health. 2019 Dec 23;
  29. Thomas SK, McDowell SE, Hodson J, Nwulu U, Howard RL, Avery AJ, et al. Developing consensus on hospital prescribing indicators of potential harms amenable to decision support. Br J Clin Pharmacol. 2013 Nov;76(5):797–809.
  30. Cooper JA, Ryan C, Smith SM, Wallace E, Bennett K, Cahir C, et al. The development of the PROMPT (PRescribing Optimally in Middle-aged People’s Treatments) criteria. BMC Health Serv Res. 2014 Oct 30;14.
  31. Khawagi WY, Steinke D, Pontefract S, Keers RN. Development of indicators to assess the safety of prescribing for populations with mental illness using a modified Delphi approach. Pharmacoepidemiol DRUG Saf. 2020 Mar;29(2, SI):12.