Audit and feedback for reducing long-term prescribing of benzodiazepines and opioids by general practitioners

Brief name: Audit and feedback and printed educational materials General practices in the same Australian postcode and remoteness area (RA), containing general practitioners (GPs) and other medical practitioners (OMPs) will be simultaneously randomised to no intervention control or to one of four intervention groups at baseline. Purpose of the intervention(s): To reduce long-term prescribing of benzodiazepines and/or opioids by Australian GPs and OMPs Procedures: Written audit and feedback with or without printed educational materials (PEM) sent to Australian GPs and OMPs Materials: Audit and feedback letter and PEM to facilitate prescribers to identify long-term use of benzodiazepines and/or opioids in their patient cohort and support GPs and OMPs to reduce long-term prescribing. The PEM related to benzodiazepine prescribing will provide prescribers with conversation starters to initiate a discussion with their patients about reducing long-term benzodiazepine use and a tapering algorithm to guide benzodiazepine tapering. Similar PEM related to opioid prescribing will be used - i.e. conversation starters for prescribers to initiate a discussion with their patients about reducing long term opioid use and a tapering algorithm to guide opioid tapering. Provider: NPS MedicineWise Mode of delivery: Mailed to the majority of participants at their nominated mailing address. A small proportion of participants (~1000-1500) have opted to receive an electronic version of the materials via their nominated email address. Tailoring: Audit and feedback on long-term benzodiazepine and opioid prescribing individualised to the recipient. PEM not tailored to individual recipients Fidelity: Return to sender documented Duration of intervention: Two separate letters mailed two months apart Interventions GPs and OMPs within general practices allocated to one of four intervention groups (Groups 2 to 5) will receive written audit and feedback on their overall rate of prescribing of five targeted benzodiazepines and eight targeted opioids over the preceding financial year, compared with his/her peers, with or without PEM, from NPS MedicineWise. The targeted benzodiazepines are: 1) diazepam, 2) temazepam, 3) alprazolam, 4) nitrazepam, 5) oxazepam. The targeted opioids are: 1) buprenorphine, 2) fentanyl, 3) hydromorphone hydrochloride, 4) morphine sulfate pentahydrate, 5) oxycodone hydrochloride 6) oxycodone hydrochloride + naloxone) 7) tapentadol, 8) tramadol hydrochloride. Written audit and feedback with or without PEM targeting opioid prescribing will be delivered two months following the intervention targeting benzodiazepines. Group 2 will receive standard audit and feedback illustrated in graphical format: (a) the recipient’s overall rate of prescribing of five targeted benzodiazepines that were dispensed per 1000 consultations over the preceding three financial years (1 July 2018 to 30 June 2019; 1 July 2019 to 30 June 2020; 1 July 2020 to 30 July 2021) compared with the median, 25th and 75th percentile of his/her peers located in a similar geographical region (i.e. Remoteness Area (RA)); (b) the number and percentage of patients prescribed a targeted benzodiazepine who were prescribed 4 or more prescriptions of any of the targeted benzodiazepines that were dispensed by a pharmacist over the preceding financial year (1 July 2020 to 30 July 2021) compared with the median, 25th and 75th percentile of his/her peers; c) for those patients prescribed a benzodiazepine between 1 July 2020 to 30 July 2021, the number and percentage of benzodiazepine prescriptions they received that were dispensed (1-2, 3-4, 5-6, and 7 or more). Two months later, group 2 will receive standard audit and feedback that illustrates in graphical format: (a) the recipient’s overall rate of prescribing of eight targeted opioids that were dispensed per 1000 consultations over the preceding three financial years (1 July 2018 to 30 June 2019; 1 July 2019 to 30 June 2020; 1 July 2020 to 30 July 2021) compared with the median, 25th and 75th percentile of his/her peers located in a similar geographical region (i.e. RA); (b) the number and percentage of patients prescribed a targeted opioid who were prescribed 7 or more of any of the targeted opioids that were dispensed by a pharmacist over the preceding financial year (1 July 2020 to 30 July 2021) compared with the median, 25th and 75th percentile of his/her peers; c) for those patients prescribed a long-acting opioid by the recipient between 1 July 2020 to 30 July 2021, the number and percentage of targeted opioid prescriptions they received that were dispensed by a pharmacist (1-2, 3-4, 5-6 or 7 or more); and d) between 1 July 2020 to 30 July 2021 the number and percentage of patients prescribed and dispensed a long acting opioid 7 or more times who were also were prescribed and dispensed a benzodiazepine compared with the median, 25th and 75th percentile of his/her peers. Group 3 will receive the same content as Group 2 but using a peer comparator tailored to the recipient’s baseline performance for long-term benzodiazepine and opioid prescribing. If the recipient’s baseline performance over the preceding financial year (1 July 2020 to 30 July 2021) for the benzodiazepine chart b (that relates to long-term benzodiazepine prescribing) is above the median percentile of his/her peers located in a similar geographical region during that time period, then the median rate will be used as the peer comparator for that medicines class and for all figures in the benzodiazepine feedback report where a peer comparator is used. If the recipient’s baseline performance over the preceding financial year for the benzodiazepine chart b is below or equal to the median percentile of his/her peers located in a similar geographical region during that period, then the 25th percentile of their peers located in a similar geographical region will be used as the peer comparator for that medicine’s class and for all figures in the benzodiazepine feedback report where a peer comparator is used. Similarly, if the recipient’s baseline performance over the preceding financial year (1 July 2020 to 30 July 2021) for the opioids chart b (that relates to long-term opioids prescribing) is above the median percentile of his/her peers located in a similar geographical region during that time period, then the median rate will be used as the peer comparator for that medicines class and for all figures in the opioids feedback report where a peer comparator is used. If the recipient’s baseline performance over the preceding financial year for the opioids chart b is below or equal to the median percentile of his/her peers located in a similar geographical region during that period, then the 25th percentile of their peers located in a similar geographical region will be used as the peer comparator for that medicines class and for all figures in the opioids feedback report where a peer comparator is used. Additional peer comparators (e.g., 75th percentile) will not be used in feedback provided to recipients allocated to group 3. Group 4 will receive the same intervention as Group 2 but with a copy of the PEM for benzodiazepines enclosed with their benzodiazepine feedback and the opioid PEM enclosed with their opioid feedback. The PEM related to benzodiazepine prescribing will provide prescribers with conversation starters to initiate a discussion with their patients about reducing long-term benzodiazepine use and a tapering algorithm to guide benzodiazepine tapering. Similar PEM related to opioid prescribing will be used- i.e. conversation starters for prescribers to initiate a discussion with their patients about reducing long term opioid use and a tapering algorithm to guide opioid tapering. Group 5 will receive the same intervention as Group 3 but with PEM enclosed as described for group 4. Group labels Group 1 – no intervention control Group 2 - standard audit and feedback using median, 25th and 75th percentile peer comparators without PEM Group 3 – audit and feedback using tailored peer comparator without PEM Group 4 – standard audit and feedback using median, 25th and 75th percentile peer comparator with PEM Group 5 - audit and feedback using tailored peer comparator with PEM