gms | German Medical Science

Background: Hypnotics and sedatives, such as benzodiazepines, are still regularly prescribed in the hospital setting for patients with sleeping problems—in spite of well-known safety concerns, such as craving, withdrawal symptoms upon discontinuation and increased falls, especially in older and geriatric patients. While the prevalence of benzodiazepine use in hospitals is well studied and there are calls to reduce the use of benzodiazepines, there is a lack of evidence-based recommendations about how to reach this aim. We know only little about the reasons for benzodiazepine use from the prescriber perspective, especially in hospitals, with different professional groups being responsible for the patient. Underlying beliefs and values, as well as perceptions of innovation and an individual prescriber’s global risk-benefit ratio of drugs (the benefits outweigh the risks, the risks outweigh the benefits, benefits and risks are equal) influence prescribing.

Research questions: To reduce the use of benzodiazepines in hospitals, we wanted to know which benefits and risks doctors and nurses consider strongest. In addition, we wanted to know if certain benefits and risks are significantly related to the global risk-benefit ratio.

Methods: All doctors and nurses in a German hospital were asked about their global risk-benefit ratio, i.e. whether they think the risks of benzodiazepines outweigh their benefits or vice versa. We determined which individually-rated risks and benefits of benzodiazepines influenced the global risk-benefit ratio most, with adjusted odds ratios (ORs) and 95% confidence intervals (CI).

Results: Sixty-five doctors (56%) and 73 nurses (30%) participated. More than 60% reported strong benefits for ‘reduced fear or agitation’. Twenty (27%) nurses and 30 (48%) doctors perceived the risks of benzodiazepines to outweigh the benefits. Nearly 80% of doctors who rated ‘falls’ to happen often, perceived the risks of benzodiazepines to outweigh the benefits, compared to 34% of those who did not rate ‘falls’ to happen often (OR: 12.04; 95% CI: 1.72 to 84.54). ‘Craving’ was a similarly strong predictor. For nurses, ‘confusion’ and ‘increased sleep’ had the largest effect on the individual risk-benefit ratio (with ORs>12).

Conclusions: Doctors rated benzodiazepines as strong drugs—both in benefits, such as ‘reduced fear or agitation’, and risks, such as ‘craving’. Nurses estimated the benefits and risks of benzodiazepines to be somewhat weaker than doctors did. For many doctors, the risks of benzodiazepines outweighed the benefits if they rated ‘falls’ or ‘craving’ as a frequent risk; for nurses, it was ‘confusion’ and if they did not consider 'increased sleep’ a benefit.

Implications for practice: A strategy to increase patient safety by reducing benzodiazepine use in the hospital setting should take especially two factors into account: (1) Doctors and nurses perceive the reduction of fear or agitation to be the strongest benefit of benzodiazepines. If benzodiazepines are to be reduced, effective non-pharmacological alternatives to curb fear or agitation must in turn be made available and implemented in the hospital setting. (2) Educating personnel about the risks and benefits of benzodiazepines should focus upon the perception of ‘falls’ and ‘craving’ (in the case of doctors) or ‘confusion’ and ‘sleep’ (in the case of nurses) in order to have a strong impact on the global risk-benefit ratio. It will be important (and challenging) to tone down the benefit of increased sleep. A hospital policy may be helpful that informs patients that sleeping problems in stressful new environments are normal. Moreover, nurses should know that doctors and the hospital administration do not expect that every patient must sleep in the hospital like they do at home. Stressing other typical risks of benzodiazepines, such as ‘tolerance’ and ‘withdrawal’ would—according to our data—most likely be ineffective in altering benzodiazepine use, because doctors already know this and neither they nor nurses are influenced in their global risk-benefit ratio by this knowledge.