Department of Internal Medicine, Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale, Bellinzona, Switzerland.
Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland.
Swiss Med Wkly. 2024 Nov 1;154:3409. doi: 10.57187/s.3409.
Physicians frequently prescribe antipsychotics off-label to treat, among others, insomnia and anxiety. The Swiss "smarter medicine - Choosing Wisely" campaign has tried to raise awareness about the risks and to limit benzodiazepine and Z-drug prescriptions. In the Italian-speaking part of Switzerland, our network of public hospitals joined the campaign with the aim of avoiding unnecessary benzodiazepine and Z-drug treatments, with prescription monitoring, benchmarking and educational contributions. Considering the risks of a possible shift towards the prescription of antipsychotics, and aware of the potential role of the COVID-19 pandemic, we decided to analyse the prescription trends of antipsychotics and benzodiazepines/Z-drugs before, during (2016-2017) and after the intervention.
For this longitudinal study, we reactivated a continuous monitoring of inpatient benzodiazepine/Z-drug and antipsychotics prescriptions/deprescriptions, paused in 2018 after the end of the internal Choosing Wisely campaign, based on routinely collected observational health data. We screened all demographic, administrative and prescription data of patients admitted to the internal medicine department of the four teaching hospitals (H1-H4) belonging to the EOC (Ente Ospedaliero Cantonale) network, from the fourth quarter of 2014 to the second quarter of 2023.
We analysed 74,659 hospital stays (14,645 / 16,083 / 24,285 / 19,646 at hospitals H1 / H2 / H3 / H4 respectively). The mean (± SD) case mix (a metric that reflects the diversity, complexity and severity of the treated patients) and patient age were 1.08 ± 0.14 and 73 ± 2 years. 10.6% and 12.1% of patients received antipsychotics prior to admission and at discharge respectively (new prescriptions 3.3 ± 0.7%; deprescriptions 13.3 ± 5.2%). New prescriptions showed an upward trend, with +0.20% per year (p <0.001). Patients admitted with ongoing antipsychotics therapy increased 0.36% per year (p <0.001). New benzodiazepine/Z-drug prescriptions showed a 0.20% per year decrease (p = 0.01). Patients admitted with ongoing benzodiazepine/Z-drug therapy decreased 0.32% per year (p <0.001). New antipsychotics prescriptions showed differences between hospitals, with H3 above and H2 below the average.
The increase in antipsychotics quantitatively matched the decrease in benzodiazepine/Z-drug prescribing, suggesting a shift from one to the other sedative therapy. The same trend was visible in the ongoing prescriptions at admission revealing a similar out-of-hospital approach. This suggests a change in sedative prescribing strategy rather than the choice of alternative, non-pharmacological approaches. Furthermore, the variation between similar services of different hospitals points out the consequences of local prescribing cultures and the importance of continuously monitoring and benchmarking medication prescriptions.
医生经常开抗精神病药进行超适应证治疗，包括失眠和焦虑等。瑞士的“更明智的药物 - 明智选择”运动旨在提高人们对抗精神病药风险的认识，并限制苯二氮䓬类药物和 Z 类药物的处方。在瑞士意大利语区，我们的公立医院网络加入了该运动，旨在通过处方监测、基准测试和教育贡献来避免不必要的苯二氮䓬类药物和 Z 类药物治疗。考虑到可能转向开抗精神病药的风险，并且意识到 COVID-19 大流行的潜在影响，我们决定分析抗精神病药和苯二氮䓬类药物/Z 类药物的处方趋势，包括干预之前（2016-2017 年）、期间和之后。
这项纵向研究重新激活了对住院患者苯二氮䓬类药物/Z 类药物和抗精神病药处方/减方的连续监测，在内部明智选择运动结束后于 2018 年暂停，监测数据基于常规收集的观察性健康数据。我们筛选了属于 EOC（Ente Ospedaliero Cantonale）网络的四所教学医院（H1-H4）内科住院患者的所有人口统计学、行政和处方数据，时间范围从 2014 年第四季度到 2023 年第二季度。
我们分析了 74659 例住院病例（H1/H2/H3/H4 医院分别为 14645/16083/24285/19646 例）。平均（± SD）病例组合（反映治疗患者多样性、复杂性和严重程度的指标）和患者年龄分别为 1.08 ± 0.14 和 73 ± 2 岁。入院前和出院时分别有 10.6%和 12.1%的患者接受了抗精神病药治疗（新处方 3.3 ± 0.7%；减方 13.3 ± 5.2%）。新处方呈上升趋势，每年增加 0.20%（p <0.001）。接受持续抗精神病药治疗的入院患者每年增加 0.36%（p <0.001）。新苯二氮䓬类药物/Z 类药物处方每年减少 0.20%（p = 0.01）。接受持续苯二氮䓬类药物/Z 类药物治疗的入院患者每年减少 0.32%（p <0.001）。新抗精神病药处方在医院之间存在差异，H3 高于平均水平，H2 低于平均水平。
抗精神病药处方的增加与苯二氮䓬类药物/Z 类药物处方的减少相匹配，表明从一种镇静治疗转向另一种。在入院时的持续处方中也可以看到相同的趋势，表明在院外也有类似的方法。这表明镇静药物处方策略发生了变化，而不是选择替代的非药物治疗方法。此外，不同医院类似服务之间的差异表明了当地处方文化的后果，以及持续监测和基准测试药物处方的重要性。
