Did the new French pay-for-performance system modify benzodiazepine prescribing practices?

Abstract

BackgroundFrench general practitioners (GPs) were enrolled in a new payment system in January 2012. As part of a national agreement with the French National Ministry of Health, GPs were asked to decrease the proportion of patients who continued their benzodiazepine treatment 12 weeks after its initiation and to decrease the proportion of patients older than 65 who were prescribed long half-life benzodiazepines. In return, GPs could expect an extra payment of up to 490 euros per year. This study reports the evolution of the corresponding prescribing practices of French GPs during that period regarding patients who were prescribed a benzodiazepine for the first time.MethodsThe national healthcare system's administrative database was used to report the longitudinal follow-up of two historical cohorts of French patients from the Pays de la Loire area.Study patients: The “2011” and “2012” cohorts included all patients who initiated benzodiazepine regimens from April 1 to June 30 in 2011 and 2012, respectively.The primary outcomes were the proportion of those study patients who continued benzodiazepine treatment after 12 weeks and the proportion of study patients >65 years who were prescribed long half-life benzodiazepines.Analyses were performed using a multi-level regression.ResultsIn total, 41,436 and 42,042 patients initiated benzodiazepine treatment in 2011 and 2012, respectively. A total of 18.97% of patients continued treatment for more than 12 weeks in 2012, compared with 18.18% in 2011. In all, 27.43% and 28.06% of patients >65 years continued treatment beyond 12 weeks in 2011 and 2012, respectively. The proportion of patients >65 years who were prescribed long half-life benzodiazepines decreased from 53.5% to 48.8% (p < 0.005) due to an increase in short half-life benzodiazepine prescriptions. Patients >65 years who were prescribed short half-life benzodiazepines were more likely to continue treatment after 12 weeks (p < 0.005).ConclusionsDespite the pay-for-performance strategy, the number of short half-life benzodiazepine prescriptions increased between 2011 and 2012, and the number of long half-life benzodiazepine initiations remained unchanged. Reducing the proportion of long half-life benzodiazepine prescriptions might be counterproductive because prescribing short half-life benzodiazepines was associated with higher rates of continuation beyond the recommended duration.

Trends in incident use of benzodiazepines and Z-drugs in France from 2006 to 2012: a population-based study

“…Our results are consistent with recently published data. A similar reduction in long half‐life benzodiazepine prescriptions in elderly patients between 2011 and 2012 was found in the study by Rat et al based on the population of a French administrative area. Changes observed in other countries such as Canada, Australia and the Netherlands are broadly consistent with those we found in France over the study period, with an overall decrease in benzodiazepine use but still a high level of use suggesting the persistence of probable misuse.…”

“…This explains why the potential lowering of the drug reimbursement rate is likely to have little impact other than an economic one in France where they are also cheap. Indeed, while the extent of benzodiazepine incident use pleads for further prescription minimization strategies, developing them will be a major challenge for health authorities as so many plans designed with this aim in mind have failed to have a significant impact in the past . The decrease in incidence herein reported could relate to a long history of information and educational campaigns; the impact of each being limited, if existing.…”

Explicit and implicit influences on economic reasoning of health professionals after the global crisis 2008/2009: Challenges or keys in the recovery of health systems in the forthcoming global crisis?

“…We have shown that under implicit influences a lower degree of inadequate resource allocation can be expected by nonmedical administrative authority, while paradoxically, implicit influences lead to an increasing degree of unjustified spending by healthcare professionals. This is confirmed by examples of interventions in European countries related to the control of adverse outcomes in the use of benzodiazepines, where, true, "at all costs" not only wanted to save, but an attempt was made to reduce the possibility of serious adverse health outcomes in the elderly population [22]. A new physician payment model ("pay-to-performance") was applied here, where physicians received bonuses if they replaced one benzodiazepine drug in the elderly with another, safer for the elderly population.…”

Effect of reimbursement restriction policy on the use of benzodiazepines in the Netherlands: an interrupted time series analysis

“…Despite the reimbursement policy the total BZDs sold from 1989 to 1999 showed a 53% increase in Italy 30. Although a French pay-for-performance strategy had a modest effect on the achievement of GPs regarding BZD indicators,16 it did not lead to the intended decrease of the use of BZDs in 2012 31. In a US policy, exclusion from the Medicare Part D formulary in 2006 led to an immediate and sustained drop of 5% in number of BZD prescriptions filled by seniors 32…”