JMIR Publications

ABSTRACT

Background:

Long-term use of benzodiazepine receptor agonists (BZRAs) remains common despite European guidelines advising these drugs to be used in the lowest possible dose and for the shortest possible duration. Half of all BZRAs are prescribed in family practice. This creates a window of opportunity for discontinuation in primary care. Therefore, the effectiveness of blended care for the discontinuation of long-term BZRA use in adult primary care patients with chronic insomnia disorder was tested with a multicenter, pragmatic, cluster randomized, controlled, superiority trial in Belgium. In literature, information on implementing blended care in a primary care setting is scarce.

Objective:

To contribute to a framework for the successful implementation of blended care in a primary care setting by increasing our understanding of this complex intervention, through an evaluation of e-tool usage, and views and ideas of participants in a BZRA discontinuation trial.

Methods:

Based on the framework of Grant et al. (2013) this study evaluated the processes of recruitment, delivery, and response via four components: a survey on recruitment (n=76), semi-structured in-depth interviews with patients (n=18), online asynchronous focus groups with GPs (n=19), and usage data of the web-based tool. Quantitative data was analyzed descriptively, and qualitative data thematically.

Results:

For recruitment, the most common barriers were refusal by the patient, and lack of digital literacy, while facilitators were starting the conversation, and the curiosity of patients. Delivery of the intervention to the patients was very diverse, ranging from GPs who never informed the patient about their access to the e-tool, to GPs consulting the e-tool in between consultations to have discussion points when the patient visited. Concerning response, patients’ and GPs’ narratives also showed much variety. On the one end, daily practice changed for some GPs because they received more positive reactions than expected and felt empowered to talk more often about BZRA discontinuation. On the other end, some reported no changes in practice or among patients. In general, patients found follow-up by an expert to be the most important component in blended care, whereas GPs deemed the intrinsic motivation of patients as the key element of success. An important barrier to implementation by the GP was time.

Conclusions:

Overall, participants who had used the e-tool were positive about its structure and content. Nevertheless, many patients desired a more tailored application with feedback from an expert and personal tapering schedules. Strict pragmatic implementation of blended care seems to only reach GPs with an interest in digitalization. Although not superior to usual care, blended care could be a complementary tool that allows tailoring the discontinuation process to the personal style of the GP and the needs of the patient. Clinical Trial: ClinicalTrials.gov NCT03937180