Barriers and facilitators to BSH deprescribing
In this section, we present the results of the qualitative analysis for which there was no quantitative counterpart, based on the TDF. The TDF domains and constructs that were found during the coding process are displayed in Additional File 1: Appendix Table 3. Below are the domains presented with some examples of the qualitative analysis.
Knowledge
This section reports knowledge of PCPs and patients influencing BSH deprescribing, which was identified as a barrier. Regarding patient knowledge, unrealistic sleep expectations of patients were experienced as a major issue [PCP16, I7, G]: “… the main problem, it seems to me, is that patients simply need to be able to sleep when it gets dark and nothing is going on, to sleep the whole night if possible, and only wake up again when the day begins.” Furthermore, PCPs mentioned that their patients lacked knowledge about BSH risks [PCP7, FG1, G]: “Well, so what I find difficult is, hmm, that patients are not aware that these are problematic drugs. (…) Because, hmm, apparently this was either not communicated when they were prescribed or, which is also quite possible, it [the information] was put aside afterwards.” Regarding knowledge of PCPs, some PCPs expressed a lack of knowledge about side effects of BSHs [PCP15, FG3, G]: “And what is the evidence regarding the, hmm, harmfulness of these, hmm, Z-substances?”.
Skills
Lack of skills was identified as a barrier. PCPs mentioned they had not received enough training on the treatment of sleep problems and BSH deprescribing [PCP13, FG2, G]: “So it's such a huge problem. I think it would need some kind of course during medical school. And during residency, hmm, definitely too, or simply that it becomes more important. (…) So I think it has far too little importance. Already during the whole training.”
Motivation and goals
Both barriers and facilitators were classified in this construct. A main barrier encountered by PCPs was patient lack of motivation [PCP2, I2, F]: “And then when we come to it [discussing BSH deprescribing], well, they don't want to talk about it too much. They avoid the subject and then say, ‘Oh no, but we'll do it next time.’” PCPs didn’t consider BSH deprescribing as a priority [PCP12, FG2, G]: “Of course, it [BSH deprescribing] is also time-consuming. So, in the primary care practice, apparently there are on average over four problems per consultation and, hmm, then you have to think about how to use the time. And if there are three much more important problems, then, hmm, you just look at those.” Regarding facilitators, some physicians reported using side effects to motivate their patients to discontinue or not to start BSHs [PCP5, I5, F]: “So, I often talk to them about cognitive impairment and the risk of fall. I think these are really important problems for older adults.” Beside these side effects, patient fear of dependence was mentioned as a facilitator to discontinue or not to start BSHs [PCP4, I4, F]: “The fear of dependence too, I think that's also something that, that can be a lever.”
Environmental context and resources
Environmental context and resources were identified as barriers. Regarding external factors, PCPs experienced lack of time as a barrier to deprescribe BSHs [PCP8, FG1, G]: “Hmm, what I miss is simply the setting and the peace and quiet to discuss it [BSH deprescribing] with the patient, because that also takes a lot of time, so the quarter of an hour I have in the agenda is often not enough.” When coming to the prescription of CBT-I, the limited availability and access to it were mentioned as barriers, making prioritization needed [PCP7, FG1, G]: “But of course, there are too few therapy places, so they are very quickly booked. And, I have to say, I would almost be a bit reluctant to take up such a place for a simple sleep disorder, because there are really many patients with much bigger problems who need it [cognitive behavioral therapy] more urgently.”
Social influences
Lack of public dialogue about BSHs was identified as a barrier, while PCP thought it could facilitate BSH deprescribing [PCP8, FG1, G]: “And I also think a social dialogue, that these are addictive substances, would be very helpful, because then, hmm, maybe they [the health authorities] would give me more time to deal with it [BSH deprescribing] in peace, to get away from these addictive substances.”
Emotion
Several barriers were related to emotions. PCPs said patient fear of not being able to sleep was a barrier to deprescribe BSHs [PCP3, I3, F]: “The first argument, very often, is, ‘No, no, but you can't take away my [BSH] (…) Since I have it, I can sleep. I don't want to disturb that balance. And it's so important for me to sleep, as I've gone through periods with so much insomnia.’” PCPs reported frustration following repeated failed attempts to deprescribe BSHs to be a barrier to try again [PCP17, S, G]: “My attempts often or almost always fail. (…) So I don't have the courage to try again.”
Behavioral regulation
Several issues related to behavioral regulation were identified as barriers, while other were rather facilitators. PCPs mentioned that costs could impact patient behavior related to BSH deprescribing [PCP18, S, F]: “Difficulties in getting patients to come back for follow-up consultations. High deductibles, fear of costs.” On the other hand, it was perceived positively that in Switzerland CBT-I is now covered by universal health insurance [PCP5, I5, F]: “So, since, since the, hmm, psychotherapy by psychologists started to be covered by health insurance last year, I've really been trying to guide patients by saying, ‘Well, now you can have twice fifteen sessions with a psychologist. It's covered by insurance.’” PCPs experienced patient social situation and interests as a barrier to deprescribe BSHs and implement sleep hygiene measures [PCP14, FG3, G]: “Hmm, but then we end up slipping into complex social difficulties because the problem is, especially in winter: ‘What do you do until eleven in the evening and what do you do at six in the morning?’”.
Nature of the behaviors
Starting deprescribing at hospital was identified as a facilitator [PCP1, I1, F]: “If, if they [the physicians at hospital] can remove [BSHs], and, in parentheses, prove that in hospital they [the patients] sleep without, hmm, they can, in parentheses, more easily keep building on that momentum.” Nevertheless, PCPs made the experience that tapering was often not continued by patients after hospital discharge, which could be addressed by improving continuity of follow-up [PCP5, I5, F]: “… sometimes, when they [the patients] come out of geriatrics, they come out of a unit where there was a lot of motivated people who managed to, supposedly, wean them off benzos. But when the patients come out, well, they run to the pharmacy to get them [the benzodiazepines]. So, hmm, would it also be necessary for a psychologist to be directly involved in the discharge process? To say, “Ah, we're going to support you now that you're going home, to prevent a relapse.” Could it be?”.
PCP opinions on patient material
In this section, we present the mixed methods results about PCP opinions on what could support them and their patients to discontinue BSHs. Meta-interferences are presented in Tables
2 and
3 and complete quantitative survey results in Additional File
1: Appendix Tables 1 and 2.
Table 2
Meta-interference: PCPs opinions on patient material (N = 126)
FORMAT | Flyers | 62 (49.2) | [PCP4, I4, F]: “But I'd avoid making leaflets, well, little brochures that are too, hmm, too thick. Sometimes making a, a flyer that fits on one page, on both sides, that could be pretty good.” | Divergent |
[PCP1, I1, F]: “I don't know. In the waiting room, well, I have lots of leaflets on lots of things.” | Convergent |
Brochures | 87 (69.1) | [PCP2, I2, F]: “If it [a brochure] was available, I'd put it in the waiting room. Because people always leaf through what's in the waiting room.” | Convergent |
[PCP12, FG2, G]: “Overall, I really like it online. I was previously in another practice and we had a cupboard full of brochures, but you have to manage them, then something is old, then you have to replace something and so on. And if you have it online, you can also print something for patients if they really only want something on paper. But then you always have access and, hmm, and everyone has access from the practice.” | Expanding |
App for smartphone | 34 (27.0) | [PCP2, I2, F]: “But obviously, well, for older people, it [a smartphone app] doesn't work. And they don't have smartphones.” | Convergent |
[PCP12, FG2, G]: “I think a lot of older patients, my [my patients] write, most of them write emails, they google, they also deal with that [online media]. I could also imagine that they would also use apps.” | Divergent |
Website | 26 (20.6) | [PCP14, FG3, G]: “Hmm, giving patients a link. I feel that the path is even longer. If you give them a brochure, they might find it in their handbag two weeks later. A link is probably less likely to be clicked on.” | Convergent |
Documents for relatives/caregivers | 63 (50.0) | [PCP14, FG3, G]: “Hmm, yes, I think that [recommendations for sleep hygiene] would sometimes be good for the relatives too. Hmm, that you could just explain it or hand it [a brochure] over. So mostly we have the patients. But occasionally the daughter says, ‘Yes, my mother cannot anymore get enough sleep.’” | Expanding |
CONTENT | Explanations about risks and benefits of BSHs | 112 (88.9) | [PCP5, I5, F]: “Then indeed, ‘What are the side effects of, of benzos and Z-drugs?’. I think that's really important. Cognitive disorders, the risk of falling, of injuring oneself, I think that's really something that can affect patients.” | Convergent |
Explanations about the discontinuation process | 95 (75.4) | [PCP5, FG5, F] “And then effectively tell them [the patients] that we're going to try to wean them off, and maybe give them some contact details of people who can help them with cognitive behavioral therapy.” | Convergent |
Tapering schemes | 92 (73.0) | [PCP3, I3, F]: “If some schemes are deemed to work better than others, why not. I'm sure it could be a useful tool. And then, of course, you have to adapt it individually to each person.” | Convergent |
Recommendations for sleep hygiene | 101 (80.2) | [PCP5, I5, F] “So I think we have to talk about hygiene, we have to talk about screens, we have to talk about light, we have to talk about meals, hmm, all that sort of things. (…) It's more in relation to behavioral aspects that we could have a benefit.” | Convergent |
Testimonials | 46 (36.5) | [PCP13, FG2, G]: “So I think that [testimonials] is certainly interesting. But I don't know whether it's even more effective if, hmm, the case description is from someone you know. So there's often an emotional connection involved somehow. And if they [the patients] know, “I know this person, they can do it, then I can do it too.” I don't know how effective it would be if it was anonymous.” | Expanding |
Table 3
Meta-interference: Needs of PCPs (N = 126)
FORMAT | Online training | 79 (62.7) | [PCP11, FG2, G]; “Well, I find that [accreditable online training] very interesting.” | Expanding |
In-person training | 47 (37.3) | [PCP14, FG3, G]: “And it [BSH deprescribing] probably, hmm, just, hmm, needs to be discussed why it's important. And then, how to approach that probably needs to be more workshop-like (…). Obviously, many of us don't know why it's worth doing it at all. And just how little use the drugs really are in the end for how many side effects they cause. I think that would shake us up. That would be a good thing.” | Divergent |
Information on a website | 65 (51.6) | [PCP13, FG2, G]: “Hmm, I could, I would find some instruction or an informative site very helpful, yes.” | Convergent |
CONTENT | Practical recommendations for pharmacological and non-pharmacological treatment of sleep problems in older people with current BSH consumption | 111 (88.1) | [PCP14, FG3, G]: “And yes, I think I'm not good enough at explaining to people why it's counterproductive for them to take these substances. I think that's the beginning and if I don't manage that, then even if I have a good discontinuation plan, it's no use to me.” | Expanding |
[PCP6, I6, F]: “I think that, I think that the main recommendation is to say that you have to make a sleep diary and then do an exact investigation of what's going on.” | Expanding |
Deprescription scheme for BSHs | 86 (68.3) | [PCP 11, FG2, G]: “So I think I would find it very helpful to get instructions on exactly how to proceed. Because I don't have much experience in this area.” | Convergent |
[PCP 3, I3, F]: “After that, what we primary care physicians really need, it’s like a recipe.” | Convergent |
Principles of CBT-I for the treatment of sleep problems | 77 (61.1) | [PCP 20, S, F]: “What I found most useful was the CBT training day on sleep.” | Convergent |
Implementation of CBT-I for the treatment of sleep problems in the primary care practice | 72 (57.1) | [PCP6, I6, F]: “I use, I use sleep restriction quite willingly. I use it myself as an internist.” | Convergent |
PCP would like to complete CBT-I training if possible | 74 (58.7) | [PCP13, FG2, G]: “Yes, I would also be motivated [to complete CBT-I training]. Of course, it also depends on how time-consuming the training would be. But I think it's an important topic. I have, so, I feel that currently we are taking over a lot of psychotherapist work, hmm, and we have zero training.” | Convergent |
Motivational interviewing for BSH discontinuation (e.g., videos/text providing examples of conversations about BSH discontinuation with patients) | 33 (26.2) | [PCP 14, FG3, G]: “Yes, or perhaps communicatively. To be honest, I rarely manage to get someone to stop smoking. So I think that's the challenge.” | Divergent |
[PCP4, I4, F]: “So it seems to me that motivational interviewing is something that is now widely taught and one masters more or less. It's always good to repeat it, but for me it's more about practical tools. For how to do it, when the person is motivated to listen. But how to get them to change their behavior. I think that's what would interest me.” | Expanding |
Shared-decision-making tools for BSH discontinuation | 52 (41.3) | [PCP10, FG1, G]: “… and the second type [of tools] would also be like participatory decision-making when a person is in need and has the feeling that “Now I have to sleep again or it will be bad at work” or wherever. (…) And then, if you get into a position of refusal, then, hmm, I don't think you're really helping people. And I think it would be good to look for solutions with the people themselves, but I haven't seen any documentation on this yet. Where you could really discuss a participatory decision-making process with the advantages and disadvantages of the different options with them.” | Divergent |
Preferences
PCPs were asked whether they preferred standardized materials, i.e., where the information and tapering schemes are similar for all patients, or customizable materials, where the information and tapering schemes can be individualized to each patient. Eighty-eight (69.8%) PCPs preferred customizable and 36 (28.6%) standardized materials for patients, while 2 (1.6%) PCPs had no preference.
Eighty-seven (69.1%) PCPs mentioned they would find brochures for patients useful and that giving a brochure to the patients to read at home could facilitate deprescribing [PCP2, I2, F]: “I mean, if there was something we could give our patients so that, in fact, we could already talk about it at the consultation. So that they can read their brochure or not. But it also tells us if the patient is a bit motivated. And then, afterwards, we can discuss it. It would probably save us time.” Sixty-three (50.0%) PCPs wished documents for relatives, 62 (49.2%) materials for patients with cognitive impairment, and 62 (49.2%) flyers. Figures, apps or websites were thought as less useful.
Content
A clear preference was found for explanations about risks and benefits of BSHs, wished by 112 (88.9%) PCPs [PCP2, I2, F]: “I think what would be important is the, the, that, it's the undesirable effects. So that we, so that they [the patients] understand why we have to change, obviously.” A majority of PCPs also considered recommendations for sleep hygiene, explanations about alternative treatments and about the discontinuation process, as well as tapering schemes, as potentially helpful. Additionally, PCPs wished explanations about sleep physiology for their patients [PCP5, I5, F]: “So, I think one of the main elements is to talk about sleep cycles and explain that these micro-awakenings are natural and difficult to avoid. I think there really needs to be this aspect of ‘What is normal sleep?’, and then, ‘What can we expect from sleep?’, and then, ‘What can't we expect too much of, let's say, with age?’”. A table comparing the effectiveness of the different treatments or testimonials were wished by few PCPs, 50 (39.7%) and 46 (36.5%), respectively.
PCP needs
Concerning useful resources for PCPs, 79 (62.7%) preferred online training, followed by online documents, information on a website and exchange with colleagues. In-person training, printed documents and apps for smartphone were wished by less PCPs. Regarding training in general, PCPs mentioned that sleep problems were just one relevant topic among lots of others [PCP12, FG2, G]: “I don't know if we all really need to do so much training now on how to reduce it [BSH use] exactly. But, hmm, maybe a few basics. (…) But we have to, it's so varied, we have to be fit in so many topics and so I wouldn't want to spend half a day just talking about sleep problems, hmm, or.”
Content
Practical recommendations for pharmacological and non-pharmacological treatment of sleep problems in older people with current BSH consumption were wished by 111 (88.1%) PCPs and deprescribing schemes by 86 (68.3%) [PCP 11, FG2, G]: “So, I think I would find it very helpful to get instructions on exactly how to proceed. Because I don't have much experience in this area.” Concerning CBT-I, 72 (57.1%) PCPs wished its implementation into primary care practice. Seventy-seven (61.1%) said they would be willing to receive information about CBT-I and 74 (58.7%) to complete CBT-I training if it was offered. A minority of PCPs (46, 36.5%) wished recommendations for follow-up and information about motivational interviewing (33, 26.2%). PCPs said, a list of therapists offering CBT-I for sleep problems for older adults using BSHs would be helpful [PCP5, I5, F]: “Well, maybe a list of psychologists who, who willingly take on this type of patients.”