Kaiser Permanente project lowered use of benzodiazepines, which carry side effects
A Kaiser Permanente quality improvement effort to update hospital management of alcohol withdrawal was associated with shorter time in the hospital and less use of the intensive care unit (ICU), according to research published Feb. 22 in JAMA Network Open.
“Our study provides new insights into an area of hospital care that has changed little over several decades and has had a limited evidence base,” said lead author Joshua T. Smith, PharmD, who carried out the analysis as an informatics research fellow at the Kaiser Permanente Division of Research. “The findings suggest there is room for new approaches that rely less on a single class of medications that can carry risks for patients when there may be effective alternatives available.”
Severe alcohol withdrawal can be life threatening and benzodiazepines have been a mainstay of treatment to assist patients. However, the drugs are known to have some negative side effects in hospitalized patients such as delirium, depressed respiration, excessive sedation, and an increased risk of falls.
In this quality improvement effort, an existing order set was revised to reduce the use of benzodiazepines while increasing the use of anticonvulsants and alpha adrenergic agonists. An order set is a bundle of treatment recommendations for a particular condition that are grouped together in the electronic health record (EHR) so that doctors can quickly and easily choose the recommended, evidence-based treatment.
The retrospective study analyzed the records of Kaiser Permanente Northern California (KPNC) patients hospitalized with a diagnosis of alcohol withdrawal between 2014 and 2019. These patients represented 2.5% of hospitalizations during the study period, or 22,899 hospitalizations among 16,323 separate patients.
The analysis compared medication use, patient outcomes, and other factors before and after the order set was changed. About half (56%) of all the withdrawal-associated hospitalizations involved use of either the old or revised order set; some doctors chose not to use it but to select treatments manually.
The study found that with the revised order set, use of benzodiazepine prescriptions decreased from 78% to 61% of hospitalizations. The mean total dosage of the main drug in that class – lorazepam – declined from 19.7 mg to 6 mg after implementation. Use of alternative and supportive medications including gabapentin, clonidine, thiamine, valproic acid, and phenobarbital increased.
The researchers also compared patient outcomes before and after the new treatment regime. Alcohol withdrawal patients treated with the revised order set had a 29% shorter hospital stay and were 29% less likely to be admitted to the ICU than those who were not.
“Alcohol withdrawal treatment is complicated because it is multiphasic and multifaceted,” said co-author Mary E. Sage, MD, a psychiatrist with The Permanente Medical Group who specializes in treating hospital inpatients. “A one-size-fits-all approach will not work because different patients with alcohol withdrawal may need tailored management. Each physician also comes with different prior training on how to manage alcohol withdrawal.”
Sage noted that the revised order set was the result of a large multidisciplinary team using the best available evidence with options to help physicians get their patients through withdrawal with few complications. “Patients needing less ICU care and getting out of the hospital sooner means that patients are doing better and suffering fewer complications, so they can move forward with their recoveries and their lives,” she said.
Care improvement project
The transition to a new approach for Kaiser Permanente Northern California patients undergoing alcohol withdrawal while hospitalized – often for an unrelated health problem – took several years. Individual clinicians tried pilot projects to introduce benzodiazepine-sparing regimens, but they were not adopted across hospitals.
Then a multidisciplinary group of physicians from psychiatry, addiction medicine, intensive care, and hospital-based care came together around 2015 to start work on an order set that could be embedded in the EHR. Over 4 years they developed a bundle that includes medication choice and dosing recommendations for alcohol withdrawal, along with options for additional care such as IV fluids, electrolyte replacement, vitamins, fall precautions, aspiration precautions, oral care, and social work consultation.
“Many of our medical centers had already started to move toward these adjunctive treatments resulting in lower use of benzodiazepines,” noted co-author Herb Szeto, MD, a hospitalist with The Permanente Medical Group. “The group leveraged those experiences to revise the order set which was then approved by clinical leaders. It was a classic example of identifying and spreading a best practice within Kaiser Permanente.”
The evaluation of the revised order set was supported by The Permanente Medical Group’s Delivery Science and Applied Research Targeted Analysis Program. The evaluation was overseen by co-author Vincent Liu, MD, MS, a research scientist with the Division of Research.
“We undertook this evaluation as a learning health system seeking to learn from and improve our patient care,” Liu said. “What is particularly exciting about this study is that we were able to make advances in an area of hospital care with a very limited evidence base.”
Co-authors also included Laura C. Myers, MD, MPH, Yun Lu, MD, MS, and Patricia Kipnis, PhD, of the Division of Research; and Adriana Martinez, BS, of the University of California, Davis.
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About the Kaiser Permanente Division of Research
The Kaiser Permanente Division of Research conducts, publishes and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. It seeks to understand the determinants of illness and well-being, and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 600-plus staff is working on more than 450 epidemiological and health services research projects. For more information, visit divisionofresearch.kaiserpermanente.org or follow us @KPDOR.