Evaluation of a multi-modal educational package for GP registrars in improving guideline compliance for prescription of benzodiazepines and related drugs in general practice.

The educational package being evaluated is one that is being developed to be incorporated as part of the usual ongoing educational program of a single, large Australian general practice vocational Regional Training Organisation (RTO). The outcomes in this training program will be compared using data from the ongoing cohort study, Registrar Clinical Encounters in Training (ReCEnT), (an ongoing cohort study of GP trainee’s in practice clinical and educational experiences and behaviours) with outcomes from two other RTOs which have not incorporated the educational package in their training programs. Thus, the study can be viewed as observational with evaluation of the educational package being nested within an ongoing cohort study. For the purposes of the ANZCTR format, however, we have classified the study type as Interventional. Similarly, in this document the educational package will be referred to as the ‘intervention’ rather than the exposure. In this document ‘benzodiazepines’ will refer to benzodiazepines and related drugs such as Z-drugs (zopiclone and zolpidem). The multicomponent educational intervention will be delivered during 2018 to all registrars (trainees) training with GP Synergy (the RTO responsible for delivering education and training for all GP registrars in New South Wales and the Australian Capital Territory) and consists of four educational components. These components are: 1) Pre- and post-workshop educational resources: A small number of relevant journal articles will be provided by email and specified as pre-reading (two weeks prior) for the face-to-face educational session. Electronic links to post-workshop resources will be available immediately after the workshop. Pre-workshop readings will cover anxiety and sleep disorders and provide background and evidence highlighting the harms of benzodiazepine use. Pre-reading will address the literature / guidelines which advocate benzodiazepines as a third-line, short-term treatment option for anxiety and insomnia. 2) Face-to-face session: The face-to-face session will consist of a 40-minute educational presentation in a group setting with approximately 450 registrars scheduled to attend as part of the standard training program for GP registrars delivered by GP Synergy, their RTO. The face-to-face session will be led by an experienced GP/ addiction physician and an experienced clinical psychologist. In the face-to-face session, data on GP registrars' benzodiazepine prescribing collected in the ReCEnT project will be used to contextualize and reinforce the practical relevance and importance of the educational message (the ReCEnT data will be that of registrars who have participated in ReCEnT during 2010 to 2017). The presentation will acknowledge the factors leading to benzodiazepine use, and the focus of the presentation will be the practicalities of how to manage anxiety and insomnia within a general practice setting utilizing psychological strategies. The psychological strategies will aid registrars in avoiding initiation of benzodiazepines and may potentially augment benzodiazepine withdrawal management approaches. The session will incorporate clinical scenarios of anxiety or insomnia in which non-pharmacological, psychological approaches rather than benzodiazepine prescription will be appropriate. The clinical psychologist will lead activities on rehearsing Cognitive Behaviour Therapy (CBT), distracting, mindfulness, relaxation/self-calming techniques. These non-pharmacological techniques will be recommended to registrars as practical strategies to employ in their management of patients with anxiety or insomnia. The workshop session has been constructed by the research team of GPs, GP vocational training educators, academic GP’s, an experienced specialist addiction physician, and an experienced clinical psychologist. The process will be informed by the current literature in the area, and the findings of the ReCEnT project in documenting GP registrar’s benzodiazepine prescribing and management of anxiety and insomnia. 3) Supervisor Webinar: A one-hour webinar will be held for supervisors during July 2018, after the registrar face-to-face session. The webinar content will be a more succinct version of the face-to-face registrar session, because supervisors will be more aware of benzodiazepine use and non-pharmacological management of anxiety and insomnia. The webinar will, additionally, emphasize potential models of supervisor-registrar collaboration in minimizing benzodiazepine prescription and in incorporating non-pharmacological methods of managing anxiety and insomnia in the general practice setting. The webinar content will thus promote supervisor facilitation of guideline-consistent practice in benzodiazepine prescribing and insomnia/anxiety management by their registrars. It is also intended that supervisors will reflect on and modify their own practice in this area (as supervisors’ clinical behavior influences registrar behaviour). 4) Joint registrar/supervisor activity: Each registrar-supervisor dyad will be encouraged to include case-based discussions of evidence-based anxiety and/or insomnia management in their regular weekly one-on-one teaching meetings. The supervisor will be offered a set of three or four structured cases to include in the meeting (e.g. new patient presenting with insomnia/anxiety, or a patient with an existing prescription for benzodiazepines). The joint registrar/supervisor activity will be optional as the content of registrar-supervisor weekly meetings is at the discretion of the supervisors and registrars rather than the RTO. Who: The face-to-face educational workshop and online supervisor session will be delivered by Dr Simon Holliday (GP and specialist addiction physician with previous experience as chair of the Pain Management Network of the Royal Australia College of General Practitioners (RACGP)). The face-to-face educational workshop and online supervisor session will be co-delivered by a clinical psychologist, Professor Michael Nicholas. Delivery Mode: Face-to-face workshop delivered within a large group setting, online supervisor webinar, and provision of supporting resources, papers, links to appropriate online material. Number of Times: The registrar face-to-face educational workshop will be delivered as one forty-minute session. The online supervisor session via webinar will be delivered as one one-hour session. The emailed supporting resources may be accessed as often as the participant requires. Location: The registrar face-to-face session will be delivered as one forty minute session during a routinely-scheduled educational workshop in Sydney. Supporting resources may be accessed as often as the participant requires. The online supervisor educational intervention will be delivered as a single one hour session, and will be accessed by supervisors at sites convenient to them. The optional registrar-supervisor teaching session will be held in the general practice of the particular registrar/ supervisor dyad. Strategies used to monitor fidelity/adherence to the intervention: Attendance rolls (face-to-face registrar session and supervisor webinar).