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BACKGROUND: Benzodiazepine use is associated with adverse drug events and higher mortality. Known risk factors for benzodiazepine-related adverse events include lung disease, substance use, and vulnerability to fracture. OBJECTIVE: To determine whether benzodiazepine prescribing is associated with risk factors for adverse outcomes. DESIGN: Longitudinal cohort study between July 1, 2011, and June 30, 2012. PARTICIPANTS: Patients who visited hospital-and community-based practices in a primary care practicebased research network. MAIN MEASURES:Odds ratio of having a target medical diagnosis for patients who received standard and highdose benzodiazepine prescriptions; rates per 100 patients for outpatient and emergency department visits and hospitalizations. KEY RESULTS: Among 65,912 patients, clinicians prescribed at least one benzodiazepine to 15 % (9821). Of benzodiazepine recipients, 5 % received high doses. Compared to non-recipients, benzodiazepine recipients were more likely to have diagnoses of depression (OR, 2.7; 95 % CI, 2.6-2.9), substance abuse (OR, 2.2; 95 % CI, 1.9-2.5), tobacco use (OR, 1.7; 95 % CI, 1.5-1.8), osteoporosis (OR, 1.6; 95 % CI, 1.5-1.7), chronic obstructive pulmonary disease (OR, 1.6; 95 % CI, 1.5-1.7), alcohol abuse (OR, 1.5; 95 % CI, 1.3-1.7), sleep apnea (OR, 1.5; 95 % CI, 1.3-1.6), and asthma (OR, 1.5; 95 % CI, 1.4-1.5). Compared to low-dose benzodiazepine recipients, high-dose benzodiazepine recipients were even more likely to have certain medical diagnoses: substance abuse (OR, 7.5; 95 % CI, 5.5-10.1), alcohol abuse (OR, 3.2; 95 % CI, 2.2-4.5), tobacco use (OR, 2.7; 95 % CI, 2.1-3.5), and chronic obstructive pulmonary disease (OR, 1.5; 95 % CI, 1.2-1.9).Benzodiazepine recipients had more primary care visits per 100 patients (408 vs. 323), specialist outpatient visits (815 vs. 578), emergency department visits (47 vs. 29), and hospitalizations (26 vs. 15; p < .001 for all comparisons). CONCLUSIONS: Clinicians prescribed benzodiazepines and high-dose benzodiazepines more frequently to patients at higher risk for benzodiazepine-related adverse events. Benzodiazepine prescribing was associated with increased healthcare utilization.

BackgroundThe first Multicenter Medication Reconciliation Quality Improvement (QI) Study (MARQUIS1) demonstrated that mentored implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals, but results varied by site. The objective of this study was to determine the effects of a refined toolkit on a larger group of hospitals.MethodsWe conducted a pragmatic quality improvement study (MARQUIS2) at 18 North American hospitals or hospital systems from 2016 to 2018. Incorporating lessons learnt from MARQUIS1, we implemented a refined toolkit, offering 17 system-level and 6 patient-level interventions. One of eight physician mentors coached each site via monthly calls and performed one to two site visits. The primary outcome was number of unintentional medication discrepancies in admission or discharge orders per patient. Time series analysis used multivariable Poisson regression.ResultsA total of 4947 patients were sampled, including 1229 patients preimplementation and 3718 patients postimplementation. Both the number of system-level interventions adopted per site and the proportion of patients receiving patient-level interventions increased over time. During the intervention, patients experienced a steady decline in their medication discrepancy rate from 2.85 discrepancies per patient to 0.98 discrepancies per patient. An interrupted time series analysis of the 17 sites with sufficient data for analysis showed the intervention was associated with a 5% relative decrease in discrepancies per month over baseline temporal trends (adjusted incidence rate ratio: 0.95, 95% CI 0.93 to 0.97, p<0.001). Receipt of patient-level interventions was associated with decreased discrepancy rates, and these associations increased over time as sites adopted more system-level interventions.ConclusionA multicentre medication reconciliation QI initiative using mentored implementation of a refined best practices toolkit, including patient-level and system-level interventions, was associated with a substantial decrease in unintentional medication discrepancies over time. Future efforts should focus on sustainability and spread.