A new interview study from members of the CaHRU team, ‘Patients’ and clinicians’ experiences and perceptions of the primary care management of insomnia: qualitative study‘ provides further insights into primary care management of insomnia. The study team interviewed 28 patients and 23 health professionals (GPs, nurse, mental health workers and community pharmacists) and analysed the transcripts of these discussions.

They found that practitioners focused on treating the cause of insomnia rather than the insomnia itself, used sleep hygiene (which patients often disregarded) rather than cognitive behavioural therapy for insomnia and were ambivalent towards hypnotic drugs. They often prescribed hypnotics in ‘collusion’ with patients to prescribe to avoid confrontation or express empathy. Patients sometimes took hypnotics in ways that were not intended by their doctors, for example together with over-the-counter medication.

Both practitioners and patients were sometimes but not always concerned about addiction which led practitioners to sometimes prescribe despite these concerns but at other times withdraw hypnotics abruptly. Both patients and practitioners wanted more options and better training for the management of insomnia in primary care. The authors concluded that a better understanding of the current approaches and difficulties in the management of insomnia will help to inform more therapeutic options and health professional training. These findings build on previous work as part of the REST project (www.restproject.org.uk) which also led to development of an e-learning programme on insomnia (http://elearning.restproject.org.uk/).

Left to right: Hanne Creupelandt, Sibyl Anthierens, Susan Chipchase and Coral Sirdifield

A new study has been published in BMC Family Practice on’General practitioners’ experiences and perceptions of benzodiazepine prescribing: systematic review and meta-synthesis‘. The study was conducted by teams of researchers from the Universities of Lincoln (Coral Sirdifield, Susan Chipchase, Niro Siriwardena), Antwerp (Sibyl Anthierens) and Ghent (Hanne Creupelandt, Thierry Christiaens) who have been working on benzodiazepine and sleeping tablet prescribing by family doctors over the past decade.

The investigators systematically reviewed and synthesised the qualitative literature on benzodiazepine prescribing by family doctors. The analysis of eight studies from seven countries published between 1993 and 2010 showed that prescribing decisions for benzodiazepines were complex, uncomfortable, and demanding. There was variation between GPs and in individual GPs in the extent to which they were willing to prescribe benzodiazepines. GPs were ambivalent and inconsistent in attitudes towards benzodiazepines prescribing because of the changing context of prescribing, differing perceptions of the role and responsibility of the GP, variation in GPs’ attitudes to benzodiazepines, perceived lack of alternative treatment options and GPs’ perception of patient expectations and the doctor-patient relationship.

Model of factors influencing benzodiazepine prescribing

The model developed by the research team could be used to inform future interventions to improve adherence to benzodiazepine prescribing guidance and improve prescribing. This could be brought about through various means including education and training of professionals on benzodiazepine use and withdrawal, greater provision of alternatives to drugs, reflective practice, and better communication with patients.

Professor Niro Siriwardena from the Community and Health Research Unit joined study lead, Professor Philip Bath, and Dr Sandeep Ankolekar (from the University of Nottingham) together with a team from Nottingham University Hospitals and East Midlands Ambulance Service (EMAS) NHS trusts to complete the first ever randomised trial worldwide of paramedic treatment of ultra-acute stroke, the RIGHT trial published in the journal Stroke.

There is a strong link between (both high and low) blood pressure in patients in the early stages of stroke and future death and disability. Glyceryl trinitrate (GTN) or nitroglycerin, which is more commonly used in the treatment of angina or heart attack, was administered by paramedics from EMAS as a skin patch to lower blood pressure in the RIGHT (Rapid Intervention with GTN in Hypertensive Stroke) trial.

The trial was designed to test the safety of GTN in ultra-acute stroke and the feasibility of paramedics diagnosing, consenting, randomising and treating intervention patients in the emergency prehospital setting. In the study, published this month in the journal Stroke, 41 patients were randomised by 23 (out of 78) trained paramedics to GTN or no GTN.

Intervention patients had a significantly lower systolic blood pressure at two hours and also significantly improved functional status at 90 days with treatment. Patients given GTN were no more likely to die or suffer and adverse event. GTN may act by lowering systolic blood pressure which may be harmful in acute stroke or through some other mechanism such as neuroprotection, immunoregulation or vasodilation of cerebral arteries or small blood vessels. The study will form the basis for future studies of ambulance-based trials of stroke.