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RESEARCHARTICLEOpenAccessDidthenewFrenchpay-for-performancesystemmodifybenzodiazepineprescribingpracticesCédricRat1,2*,GallePenhouet1,AurélieGaultier3,AnicetChaslerie4,JacquesPivette4,JeanMichelNguyen2,3andCarolineVictorri-Vigneau5AbstractBackground:Frenchgeneralpractitioners(GPs)wereenrolledinanewpaymentsysteminJanuary2012.
AspartofanationalagreementwiththeFrenchNationalMinistryofHealth,GPswereaskedtodecreasetheproportionofpatientswhocontinuedtheirbenzodiazepinetreatment12weeksafteritsinitiationandtodecreasetheproportionofpatientsolderthan65whowereprescribedlonghalf-lifebenzodiazepines.
Inreturn,GPscouldexpectanextrapaymentofupto490eurosperyear.
ThisstudyreportstheevolutionofthecorrespondingprescribingpracticesofFrenchGPsduringthatperiodregardingpatientswhowereprescribedabenzodiazepineforthefirsttime.
Methods:Thenationalhealthcaresystem'sadministrativedatabasewasusedtoreportthelongitudinalfollow-upoftwohistoricalcohortsofFrenchpatientsfromthePaysdelaLoirearea.
Studypatients:The"2011"and"2012"cohortsincludedallpatientswhoinitiatedbenzodiazepineregimensfromApril1toJune30in2011and2012,respectively.
Theprimaryoutcomesweretheproportionofthosestudypatientswhocontinuedbenzodiazepinetreatmentafter12weeksandtheproportionofstudypatients>65yearswhowereprescribedlonghalf-lifebenzodiazepines.
Analyseswereperformedusingamulti-levelregression.
Results:Intotal,41,436and42,042patientsinitiatedbenzodiazepinetreatmentin2011and2012,respectively.
Atotalof18.
97%ofpatientscontinuedtreatmentformorethan12weeksin2012,comparedwith18.
18%in2011.
Inall,27.
43%and28.
06%ofpatients>65yearscontinuedtreatmentbeyond12weeksin2011and2012,respectively.
Theproportionofpatients>65yearswhowereprescribedlonghalf-lifebenzodiazepinesdecreasedfrom53.
5%to48.
8%(p65yearswhowereprescribedshorthalf-lifebenzodiazepinesweremorelikelytocontinuetreatmentafter12weeks(p<0.
005).
Conclusions:Despitethepay-for-performancestrategy,thenumberofshorthalf-lifebenzodiazepineprescriptionsincreasedbetween2011and2012,andthenumberoflonghalf-lifebenzodiazepineinitiationsremainedunchanged.
Reducingtheproportionoflonghalf-lifebenzodiazepineprescriptionsmightbecounterproductivebecauseprescribingshorthalf-lifebenzodiazepineswasassociatedwithhigherratesofcontinuationbeyondtherecommendedduration.
Keywords:Benzodiazepines,Drugprescriptions,Pay-for-performance,Guidelineadherence,Familypractice,France*Correspondence:cedric.
rat@univ-nantes.
fr1DepartmentofGeneralPractice,FacultyofMedicine,1rueGastonVeil,44035Nantes,France2FrenchNationalInstituteofHealthandMedicalResearch(INSERMU892)/NationalCenterforScientificResearch(CNRSU6299),8quaiMoncousu,44000Nantes,FranceFulllistofauthorinformationisavailableattheendofthearticle2014Ratetal.
;licenseeBioMedCentralLtd.
ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense(http://creativecommons.
org/licenses/by/2.
0),whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycredited.
TheCreativeCommonsPublicDomainDedicationwaiver(http://creativecommons.
org/publicdomain/zero/1.
0/)appliestothedatamadeavailableinthisarticle,unlessotherwisestated.
Ratetal.
BMCHealthServicesResearch2014,14:301http://www.
biomedcentral.
com/1472-6963/14/301BackgroundBenzodiazepinesareknowntohavehypnotic,anxiolytic,anticonvulsant,myorelaxantandamnesicproperties.
Manyindicationshavebeenrecognisedduetobenzodi-azepines'anxiolyticeffects,includingacutestressreac-tions,episodicanxiety,generalisedanxietyandinitialtreatmentforseverepanic.
In2010,15to20%oftheFrenchpopulationwasprescribedabenzodiazepine,whichistwiceashighasthepercentageinotherEuropeancountries[1];thus,reducingthenumberofbenzodi-azepineprescriptionsisapriorityinFrance[2].
Theextentoftheseprescriptionsincreasesthenumberofpotentiallyadverseeffectsofthisdrugclassinthegen-eralpopulation[3,4]andmayaffectmortality[5,6].
Previousresearchintheelderlypopulationalsodem-onstratedanassociationbetweenbenzodiazepinecon-sumptionandmorbidity[3,4,6].
Moreover,BilliotideGagerecentlypublishedacohortstudydemonstratingthattheuseofbenzodiazepinesinpatientsolderthan65wasassociatedwithanincreasedriskofdementiaupona15-yearfollow-up[7].
Therefore,improvingprescribingpracticesisapriority.
Guidelinesrecommendashort-termprescriptionforben-zodiazepines[8];thisperiodislimitedto2to4weeksinmostcountries[9]and12weeksinFrance[10].
How-ever,manypublicationshavereporteddifficultiesinmanagingbenzodiazepinewithdrawalinpatientswhobecamedependentbecauseoflong-termuse[11-13].
Clay[1]showedthattheanti-benzodiazepinecampaignsinitiatedinmostcountriesfrom2005-2011wereunsuc-cessfulandthattheuseofbenzodiazepinesdidnotde-crease,despitenationalrecommendations.
Anotherwaytolimitbenzodiazepinesideeffectsmightbetopromotetheprescriptionofshorthalf-lifebenzodiazepinesinsteadoflonghalf-lifebenzodiazepinesinpatientsolderthan65years[14-17].
Insum,themodificationofbenzodi-azepineconsumptioninpatientswhohaveusedbenzodi-azepinesformanyyearsremainsachallenge[18].
In2011,Frenchpolicymakersspeculatedthatapay-for-performanceinterventionmightmotivateGPstoim-provetheirpractices.
AspartofanationalagreementwiththeFrenchNationalMinistryofHealthandthefed-erationsofFrenchGPs,fourdifferentprioritieswerede-fined:medicalsurgeryorganisation,qualityofchronicdiseasemanagement,preventionpractices,andmedico-economicefficiency.
Theoverallnationalinvestmentdedicatedtothepay-for-performanceinterventionwasestimatedat282millioneuros[10].
PhysicianswerethusenrolledinthisnewreimbursementandpaymentsysteminJanuary2012[10].
ForeachGP,theextra-paymentpackagewasbasedonagradingscaleassessing29in-dicators,withamaximumof1300points[10].
Theglobalextra-paymentamountforeachGPwasestimatedat5000euros.
Benzodiazepineprescribingpracticeswereassessedbasedontwoindicatorswitharelatedspecificextra-paymentamountof490euros[10].
Aspartofthepay-for-performanceintervention,GPswereaskedtode-creasetheproportionofpatientswhocontinuedtheirbenzodiazepinetreatment12weeksafteritsinitiationto12%andtodecreasetheproportionofpatientsolderthan65whowereprescribedlonghalf-lifebenzodiaze-pinesto5%.
ThisstudyreportstheevolutionoftheprescribingpracticesofFrenchGPsbetween2011and2012regard-ingpatientswhowereprescribedabenzodiazepineforthefirsttime.
Decreasesinthefollowingindicatorswereexpected:theproportionofpatientswhodidnotinter-rupttheirbenzodiazepinetreatment12weeksafteritsinitiationandtheproportionofpatientsolderthan65yearswhowereprescribedalonghalf-lifebenzodiazepine.
MethodsDesign,setting,andpatientsThisstudyusedthenationalhealthcaresystem'sadmin-istrativedatabasetoreportthelongitudinalfollow-upoftwohistoricalcohorts.
AccesstoanonymizeddatawasprovidedbytheNationalHealthcareInsuranceserviceswhoparticipatedtothestudy,afterpermissionoftheHealthcareInsuranceauthorities.
AlleligiblepatientslivedontheFrenchWestCoastinthePaysdelaLoiregeographicarea(3,571,495inhabitants),wereolderthan16yearsandwereaffiliatedwithoneofthe1,350GPswhopractisedinthegeographicareaatthebeginningofthestudy(April1,2011).
The"2011cohort"includedallpatientswhohadbeenprescribedabenzodiazepinefromApril1toJune30,2011,andhadnottakenanybenzodiazepinesduringthepreceding4months.
The"2012cohort"includedallpa-tientswhohadbeenprescribedabenzodiazepinefromApril1toJune30,2012,andhadnottakenanybenzodi-azepinesduringthepreceding4months.
Thedrugsincludedinthisstudywereclassifiedasei-therlonghalf-lifebenzodiazepines(bromazepam,cloba-zam,potassiumclorazepate,diazepam,ethylloflazepate,nordazepam,prazepam,flunitrazepamandnitrazepam)orshorthalf-lifebenzodiazepines(alprazolam,clotiaze-pam,lorazepamandoxazepam)inaccordancewithaninternationalclassificationselectedbypolicymakersandprovidedtotheGPs[19].
Hypnoticsand"Z-drug"pre-scriptions(zopiclone,zolpidemandzaleplon)werenotincludedbecausethesedrugshavea4-weekprescriptionlimitationinFranceandprescribingthesedrugswasnotaconcerninthepay-for-performanceexperiment.
DatacollectionBenzodiazepinecharacteristicsincludedthegenericname,prescriptiondatesanddeliverydates.
Allbenzodi-azepinedeliveries(i.
e.
,instancesofdispensingmedication)Ratetal.
BMCHealthServicesResearch2014,14:301Page2of7http://www.
biomedcentral.
com/1472-6963/14/301recordedinthedatabasewereextractedfromApril1toJune30,2011,andfromApril1toJune30,2012,andthecorrespondingpatientswereidentified.
Otherbenzodiazep-inedeliveriesweretrackedforalongerperiodforeachpatient,fromDecember1,2010,toAugust20,2011,andfromDecember1,2011,toAugust20,2012.
Thepropor-tionofpatientsolderthan65yearswhoreceivedalonghalf-lifebenzodiazepinewascalculated.
Onlythefirstbenzodiazepinewasconsideredintheanalysiswhenapatienthadbeensuccessivelyprescribedtwodifferentbenzodiazepines.
Thedatacollectedincludedpatientcharacteristics,suchasgender,age,socioeconomicstatus(characterisedbyspecificreimbursementfacilities)andtwotypesofmedicalhistoryinformation:diagnosisofachronicdis-ease(includingpatientsbenefitingfrom"disorderoflongduration"reimbursementstatus)andwhetheraGPorapsychiatristinitiatedtheprescription.
PrimaryoutcomemeasuresAllpatientswhoreceivedenoughtabletstoconsumeabenzodiazepineforaperiodlongerthan12weeks(basedonthestandarddose)wereclassifiedas"continuingpa-tients".
Theproportionofpatientswhodidnotinterrupttheirbenzodiazepinetreatment12weeksafteritsiniti-ation(i.
e.
,continuingpatients)wascalculatedusingthefollowingratio:numberofcontinuingpatients/numberofpatientsinthecohort.
Theproportionofpatientswhowereprescribedalonghalf-lifebenzodiazepinewascalculatedusingthefollow-ingratio:numberofpatientswithalonghalf-lifebenzo-diazepineprescription/overallnumberofpatientswithabenzodiazepineprescription.
StatisticalanalysisAllanalyseswereperformedusingR2.
12.
0statisticalsoftware(RFoundation,Vienna,Austria),andYatescorrectionwasusedwhenrequired[20].
Amulti-levelregressionanalysiswasused.
GPswereconsideredasrandomeffect,whereaspatientage,sex,residencyloca-tion,andsocio-economicstatuswereconsideredasfixedfactors.
Analphalevelof0.
05waschosentoas-sessstatisticalsignificance.
EthicsstatementNeitherethicsapprovalnoraspecificwritteninformedconsentfromparticipantswasrequiredinFranceforthisretrospectivedatabasestudy[21].
ResultsPatientandprescribercharacteristicsatbenzodiazepineinitiationareprovidedinTable1.
Intotal,41,436and42,042patientsinitiatedbenzodiazepinetreatmentfromApriltoJune2011andApriltoJune2012,respectively.
GPsprovidedmorethan99%ofallprescriptionsin2011and2012.
Alprazolamwasthemostprescribeddrug(correspondingto41.
24%ofallprescribedbenzodiazep-inein2011and43.
69%in2012),followedbybromaze-pam(33.
31%in2011and28.
72%in2012).
Thosepatientswhowereprescribedtwobenzodiazepinesdur-ingthestudyperiodsin2011and2012numbered1,703and1,805,respectively.
Theproportionofpatientswhodidnotinterrupttheirbenzodiazepinetreatment12weeksafteritsinitiation(correspondingtothefirstindicator)isshowninTable2.
Intheoverallpopulation,18.
18%and18.
97%ofpatientscontinuedthetreatmentformorethan12weeksin2011andin2012,respectively(p=0.
030),whereas27.
43%and28.
66%ofpatientsolderthan65years,respectively,contin-uedtreatmentbeyondthe12-weekperiod(p=0.
30).
Thedistributionsofshortandlonghalf-lifebenzodi-azepineuseinpatientsolderthan65years(correspond-ingtothesecondindicator)arepresentedinTable3.
Thepercentageofpatientsolderthan65whowerepre-scribedalonghalf-lifebenzodiazepinedecreasedfrom53.
5%to48.
8%(p<0.
005)between2011and2012.
Table4synthesisestheresultsofthetwopreviousindicators.
Thistableshowsthatpatientsolderthan65yearswhowereprescribedashorthalf-lifebenzodi-azepineweremorelikelytocontinuethetreatmentbe-yondthe12-weeklimitcomparedwiththoseprescribedalonghalf-lifebenzodiazepine(p<0.
005).
DiscussionMainfindingsTheproportionofpatientswhocontinuedtheirbenzodi-azepineprescriptionsbeyondtherecommendeddur-ationdidnotdecreasebetween2011and2012,despiterecommendationsandfinancialincentives.
Onthecon-trary,thisdatabasestudyshowsaslightbutsignificantincreaseinthenumberofpatientswhodidnotinterruptTable1Patientandprescribercharacteristicsatbenzodiazepineinitiation(France,2011-2012)20112012N=41,393N=41,980Patientcharacteristicsn%n%Agea51.
77;51(17.
66)52.
66;52(17.
84)Male13,69633.
0914,01633.
39PlaceofresidenceRural14,09634.
0514,61734.
82Urban25,91162.
6026,62763.
43Unknown1,3863.
357361.
75PrescribercharacteristicsInitiationbyGP41,35799.
9141,89399.
79aMean;median(SD).
Ratetal.
BMCHealthServicesResearch2014,14:301Page3of7http://www.
biomedcentral.
com/1472-6963/14/301benzodiazepineconsumption.
Oneinfivepatientswhoinitiatedabenzodiazepineregimencontinueddrugin-takebeyondtherecommended12-weekduration,whichincreasedtomorethanoneinfourpatientsovertheageof65.
Theproportionoflonghalf-lifebenzodiazepineprescriptionsdecreasedinthelatterpopulation,whichcouldbeattributedtoa20%increasefrom2011to2012intheoverallprescriptionofshorthalf-lifebenzodiaze-pines,comparedwithnochangeinlonghalf-lifebenzodi-azepineprescription.
Thisstudyshowsthatsubstitutinglonghalf-lifebenzodiazepineswithshorthalf-lifebenzodi-azepinesmightbecounterproductivebecausetheprescrip-tionofshorthalf-lifebenzodiazepineswassignificantlyassociatedwithtreatmentcontinuationbeyondtherecom-mendedduration.
StrengthsandweaknessesThepay-for-performanceinterventionthatwasevalu-atedinthisstudywasimplementedasanationwidestrategyinacountryinwhichthesedrugsareexten-sivelyprescribed.
PolicymakersandGPsorganisationsselectedtheobjectivesandtherelatedoutcomesoftheirowninitiatives.
Ourstudywasdesignedtobeconsistentwiththeobjectivesandevaluationsputforthbypolicymakers,andtheresearchfindingsshouldberelevanttoGPsinclinicalpractice.
Thestudyhasseverallimitationsbecausepolicymakersprimarilydesignedtheimplementedinterventionwithoutresearchers'opinions.
Thispay-for-performancestudywasanuncontrolledbefore-and-afterstudy,whichdidnotallowtheassertionofacausallinkbetweentheinterventionandtheobservedchanges[22,23].
Anop-tionalpay-for-performancesystemhadbeenpilotedinFrancepreviously;consequently,theeffectivenoveltyofthepay-for-performanceschemeprobablyconcernedonlytwo-thirdsoftheGPswhoparticipatedtothestudy.
Informationinthisstudywasextractedfromlargedata-basesderivedfromhealthcareinsurancesystems,whichissimilartopreviousstudies[24-26].
Alimitationre-portedinotherstudiesofinappropriateprescribingwasthatinformationaboutdiseaseandindicationscouldnotbeconsidered.
Drugintakecouldbeassessedusingonlyproxymeasuresbecausedatacollectionwasbasedonreimbursement.
FindingsrelativetootherstudiesThepositiveimpactoffinancialincentivesonbenzodi-azepineprescribingpracticesisdifficulttoassess.
Ourresultsareconsistentwithpreviousevaluationsoftheef-fectivenessofpay-for-performancestrategies.
Evidenceofimprovementinpatienthealthislacking[22,23].
Flodgrenetal.
reportedthatfinancialincentivesforphy-siciansweregenerallyineffectiveforimprovingcompli-ancewithguidelineoutcomes[23].
Incontrast,tworecentTable2Proportionofpatientswhodidnotinterrupttheirbenzodiazepinetreatment12weeksafteritsinitiation(France,2011-2012)20112012pN=41,393N=41,980DiscontinuingpatientsContinuingpatientsDiscontinuingpatientsContinuingpatientsn,%n,%n,%n,%Allpatients33,869;81.
827,524;18.
1834,018;81.
037,962;18.
970.
030Patientsolderthan65years7,180;72.
572,714;27.
437,798;71.
943,041;28.
060.
30Table3Shortvs.
longhalf-lifebenzodiazepinesprescribedtopatientsolderthan65years(France,2011-2012)20112012N=9,894N=10,839pn;%n;%Shorthalf-lifeBZDa4,601;46.
505,550;51.
20<0.
005Clotiazepam118;1.
19137;1.
260.
69Oxazepam723;7.
31997;9.
20<0.
005Lorazepam962;9.
721,043;9.
620.
83Alprazolam2,798;28.
283,373;31.
12<0.
005Longhalf-lifeBZDa5,293;53.
505,289;48.
80<0.
005Bromazepam4,120;41.
643,907;36.
05<0.
005Clobazam115;1.
16174;1.
610.
008Diazepam64;0.
65189;1.
74<0.
005Ethylloflazepate112;1.
13113;1.
040.
58Prazepam624;6.
31664;6.
130.
61Nordazepam101;1.
0298;0.
900.
43Potassiumclorazepate157;1.
59144;1.
330.
13aBenzodiazepine.
Table4Associationbetweenbenzodiazepinediscontinuationanddrughalf-lifeinpatientsolderthan65yearsShorthalf-lifebenzodiazepineLonghalf-lifebenzodiazepinep2011N=4,601N=5,293Continuingpatients(n;%)1,425;30.
971,289;24.
35<0.
0052012N=5,550N=5,289Continuingpatients(n;%)1,755;31.
621,286;24.
31<0.
005Ratetal.
BMCHealthServicesResearch2014,14:301Page4of7http://www.
biomedcentral.
com/1472-6963/14/301Dutchstudiesdemonstratedalinkbetweenpaymentfacil-itiesandbenzodiazepineuse[27,28],althoughtheinter-ventionsinthesestudiesmostlikelyhadagreaterimpactonpatientbehaviourthanonGPs'prescribingpractices.
Inparticular,thesestudiesevaluatedtheimpactofbenzodi-azepinedelistingbyhealthinsurance.
Thefirststudyfo-cusedonindicationsfor"anxiety"and"sleepdisorders"anddemonstratedamoderateimpactofdelistingonthenumberofbenzodiazepinetreatmentinitiations[27].
Thesecondstudycomparedthenumberofdaysthateachpatientunderwentbenzodiazepinetreatmentduringthe2yearsbeforeand2yearsafterdelisting.
Thenumberofdaysoftreatmentdecreased,especiallyinpatientswithini-tiallowintake[28].
FinancialincentivesforGPsdidnotfavourthediscon-tinuationofbenzodiazepineprescribing.
Twointerpre-tationsofthisresultmustbeconsidered.
First,theinappropriatepracticesofGPsarelikelynotduetoalackofmotivation.
PreviousstudieshavealsoshownthatGPsareawareoftheiractions[29].
Thus,furtherinter-ventionsshouldfocusonothersolutions.
Forinstance,cognitivebehaviouraltherapiesarerecommended[30],butnoreimbursementisprovidedtothepatientforsuchtherapies,evenifheorsheconsultsapsychologist[31].
Second,patientswithpsychologicaldisordersarelikelytofacedifficultiesthatrequiresustainedlong-termcare.
Karanikolosreportedthattheprevalenceofmentalhealthdisordersinpeopleundergoingprimarycarein-creasedsignificantlyinEuropeancountriesinassociationwiththecurrenteconomiccrisisandausteritypolicies[32].
Manyanxietyanddepressivesymptomscanbeat-tributedtoeitherindividualorfamilyunemploymentordifficultieswithpayments[33].
ManyrecentpublicationshavealsoreportedincreasingsuicideratesinEuropeancountries[34-36],sothestudyperiodswereunfavour-ableforexpectationsofadecreaseinbenzodiazepineconsumption.
Infurtherstudies,clinicalassessmentofindicationsanddistinctionsamonganxiety,sleepdisor-dersandotherindicationswouldfacilitateanimprovedfocusoninappropriatelong-termuseofbenzodiaze-pines.
GPsshouldreconsidertreatmentindicationstoshifttowardsnon-pharmacologicaltreatmentsorotherdrugs,suchasserotoninreuptakeinhibitors,toresolvethisissueregardingbenzodiazepineprescriptions.
Thesealternativetreatmentscouldhelptoavoidthesideef-fectsofbenzodiazepines.
Thereducedproportionoflonghalf-lifebenzodiazep-ineprescriptionswasconsistentwiththekeymessageofpolicymakerstoGPs.
Previousauthorssuggestedthatreducingtheuseoflonghalf-lifebenzodiazepinesinin-dividualsolderthan65yearscouldreducetheriskofsedation,falls,hipfractures,memorydisordersandacci-dents[37,38].
However,otherpublicationsdidnotfindthesameassociations[39,40].
Theuseofshort-actingbenzodiazepineshasalsobeenassociatedwithfall-relatedinjuries[41].
Therefore,thechangesinphysicianpracticethatwereobservedinthisstudymightnotberelevant.
Prescribersshouldevaluatetheindication,doseanddurationofbenzodiazepinetreatmentaccordingtotheclinicalcharacteristicsofpatients.
Half-lifedurationisanimport-antconsiderationbutshouldnotbethemainreasonforchoosingabenzodiazepine.
Indeed,half-lifebenzodiazepineclassificationsdifferbetweendifferentauthors.
TheFrenchpay-for-performanceinterventionreferstoaninternationalclassificationpublishedbyLarochein2007[42],butotherstudiesdistinguishthreetypesofbenzodiazepines:short,intermediateandlonghalf-lifebenzodiazepines[43].
Lastbutnotleast,thisstudysuggeststhattheuseofshorthalf-lifedrugsmightincreasetheriskofaddiction,whichisconsistentwiththeirpharmacology[44].
ImplicationsforcliniciansandpolicymakersThisstudyemphasisesthedifficultiesthatcliniciansfaceinanxietymanagement.
Akeymessageisthatsubstitutionofalonghalf-lifebenzodiazepinewithashorthalf-lifeoneislikelysuboptimal.
Abettersubstitutionmightbetheuseofantidepressantsratherthanbenzodiazepinesforlong-termtreatment[45].
Ourstudyalsodemonstratedthelim-itedimpactofthepay-for-performancesystemonanxietymanagementpracticesinprimarycare.
Anewapproachmightbethetransferofpartoftheamountreservedforthepay-for-performancesystemtoreimbursementforpsychologistconsultationsinFrance[45].
ConclusionsTheimplementationofthepay-for-performancestrategydidnotaffecttheprescriptionoflonghalf-lifebenzodi-azepines,whilethenumberofprescriptionsofshorthalf-lifedrugsincreasedbetween2011and2012.
Anad-verseeffectofthisevolutionwasthecontinuationofbenzodiazepinetreatmentsformorethan12weeks,in-sofarasshorthalf-lifedrugshavebeenassociatedwithahigherrateofwithdrawalthanlonghalf-lifedrugs.
CompetinginterestsTheauthorsdeclarethattheyhavenocompetinginterests.
Authors'contributionsCRconceivedofthestudy,participatedinitsdesignandsupervisionandhelpedtodraftthemanuscript.
GPparticipatedinthedesignofthestudy,participatedindataextraction,andhelpedtodraftthemanuscript.
AGperformedthestatisticalanalysisandhelpedtodraftthemanuscript.
ACandJPparticipatedinthedesign,wereresponsiblefordataextraction,andprovidedadministrativeortechnicalsupport.
JMNparticipatedinthedesignofthestudy,andwasresponsibleforthestatisticalanalysis.
CVVparticipatedtostudysupervisionandhelpedtodraftthemanuscript.
Allauthorsreadandapprovedthefinalmanuscript.
AcknowledgmentsTheauthorswishtothanktheemployeesoftheMedicalDepartmentoftheFrenchHealthInsuranceSystemwhowereinvolvedindataextraction.
Ratetal.
BMCHealthServicesResearch2014,14:301Page5of7http://www.
biomedcentral.
com/1472-6963/14/301Authordetails1DepartmentofGeneralPractice,FacultyofMedicine,1rueGastonVeil,44035Nantes,France.
2FrenchNationalInstituteofHealthandMedicalResearch(INSERMU892)/NationalCenterforScientificResearch(CNRSU6299),8quaiMoncousu,44000Nantes,France.
3DepartmentofEpidemiologyandBiostatistics,NantesUniversityHospital,1placeAlexisRicordeau,44000Nantes,France.
4MedicalDepartmentoftheFrenchHealthInsuranceSystem,9rueduPrésidentEdouardHerriot,44000Nantes,France.
5PharmacologyDepartment,FacultyofMedicine,1rueGastonVeil,44000Nantes,France.
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