Association between Physician Intensity of Antibiotic Prescribing and the Prescription of Benzodiazepines, Opioids and Proton-Pump Inhibitors to Nursing Home Residents: a Population-Based Observational Study
Abstract
Background
Prescribing patterns for episodic medications, such as antibiotics, might make useful surrogate measures of a physician’s overall prescribing practice because use is common, and variation exists across prescribers. However, the extent to which a physician’s current antibiotic prescribing practices are associated with the rate of prescription of other potentially harmful medications remains unknown.
Objective
To examine the association between a physician’s rate of antibiotic prescribing and their prescribing rate of benzodiazepines, opioids and proton-pump inhibitors in older adults.
Design
Population-based cohort study in nursing homes in Ontario, Canada, which provides comprehensive clinical, behavioural and functional information on all patients.
Participants
1926 physicians who provided care among 128,979 physician-patient pairs in 2015.
Main Measures
Likelihood of prescribing a benzodiazepine, opioid or proton-pump inhibitor between low-, average- and high-intensity antibiotic prescribers, adjusted for patient characteristics.
Key Results
Compared with average-intensity antibiotic prescribers, high-intensity prescribers had an increased likelihood of prescribing a benzodiazepine (odds ratio 1.21 [95% CI, 1.11–1.32]), an opioid (odds ratio 1.28 [95% CI, 1.17–1.39]) or a proton-pump inhibitor (odds ratio 1.38 [95% CI, 1.27–1.51]]. High-intensity antibiotic prescribers were more likely to be high prescribers of all three medications (odds ratio 6.24 [95% CI, 2.90–13.39]) and also more likely to initiate all three medications, compared with average-intensity prescribers.
Conclusions
The intensity of a physician’s episodic antibiotic prescribing was significantly associated with the likelihood of new and continued prescribing of opioids, benzodiazepines and proton-pump inhibitors in nursing homes. Patterns of episodic prescribing may be a useful mechanism to target physician-level interventions to optimize general prescribing behaviors, instead of prescribing behaviors for single medications.
KEY WORDS
physicians practice patterns drug prescriptions anti-bacterial agents inappropriate prescribing nursing homeNotes
Acknowledgements
We wish to thank Matthew Kumar for his assistance with the creation of some of the figures. We also thank IMS Brogan Inc. for use of their Drug Information Database.
Funding Information
This research was funded in part by the Canadian Frailty Network (SIG2014-M1) which is supported by the Government of Canada through Networks of Centres of Excellence (NCE) Program, and also the Canadian Institutes of Health Research (CIHR) through an operating grant (Exploring frailty and its role in the assessment of high risk medications and risk of poor health outcomes in vulnerable populations—MOP-136854). This study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). Kieran Quinn receives funding from the CIHR Vanier Scholarship Program, the Eliot Phillipson Clinician-Scientist Training Program and the Clinician Investigator Program at the University of Toronto.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they do not have a conflict of interest.
Disclaimer
The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by IC/ES or the Ontario MOHLTC is intended or should be inferred. Parts of this material are based on data and information compiled and provided by the Canadian Institute for Health Information (CIHI). However, the analyses, conclusions, opinions and statements expressed herein are those of the author, and not necessarily those of CIHI.
Supplementary material
References
- 1.Abbasi J. VHA Initiative Reduces Risky Opioid Prescribing. JAMA. 2017;317(8):797. https://doi.org/10.1001/jama.2017.1087.CrossRefPubMedGoogle Scholar
- 2.Choosing Wisely Canada. Opioid Wisely. https://choosingwiselycanada.org/campaign/opioid-wisely/. Published March 1, 2018. Accessed 31 July 2019.
- 3.Choosing Wisely. American Geriatrics Society. http://www.choosingwisely.org/wp-content/uploads/2013/01/about_choosingwisely_fivethings.pdf. Published 2013. Accessed 31 July 2019.
- 4.Farrell B, Pottie K, Thompson W, et al. Deprescribing proton pump inhibitors: Evidence-based clinical practice guideline. Can Fam Physician 2017;63(5):354–364.PubMedPubMedCentralGoogle Scholar
- 5.Rose AJ, Bernson D, Chui KKH, et al. Potentially Inappropriate Opioid Prescribing, Overdose, and Mortality in Massachusetts, 2011-2015. J Gen Intern Med 2018;33(9):1512–1519. https://doi.org/10.1007/s11606-018-4532-5.CrossRefPubMedPubMedCentralGoogle Scholar
- 6.Woolcott JC, Richardson KJ, Wiens MO, et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med 2009;169(21):1952–1960. https://doi.org/10.1001/archinternmed.2009.357.CrossRefPubMedGoogle Scholar
- 7.Daoust R, Paquet J, Moore L, et al. Recent opioid use and fall-related injury among older patients with trauma. CMAJ. 2018;190(16):E500-E506. https://doi.org/10.1503/cmaj.171286.CrossRefPubMedPubMedCentralGoogle Scholar
- 8.Finkle WD, Der JS, Greenland S, et al. Risk of fractures requiring hospitalization after an initial prescription for zolpidem, alprazolam, lorazepam, or diazepam in older adults. J Am Geriatr Soc 2011;59(10):1883–1890. https://doi.org/10.1111/j.1532-5415.2011.03591.x.CrossRefPubMedGoogle Scholar
- 9.Vozoris NT, Fischer HD, Wang X, et al. Benzodiazepine use among older adults with chronic obstructive pulmonary disease: a population-based cohort study. Drugs Aging 2013;30(3):183–192. https://doi.org/10.1007/s40266-013-0056-1.CrossRefPubMedGoogle Scholar
- 10.Maes ML, Fixen DR, Linnebur SA. Adverse effects of proton-pump inhibitor use in older adults: a review of the evidence. Ther Adv Drug Saf 2017;8(9):273–297. https://doi.org/10.1177/2042098617715381.CrossRefPubMedPubMedCentralGoogle Scholar
- 11.Hallsworth M, Chadborn T, Sallis A, et al. Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial. Lancet. 2016;387(10029):1743–1752. https://doi.org/10.1016/S0140-6736(16)00215-4.CrossRefPubMedPubMedCentralGoogle Scholar
- 12.Chen JH, Humphreys K, Shah NH, Lembke A. Distribution of Opioids by Different Types of Medicare Prescribers. JAMA Intern Med 2016;176(2):259–261. https://doi.org/10.1001/jamainternmed.2015.6662.CrossRefPubMedPubMedCentralGoogle Scholar
- 13.Guthrie B, Donnan PT, Murphy DJ, Makubate B, Dreischulte T. Bad apples or spoiled barrels? Multilevel modelling analysis of variation in high-risk prescribing in Scotland between general practitioners and between the practices they work in. BMJ Open 2015;5(11):e008270. https://doi.org/10.1136/bmjopen-2015-008270.CrossRefPubMedPubMedCentralGoogle Scholar
- 14.Burke JP. Antibiotic Resistance—Squeezing the Balloon? JAMA. 1998;280(14):1270–1271. https://doi.org/10.1001/jama.280.14.1270.CrossRefPubMedGoogle Scholar
- 15.Hunnicutt JN, Chrysanthopoulou SA, Ulbricht CM, Hume AL, Tjia J, Lapane KL. Prevalence of Long-Term Opioid Use in Long-Stay Nursing Home Residents. J Am Geriatr Soc 2018;66(1):48–55. https://doi.org/10.1111/jgs.15080.CrossRefPubMedGoogle Scholar
- 16.Torchia MT, Munson J, Tosteson TD, et al. Patterns of Opioid Use in the 12 Months Following Geriatric Fragility Fractures: A Population-Based Cohort Study. J Am Med Dir Assoc 2019;20(3):298–304. https://doi.org/10.1016/j.jamda.2018.09.024.CrossRefPubMedGoogle Scholar
- 17.Bourgeois J, Elseviers MM, Azermai M, Van Bortel L, Petrovic M, Vander Stichele RR. Benzodiazepine use in Belgian nursing homes: a closer look into indications and dosages. Eur J Clin Pharmacol 2012;68(5):833–844. https://doi.org/10.1007/s00228-011-1188-z.CrossRefPubMedGoogle Scholar
- 18.Helvik A-S, Šaltytė Benth J, Wu B, Engedal K, Selbæk G. Persistent use of psychotropic drugs in nursing home residents in Norway. BMC Geriatr 2017;17(1):52. https://doi.org/10.1186/s12877-017-0440-5.CrossRefPubMedPubMedCentralGoogle Scholar
- 19.Daneman N, Gruneir A, Newman A, et al. Antibiotic use in long-term care facilities. J Antimicrob Chemother 2011;66(12):2856–2863. https://doi.org/10.1093/jac/dkr395.CrossRefPubMedGoogle Scholar
- 20.Daneman N, Campitelli MA, Giannakeas V, et al. Influences on the start, selection and duration of treatment with antibiotics in long-term care facilities. CMAJ. 2017;189(25):E851-E860. https://doi.org/10.1503/cmaj.161437.CrossRefPubMedPubMedCentralGoogle Scholar
- 21.Quinn KL, Macdonald EM, Gomes T, et al. Macrolides, Digoxin Toxicity and the Risk of Sudden Death: A Population-Based Study. Drug Saf 2017;30(2):1114. https://doi.org/10.1007/s40264-017-0539-9.CrossRefGoogle Scholar
- 22.Quinn KL, Macdonald EM, Mamdani MM, Diong C, Juurlink DN, Canadian Drug Safety and Effectiveness Research Network (CDSERN). Lipophilic Statins and the Risk of Intracranial Hemorrhage Following Ischemic Stroke: A Population-Based Study. Drug Saf 2017;40(10):887–893. https://doi.org/10.1007/s40264-017-0552-z.CrossRefPubMedGoogle Scholar
- 23.Daneman N, Bronskill SE, Gruneir A, et al. Variability in Antibiotic Use Across Nursing Homes and the Risk of Antibiotic-Related Adverse Outcomes for Individual Residents. JAMA Intern Med 2015;175(8):1331–1339. https://doi.org/10.1001/jamainternmed.2015.2770.CrossRefPubMedGoogle Scholar
- 24.Daneman N, Gruneir A, Bronskill SE, et al. Prolonged antibiotic treatment in long-term care: role of the prescriber. JAMA Intern Med 2013;173(8):673–682. https://doi.org/10.1001/jamainternmed.2013.3029.CrossRefPubMedGoogle Scholar
- 25.Maclagan LC, Maxwell CJ, Gandhi S, et al. Frailty and Potentially Inappropriate Medication Use at Nursing Home Transition. J Am Geriatr Soc 2017;65(10):2205–2212. https://doi.org/10.1111/jgs.15016.CrossRefPubMedGoogle Scholar
- 26.Campitelli MA, Maxwell CJ, Giannakeas V, et al. The Variation of Statin Use Among Nursing Home Residents and Physicians: A Cross-Sectional Analysis. J Am Geriatr Soc 2017;65(9):2044–2051. https://doi.org/10.1111/jgs.15013.CrossRefPubMedGoogle Scholar
- 27.Mor V. A comprehensive clinical assessment tool to inform policy and practice: applications of the minimum data set. Med Care 2004;42(4 Suppl):III50-III59.PubMedGoogle Scholar
- 28.Spiegelhalter DJ. Funnel plots for comparing institutional performance. Stat Med 2005;24(8):1185–1202. https://doi.org/10.1002/sim.1970.CrossRefPubMedGoogle Scholar
- 29.By the American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015;63(11):2227–2246. https://doi.org/10.1111/jgs.13702.
- 30.Barnett ML, Olenski AR, Jena AB. Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use. N Engl J Med 2017;376(7):663–673. https://doi.org/10.1056/NEJMsa1610524.CrossRefPubMedPubMedCentralGoogle Scholar
- 31.Bell CM, Bajcar J, Bierman AS, Li P, Mamdani MM, Urbach DR. Potentially unintended discontinuation of long-term medication use after elective surgical procedures. Arch Intern Med 2006;166(22):2525–2531. https://doi.org/10.1001/archinte.166.22.2525.CrossRefPubMedGoogle Scholar
- 32.Campitelli MA, Bronskill SE, Hogan DB, et al. The prevalence and health consequences of frailty in a population-based older home care cohort: a comparison of different measures. BMC Geriatr 2016;16(1):133. https://doi.org/10.1186/s12877-016-0309-z.CrossRefPubMedPubMedCentralGoogle Scholar
- 33.Hogan DB, Freiheit EA, Strain LA, et al. Comparing frailty measures in their ability to predict adverse outcome among older residents of assisted living. BMC Geriatr 2012;12(1):56. https://doi.org/10.1186/1471-2318-12-56.CrossRefPubMedPubMedCentralGoogle Scholar
- 34.Chang H-Y, Murimi IB, Jones CM, Alexander GC. Relationship between high-risk patients receiving prescription opioids and high-volume opioid prescribers. Addiction. 2017. https://doi.org/10.1111/add.14068.CrossRefGoogle Scholar
- 35.Ivers N, Jamtvedt G, Flottorp S, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Effective Practice and Organisation of Care Group, ed. Cochrane Database Syst Rev 2012;154(11):669–229. https://doi.org/10.1002/14651858.CD000259.pub3.CrossRefGoogle Scholar
- 36.Morrill HJ, Caffrey AR, Jump RLP, Dosa D, LaPlante KL. Antimicrobial Stewardship in Long-Term Care Facilities: A Call to Action. J Am Med Dir Assoc. 2016;17(2):183.e1-.e16. https://doi.org/10.1016/j.jamda.2015.11.013.CrossRefGoogle Scholar
- 37.Livorsi DJ, Heintz B, Jacob JT, Krein SL, Morgan DJ, Perencevich EN. Audit and Feedback Processes Among Antimicrobial Stewardship Programs: A Survey of the Society for Healthcare Epidemiology of America Research Network. Infect Control Hosp Epidemiol 2016;37(6):704–706. https://doi.org/10.1017/ice.2016.57.CrossRefPubMedGoogle Scholar
- 38.Razvi S, Weaver JU, Butler TJ, Pearce SHS. Levothyroxine Treatment of Subclinical Hypothyroidism, Fatal and Nonfatal Cardiovascular Events, and Mortality. Arch Intern Med 2012;172(10):1–7. https://doi.org/10.1001/archinternmed.2012.1159.CrossRefGoogle Scholar