Journal of General Internal Medicine

, Volume 34, Issue 12, pp 2763–2771 | Cite as

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

  • Kieran L. QuinnEmail author
  • Michael A. Campitelli
  • Christina Diong
  • Nick Daneman
  • Nathan M. Stall
  • Andrew M. Morris
  • Allan S. Detsky
  • Lianne Jeffs
  • Colleen J. Maxwell
  • Chaim M. Bell
  • Susan E. Bronskill
Original Research



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.


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.


Population-based cohort study in nursing homes in Ontario, Canada, which provides comprehensive clinical, behavioural and functional information on all patients.


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.


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.


physicians practice patterns drug prescriptions anti-bacterial agents inappropriate prescribing nursing home 



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.


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

11606_2019_5333_MOESM1_ESM.docx (286 kb)
ESM 1 (DOCX 285 kb)


  1. 1.
    Abbasi J. VHA Initiative Reduces Risky Opioid Prescribing. JAMA. 2017;317(8):797. Scholar
  2. 2.
    Choosing Wisely Canada. Opioid Wisely. Published March 1, 2018. Accessed 31 July 2019.
  3. 3.
    Choosing Wisely. American Geriatrics Society. Published 2013. Accessed 31 July 2019.
  4. 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. 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. Scholar
  6. 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. Scholar
  7. 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. Scholar
  8. 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. Scholar
  9. 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. Scholar
  10. 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. Scholar
  11. 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. Scholar
  12. 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. Scholar
  13. 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. Scholar
  14. 14.
    Burke JP. Antibiotic Resistance—Squeezing the Balloon? JAMA. 1998;280(14):1270–1271. Scholar
  15. 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. Scholar
  16. 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. Scholar
  17. 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. Scholar
  18. 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. Scholar
  19. 19.
    Daneman N, Gruneir A, Newman A, et al. Antibiotic use in long-term care facilities. J Antimicrob Chemother 2011;66(12):2856–2863. Scholar
  20. 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. Scholar
  21. 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. Scholar
  22. 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. Scholar
  23. 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. Scholar
  24. 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. Scholar
  25. 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. Scholar
  26. 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. Scholar
  27. 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. 28.
    Spiegelhalter DJ. Funnel plots for comparing institutional performance. Stat Med 2005;24(8):1185–1202. Scholar
  29. 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.
  30. 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. Scholar
  31. 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. Scholar
  32. 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. Scholar
  33. 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. Scholar
  34. 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. Scholar
  35. 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. Scholar
  36. 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. Scholar
  37. 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. Scholar
  38. 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. Scholar

Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Kieran L. Quinn
    • 1
    • 2
    • 3
    • 4
    Email author
  • Michael A. Campitelli
    • 2
  • Christina Diong
    • 2
  • Nick Daneman
    • 1
    • 2
    • 3
    • 5
    • 6
  • Nathan M. Stall
    • 3
    • 7
    • 8
  • Andrew M. Morris
    • 1
    • 4
    • 9
  • Allan S. Detsky
    • 1
    • 3
    • 4
  • Lianne Jeffs
    • 3
    • 10
  • Colleen J. Maxwell
    • 2
    • 11
  • Chaim M. Bell
    • 1
    • 2
    • 3
    • 4
  • Susan E. Bronskill
    • 2
    • 3
    • 5
    • 7
  1. 1.Department of MedicineUniversity of TorontoTorontoCanada
  2. 2.ICESTorontoCanada
  3. 3.Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoCanada
  4. 4.Department of MedicineSinai Health SystemTorontoCanada
  5. 5.Sunnybrook Research InstituteTorontoCanada
  6. 6.Division of Infectious Diseases, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoCanada
  7. 7.Women’s College Research InstituteWomen’s College HospitalTorontoCanada
  8. 8.Division of Geriatric MedicineUniversity of TorontoTorontoCanada
  9. 9.Department of MedicineUniversity Health NetworkTorontoCanada
  10. 10.St. Michael’s HospitalTorontoCanada
  11. 11.Schools of Pharmacy and Public Health & Health SystemsUniversity of WaterlooWaterlooCanada

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