Advertisement

County and Physician Variation in Benzodiazepine Prescribing to Medicare Beneficiaries by Primary Care Physicians in the USA

  • Donovan T. Maust
  • Lewei A. Lin
  • Frederic C. Blow
  • Steven C. Marcus
Original Research

Abstract

Background

Physicians widely prescribe benzodiazepines (BZD) despite well-recognized harms.

Objective

To determine county and provider characteristics that predict high-intensity BZD prescribing by primary care physicians (PCPs) to Medicare beneficiaries.

Design

Cross-sectional analysis of the 2015 Medicare Part D Public Use Files (PUF).

Subjects

n = 122,054 PCPs who prescribed 37.3 billion medication days.

Main Measures

Primary outcome was intensity of BZD prescribing (days prescribed/total medication days) at the county- and physician levels. PCP and county characteristics were derived from the Part D PUF, Area Health Resources Files, and County Health Rankings. Logistic regression determined the characteristics associated with high-intensity (top quartile) BZD prescribing.

Key Results

Beneficiaries were prescribed over 1.2 billion days of BZD in 2015, accounting for 2.3% of all medication days prescribed in Part D. Top quartile counties had 3.1 times higher BZD prescribing than the lowest (3.4% vs. 1.1%; F = 3293.8, df = 3, p < 0.001). Adjusting for county-level demographics and health care system characteristics (including supply of mental health providers), counties with more adults with at least some college had lower odds of high-intensity prescribing (per 5% increase, adjusted odds ratio [AOR] 0.80, 99% confidence interval (CI) 0.73–0.87, p < 0.001), as did higher income counties (per US$1000 increase, AOR 0.93, CI 0.91–0.95, p < 0.001). Top quartile PCPs prescribed at 6.5 times the rate of the bottom (3.9% vs. 0.6%; F = 63,910.2, df = 3, p < 0.001). High-intensity opioid prescribing (AOR 4.18, CI 3.90–4.48, p < 0.001) was the characteristic most strongly associated with BZD prescribing.

Conclusions

BZD prescribing appears to vary across counties and providers and is related to non-patient characteristics. Further work is needed to understand how such non-clinical factors drive variation.

KEY WORDS

benzodiazepine insomnia anxiety physician primary care 

Notes

Contributors

Only those acknowledged as authors.

Funders

This work was supported by the Beeson Career Development Award Program (NIA K08AG048321, the American Federation for Aging Research, The John A. Hartford Foundation, and The Atlantic Philanthropies) and NIDA 1R01DA045705.

Compliance with Ethical Standards

Conflict of Interest

Dr. Marcus reports receiving consulting fees from Alkermes, Allergan, Sage Therapeutics, Sunovion Pharmaceuticals, and Ortho-McNeil Janssen. All remaining authors declare that they do not have a conflict of interest.

Supplementary material

11606_2018_4670_MOESM1_ESM.docx (42 kb)
ESM 1 (DOCX 41 kb)

References

  1. 1.
    Tannenbaum C, Paquette A, Hilmer S, Holroyd-Leduc J, Carnahan R. A systematic review of amnestic and non-amnestic mild cognitive impairment induced by anticholinergic, antihistamine, GABAergic and opioid drugs. Drugs Aging. 2012;29(8):639–58.PubMedGoogle Scholar
  2. 2.
    Dassanayake T, Michie P, Carter G, Jones A. Effects of benzodiazepines, antidepressants and opioids on driving: a systematic review and meta-analysis of epidemiological and experimental evidence. Drug Saf. 2011;34(2):125–56.CrossRefGoogle Scholar
  3. 3.
    O’Brien CP. Benzodiazepine use, abuse, and dependence. J Clin Psychiatry. 2005;66(suppl 2):28–33.PubMedGoogle Scholar
  4. 4.
    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):1952–60.CrossRefGoogle Scholar
  5. 5.
    Wang PS, Bohn RL, Glynn RJ, Mogun H, Avorn J. Hazardous benzodiazepine regimens in the elderly: effects of half-life, dosage, and duration on risk of hip fracture. Am J Psychiatry. 2001;158(6):892–8.CrossRefGoogle Scholar
  6. 6.
    Jones CM, Mack KA, Paulozzi LJ. Pharmaceutical overdose deaths, United States, 2010. JAMA. 2013;309(7):657–9.CrossRefGoogle Scholar
  7. 7.
    Bachhuber MA, Hennessy S, Cunningham CO, Starrels JL. Increasing benzodiazepine prescriptions and overdose mortality in the United States, 1996-2013. Am J Public Health. 2016;106(4):686–8.CrossRefGoogle Scholar
  8. 8.
    Baldwin DS, Anderson IM, Nutt DJ, et al. Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines from the British Association for Psychopharmacology. J Psychopharmacol. 2014;28(5):403–39.CrossRefGoogle Scholar
  9. 9.
    Stein MB, Craske MG. Treating Anxiety in 2017. JAMA. 2017;318:235.CrossRefGoogle Scholar
  10. 10.
    Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017;13(02):307–49.CrossRefGoogle Scholar
  11. 11.
    Morin CM, Vallières A, Guay B, et al. Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial. JAMA. 2009;301(19):2005–15.CrossRefGoogle Scholar
  12. 12.
    Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD. Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2016;165(2):125–33.CrossRefGoogle Scholar
  13. 13.
    Buysse DJ, Rush AJ, Reynolds CF. Clinical management of insomnia disorder. JAMA. 2017;318(20):1973–4.CrossRefGoogle Scholar
  14. 14.
    Maust DT, Kales HC, Wiechers IR, Blow FC, Olfson M. No end in sight: benzodiazepine use in older adults in the United States. J Am Geriatr Soc. 2016;64(12):2546–53.CrossRefGoogle Scholar
  15. 15.
    Wiechers IR, Leslie DL, Rosenheck RA. Prescribing of psychotropic medications to patients without a psychiatric diagnosis. Psychiatr Serv. 2013;64(12):1243–8.CrossRefGoogle Scholar
  16. 16.
    Simon GE, Vonkorff M, Barlow W, Pabiniak C, Wagner E. Predictors of chronic benzodiazepine use in a health maintenance organization sample. J Clin Epidemiol. 1996;49(9):1067–73.CrossRefGoogle Scholar
  17. 17.
    Unützer J, Schoenbaum M, Druss BG, Katon WJ. Transforming mental health care at the interface with general medicine: report for the presidents commission. Psychiatr Serv. 2006;57(1):37–47.CrossRefGoogle Scholar
  18. 18.
    Bishop TF, Seirup JK, Pincus HA, Ross JS. Population of us practicing psychiatrists declined, 2003-13, which may help explain poor access to mental health care. Health Aff (Millwood). 2016;35(7):1271–7.CrossRefGoogle Scholar
  19. 19.
    Klap R, Unroe KT, Unutzer J. Caring for mental illness in the United States: a focus on older adults. Am J Geriatr Psychiatry. 2003;11(5):517–24.CrossRefGoogle Scholar
  20. 20.
    Olfson M, King M, Schoenbaum M. Benzodiazepine use in the United States. JAMA Psychiatry. 2015;72(2):136–42.CrossRefGoogle Scholar
  21. 21.
    Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci U S A. 2015;112(49):15078–83.CrossRefGoogle Scholar
  22. 22.
    Dwyer-Lindgren L, Bertozzi-Villa A, Stubbs RW, et al. Inequalities in Life expectancy among US counties, 1980 to 2014: temporal trends and key drivers. JAMA Intern Med. 2017;177(7):1003–11.CrossRefGoogle Scholar
  23. 23.
    Cook JM, Biyanova T, Masci C, Coyne JC. Older patient perspectives on long-term anxiolytic benzodiazepine use and discontinuation: a qualitative study. J Gen Intern Med. 2007;22(8):1094–100.CrossRefGoogle Scholar
  24. 24.
    Cook JM, Marshall R, Masci C, Coyne JC. Physicians’ perspectives on prescribing benzodiazepines for older adults: a qualitative study. J Gen Intern Med 2007;22(3):303–7.CrossRefGoogle Scholar
  25. 25.
    Centers for Medicare & Medicaid Services. medicare fee-for-service provider utilization & payment data part d prescriber public use file: a methodological overview. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Downloads/Prescriber_Methods.pdf. Accessed July 24, 2018.
  26. 26.
    Center for Medicare & Medicaid Services. Part D Drug National Summary table, CY2015. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/PartD2015.html. Accessed July 24, 2018.
  27. 27.
    U.S. Department of Housing and Urban Development. HUD USPS Zip Code Crosswalk Files. https://www.huduser.gov/portal/datasets/usps_crosswalk.html#codebook. Accessed July 24, 2018.
  28. 28.
    Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute. County Health Rankings & Roadmaps. http://www.countyhealthrankings.org/. Accessed July 24, 2018.
  29. 29.
    Health Resources and Services Administration. Area Health Resources Files (AHRF): Overview. Rockville, MD. http://ahrf.hrsa.gov/overview.html. Accessed July 24, 2018.
  30. 30.
    Centers for Medicare & Medicaid Services. Physician Compare Datasets. https://data.medicare.gov/data/physician-compare. Accessed July 24, 2018.
  31. 31.
    Hofer TP, Hayward RA, Greenfield S, Wagner EH, Kaplan SH, Manning WG. The unreliability of individual physician “report cards” for assessing the costs and quality of care of a chronic disease. JAMA. 1999;281(22):2098–105.CrossRefGoogle Scholar
  32. 32.
    Maust DT, Blow FC, Wiechers IR, Kales HC, Marcus SC. National trends in antidepressant, benzodiazepine, and other sedative-hypnotic treatment of older adults in psychiatric and primary care. J Clin Psychiatry. 2017;78(04):e363-e71.CrossRefGoogle Scholar
  33. 33.
    Wiechers IR, Kirwin PD, Rosenheck RA. Increased risk among older veterans of prescribing psychotropic medication in the absence of psychiatric diagnoses. Am J Geriatr Psychiatry. 2014;22(6):531–9.CrossRefGoogle Scholar
  34. 34.
    Centers for Disease Control and Prevention. Vital signs: binge drinking prevalence, frequency, and intensity among adults-United States, 2010. MMWR Morb Mortal Wkly Rep.. 2012;61(1):14.Google Scholar
  35. 35.
    Guy GP Jr, Zhang K, Bohm MK, et al. Vital signs: changes in opioid prescribing in the United States, 2006-2015. MMWR Morb Mortal Wkly Rep. 2017;66(26):697–704.CrossRefGoogle Scholar
  36. 36.
    Stein BD, Mendelsohn J, Gordon AJ, et al. Opioid analgesic and benzodiazepine prescribing among Medicaid-enrollees with opioid use disorders: the influence of provider communities. J Addict Dis. 2017;36(1):14–22.CrossRefGoogle Scholar
  37. 37.
    Dasgupta N, Beletsky L, Ciccarone D. Opioid crisis: no easy fix to its social and economic determinants. Am J Public Health. 2018;108(2):182–6.CrossRefGoogle Scholar
  38. 38.
    Weintraub M, Singh S, Byrne L, Maharaj K, Guttmacher L. Consequences of the 1989 New York State triplicate benzodiazepine prescription regulations. JAMA. 1991;266(17):2392–7.CrossRefGoogle Scholar
  39. 39.
    Ray WA, Griffin MR, Downey W. Benzodiazepines of long and short elimination half-life and the risk of hip fracture. JAMA. 1989;262(23):3303–7.CrossRefGoogle Scholar
  40. 40.
    Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly: an update. Arch Intern Med. 1997;157(14):1531–6.CrossRefGoogle Scholar
  41. 41.
    Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003;163(22):2716–24.CrossRefGoogle Scholar
  42. 42.
    Wagner AK, Zhang F, Soumerai SB, et al. Benzodiazepine use and hip fractures in the elderly: who is at greatest risk? Arch Intern Med. 2004;164(14):1567–72.CrossRefGoogle Scholar
  43. 43.
    By the American Geriatrics Society Beers Criteria Update Expert P. American Geriatrics Society 2015 updated beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227–46.CrossRefGoogle Scholar
  44. 44.
    Tsugawa Y, Jena AB, Figueroa JF, Orav E, Blumenthal DM, Jha AK. Comparison of hospital mortality and readmission rates for medicare patients treated by male vs female physicians. JAMA Intern Med. 2017;177(2):206–13.CrossRefGoogle Scholar
  45. 45.
    Berthold H, Gouni-Berthold I, Bestehorn K, Böhm M, Krone W. Physician gender is associated with the quality of type 2 diabetes care. J Intern Med. 2008;264(4):340–50.CrossRefGoogle Scholar
  46. 46.
    Baumhäkel M, Müller U, Böhm M. Influence of gender of physicians and patients on guideline-recommended treatment of chronic heart failure in a cross-sectional study. Eur J Heart Fail. 2009;11(3):299–303.CrossRefGoogle Scholar
  47. 47.
    Roter DL, Hall JA. Physician gender and patient-centered communication: a critical review of empirical research. Annu Rev Public Health. 2004;25:497–519.CrossRefGoogle Scholar
  48. 48.
    Roter DL, Hall JA, Aoki Y. Physician gender effects in medical communication. JAMA. 2002;288(6):756–64.CrossRefGoogle Scholar
  49. 49.
    Davis MA, Guo C, Sol K, Langa KM, Nallamothu BK. Trends and disparities in the number of self-reported healthy older adults in the United States, 2000 to 2014. JAMA Intern Med. 2017;177(11):1683–4.CrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  • Donovan T. Maust
    • 1
    • 2
    • 3
  • Lewei A. Lin
    • 1
    • 2
    • 3
  • Frederic C. Blow
    • 1
    • 2
    • 3
  • Steven C. Marcus
    • 4
  1. 1.Department of PsychiatryUniversity of MichiganAnn ArborUSA
  2. 2.Institute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborUSA
  3. 3.Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborUSA
  4. 4.School of Social Practice and PolicyUniversity of PennsylvaniaPhiladelphiaUSA

Personalised recommendations