Journal of General Internal Medicine

, Volume 33, Issue 12, pp 2180–2188 | Cite as

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



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


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


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


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.


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.


benzodiazepine insomnia anxiety physician primary care 



Only those acknowledged as authors.


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)


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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

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